Idiopathic toe walking: causes and treatment

There is a group of children who tend to walk on their toes some, if not all, of the time, despite there being no neurological or muscular condition that would commonly cause toe walking. 

The medical term for habitual toe walking is idiopathic toe walking. (Idiopathic = arising spontaneously or from an obscure or unknown cause)  

Check with your child's doctor or physical therapist

Idiopathic toe walking is only diagnosed if there there is no other condition that may lead to toe walking.  

It is particularly important to consult a doctor if your child suddenly starts to walk on the toes, on one or both legs to check for an infection or injury

Conditions that may cause toe walking

  • Mild diplegic cerebral palsy.  
  • Duchenne muscular dystrophy
  • Spinal conditions such as syringomyelia  can present with equinus contractures and/or toe walking
  • Tethered cord syndrome may present as gait abnormalities and subtle neurological signs.  
  • Muscular skeletal disorders of the lower limbs (injuries, infection) present as acute onset of toe walking, usually in one leg.  

Why do some children walk on their toes? 

We do not know why some children with no neurological or muscle disorder, habitually walk on their toes. There is no evidence to support the idea that toe walking is due to a sensory processing disorder. 

Children who walk on their toes often have tightness in the calf muscles, but often this is not enough to explain why the child does not adopt a normal heel-toe gait. 

The majority of children who walk on their toes do so from when they start to walk independently.  

Toe walking may be associated with developmental coordination disorder (DCD). Children with DCD have difficulties with learning new motor skills, are often late reaching the major milestones, and have poor gross and fine motor skills as well as poor ball skills and motor planning difficulties. Their balance is poor and they often trip and fall a lot. 

Although there is no research that links toe walking and generalised joint hypermobility, clinical experience indicates that the majority of toe walkers have joint hypermobility with tightness in the iliotibial band and associated fascial structures, along with some coordination difficulties. 

Toe walking is often seen in children on the autistic spectrum. The underlying cause is probably the same as for neurotypical children: a combination of coordination difficulties and generalised joint hypermobility. 

Most toe walkers can adopt a heel-toe gait pattern

Although the child can walk using a typical heel-toe gait, they find this uncomfortable and tiring. It requires effort and attention, and may cause discomfort in the lower leg. 

In fact, most children walk on their toes from the start and never really develop the coordination and balance control needed for a typical heel-toe gait. 

The tendency to walk on the toes is worse when the child is tired and does not have the mental or physical energy to adopt a heel-toe gait. 

Why toddlers with joint hypermobility and coordination difficulties become toe walkers 

A normal heal-toe gait pattern requires adequate strength and flexibility in the hip, knee and calf muscles. 

As the leg is moved forwards the ankle is flexed to allow the heel to make contact with the floor. This movement requires at least 90 degrees of dorsiflexion. 

right heel strike.jpg

900 of dorsiflexion is needed for effective heel strike

Once the foot is flat on the floor, the body moves over the foot which requires an additional few degrees of ankle dorsiflexion. 

right foot midstance_1.jpg  right foot pivot.jpg

 

As the body moves over the supporting foot the amount of dorsiflexion increases. 

During the weight bearing phase of the gait cycle, the trunk is body slightly sideways to balance the trunk over the leg. .

swing leg foot straight at heel strike.jpg  

This shift requires adequate flexibility in the hip joint - the hip moves into a position of adduction.

 

When toddlers first starts to walk, they keep the legs wide apart and tip their trunks sideways to maintain balance.  It takes practice before the toddler learns to adduct the hip and keep the trunk upright.

Toddlers with tightness in the hip muscles tend to walk with their feet wide apart  and also turned out. 

Children who toe-walk have tightness in the calf and the hip muscles 

When examining a child who toe walks, doctors and physical therapists often emphasize the restricted range of movement in the calf muscles. The restricted movement in the hip muscles is very often neglected, which is a pity because tightness in the iliotibial band is an important underlying factor in ITW. 

Calf muscle tightness 

The child may have some tightness in the calf muscles which limits dorsiflexion (bending) of the ankle, but very often this movement is not particularly tight.

 A child with good flexibility can bend the ankle to 90 plus degree of dorsiflexion.

dorsiflexion 90 plus.jpgM dorsiflex 1_1.jpg

Children with tight calf muscles can only bend the ankle to 90 degrees or less.

This affects the child's ability to bend the ankle in preparation for heel strike, as well as during the single leg phase of walking.

dorsiflex 90_1.jpg

Hip muscle tightness

Most children who toe walk have tightness in the muscle (and associated fascial structures) that crosses over the side of the hips and knees, called the iliotibial band. 

fascia lata.jpg

Tightness in this muscle makes it uncomfortable to stand with the knees and feet in line with the hips.  Instead the child stands with the legs wide apart and the feet turned out. 

Standing feet wide apart_1.jpg

A simple test for iliotibial band tightness

Let your child stand with the feet parallel and about 10 cm apart.  

Is this comfortable?  Does it feel good or "not nice"?  Is it boring?  (Children often do not recognize discomfort, but know that something is unpleasant and will often refer to this as boring.)

stand.jpg

Next let your child stand with the feet wide apart.

Does this feel better? Children are usually quite clear about the difference in comfort between the two positions. 

Standing feet wide apart_1.jpg

How calf and hip muscle tightness affects walking

As mentioned above, when a child walks with typical gait pattern, the ankle has to dorsiflex beyond 900 as the body shifts forwards over the foot during the single stance phase of walking. 

At the same time, in order the balance the trunk over the foot, there needs to be adduction of the hip joint. 

right foot midstance_1.jpg   swing leg foot straight at heel strike.jpg

If a child has tightness in the ankle and hip muscles, this combination of ankle dorsiflexion at 900 plus as well adduction of the hip causes discomfort in the these muscles. Walking with the foot flat on the floor is uncomfortable, with the discomfort often being felt on the outside of the lower leg. 

What can be done for a child who walks on the toes?

Serial casting

If the calf muscles are very tight and the ankle cannot be bent past 900, then serial casting is the most effective intervention.

A below knee cast is fitted on the child with the ankle flexed as fat as it will go. The cast is replaced at weekly intervals, with the amount of dorsiflexion being increased each time. 

Although attention to hip flexibility is not mentioned in most descriptions of serial casting, it is probably a good idea to include a program of hip and knee stretches. 

More details and references: Idiopathic toe walking: for therapists

The SfA Stretching and Balance Training Program for toe walkers

Research has shown that if a child can dorsiflex the ankle to at least 900, a program of calf muscle and iliotibial band stretching, hip strengthening and balance exercises to train effective active dorsiflexion will usually improve the child's ability to walk with a heel-toe gait. 

  • The SfA program differs from the usual stretching routines prescribed for toe walkers, in that it pays attention to the hip muscles as well as to training balance. 

This is not a quick fix program, and will need 15 minutes a day, 4-5 times per week over a period of 5-6 weeks to achieve a good result. 

However, a regular 15 minutes-a-day training program has additional benefits: regular exercise doing activities with a goal, that challenge the child and require persistence and tolerance of effort will usually improve your child's capacity for paying attention, working memory and managing emotional responses and general fitness will be improved, and the ability to sit erect will also be improved. 

Your exercise program should be fun: children enjoy the challenge of achieving goals, and using the right incentives and feedback motivates a child to work hard.       

The SfA Stretching and Balance Training Program for toe walkers includes:

  • Active stretching for the iliotibial band and calf muscle 
  • Balance exercises in standing 
  • Training standing on one leg
  • Suggestions for training heel strike and flat foot gait

Subscribe to the SfA Fitness and Coordination Training Guide to access this program. 


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