Toe walking: What is it?
Toe walking is when a child is walking on their feet but their heels do not touch the ground, or their heels very briefly touch the ground and they walk with a sort of ‘bounce’ in their step. Toe walking is more or less a controlled fall, making it difficult to stop with intention and change direction without a loss of balance.

Why I don’t want your child to be a toe walker
Toe walking causes strain and use of certain musculature that should not be used during a typical gait (walking) cycle. It overuses muscles that should be used to stabilize as force producers, and it under utilizes muscles that should be force producers, causing them to become weak and inefficient. It increases their risk of falling due to a smaller base of support between their bodies and the ground and leads to joint and ligament breakdown, which can cause arthritis and joint pain later on. It prevents them from safely walking on uneven terrain at a park, safely going up/down stairs, fitting their feet into ice skates/ ski boots/ rollerskates, water skis, squatting with control, jumping the expected height and distance for their age, and sitting with upright posture. By over utilizing muscles that should be resting when we are walking, it causes these muscles to flex and shorten, and does not allow them to return to their natural resting muscle length. Without the ability to return to the natural length, the muscle accommodates and starts to become tighter and shorter, and eventually is unable to achieve the full range of motion it is meant to. When a muscle is unable to move through its typical range, it turns into a contracture, which is only managed through surgical intervention, such as an achilles release.

Why is my kid a toe walker?
Risk factors for toe walking include a growth spurt at the time that they started to walk independently, visual processing difficulties, family history of toe walking, history of torticollis, reflexes that have not been incorporated, W sitting, and spending time in containers. Examples of containers include: jumpers, contained walkers, car seats, standing activity centers, swings, bumbo chairs, high chairs, etc. Anything that keeps your child’s hips stationary, allows them to ‘stand’ while also in a sling-like seat, and has a strap around them. If you must keep your child in a container, please limit it to 20 minutes per day outside of mealtimes. Research has found that <20 minutes per day is not a risk factor for your child becoming a toe walker. If you catch your child sitting in a ‘w’ position, please guide them with a verbal prompt such as ‘let’s fix your feet,’ ‘legs in front,’ or ‘criss cross applesauce please,’ and guide at least 1 of their legs forward. As you can see, many children will start to walk on their toes due to conditions that you are unable to modify. Focus on what you can change with this information, and let us help you with the rest.

Toe walking is broken down into 3 categories: neurological, sensory and musculoskeletal.

Neurological contributors of toe walking can be diagnoses such as cerebral palsy. Cerebral palsy limits the communication between the brain and the muscles and causes a change in a child’s muscle tone and ability to turn the muscle ‘on’ and ‘off.’ Visual processing difficulty is another example of a neurological factor. The child may feel like the world is slanted or tilted, and are staying up on their toes to avoid falling forward; they could also demonstrate dyslexia, double vision, and/ or lack of eye contact. If your child is school aged, they may be reported by the teacher as the class clown, goofing off, or unable to pay attention, possibly leading to misdiagnosis of a learning disorder. They may not have integrated their reflexes from infancy, resulting in a lack of conscious awareness of what their body does when presented with a certain stimulus or position.

Sensory contributors of toe walking include a desire to seek, or reduce, input from our sensory systems. For example, a child who is seeking more tactile sensations may also like touching different textures, always needing to grab items on a clothes rack when you’re out shopping. A child who wants to reduce the sensation of the ground on their feet may go up onto their toes so that less of their foot needs to experience that sensation. Generally speaking, children who are seeking out more sensory experiences also enjoy vestibular input, which includes spinning, crashing, jumping, rolling or hand flapping. They can be described as clumsy or rough. Sometimes, if a child is overwhelmed by their sensory systems, they will go through an emotional reaction, and a symptom of this is a physical result, including going up onto their toes. An example could be that your child often goes up onto tiptoes when they get excited, upset, or scared.

Musculoskeletal contributors of toe walking include a predisposition for high or low muscle tone, such as someone who would be described as tight or tense like a body builder, or like a wet, floppy noodle. They may exhibit decreased core strength and activation, and could be described as lazy. They will likely sit with a large base of support (legs out in front in a v or w sit), or found frequently learning on others or furniture. They may have limited range of motion at their ankle that allows them to sufficiently lift their foot up so it doesn’t drag when they walk.

What would PT for my kid who is a toe walker look like?
Toe walking is managed by stretching, strengthening, body awareness activities, visual processing activities, kinesiotape, spio vest, vestibular integration, prism glasses, visual tracking, reflex integration, balance, or core activation…. Generally if a child is very tight, I will refer for orthotics from the orthotist and/ or the orthopedic surgeon’s opinion on serial casting or botox. If they are demonstrating other sensory processing difficulties or seeking behaviors, I will also refer to OT (occupational therapy).

At what point should my child start PT if they are a toe walker Here is a guide to follow:

Does your child demonstrate any of the signs or symptoms beyond toe walking that I mentioned above?
Have they been consistently up on their toes for > 1 month?
Are they frequently in a container?
Do they seem uncomfortable when you try to stretch their legs and feet so their feet are flat?
Do they struggle to remain safe while they are playing based on falls/ crashing into furniture or others/ unable to stop or change direction when they are walking?

If you answered ‘yes’ to any of the aforementioned conditions, it is time to seek a PT referral.

If your child is a pre-walker and they are up on their tiptoes often, they may be exploring their environment, feeling what it is like to change their degree of standing, looking to peer over the table or into containers their aren’t supposed to get into, or locking out their knees to feel more stable. Based on these statistics, your child is not in need of PT.

Toe walking is not a ‘one treatment fits all’ based on what I mentioned above. A PT who is highly trained in toe walking is the only qualified PT to treat your child. Do not allow your child to be treated by a PT without this experience.

Have more questions? Reach out to schedule a free consultation!