Toe Walking: Implications for Therapy

Toe walking is commonly observed in all children up to 2 years of age as they

learn to navigate, explore and manage their environment in a dynamic upright position.

When toe walking is either observed consistently or beyond the age of 2-3 years, it could

implicate a neurological illness, a muscular illness, a congenital heel cord contracture

(tightness) or a sensory processing deficit.

Children who walk on their toes either have existing muscle tightness or develop

tightness/contractures in their ankle muscles. This tightness could lead to serious injury.

Toe walking changes the position of each joint in the legs (ankles, knees, hips) and could

also lead to additional orthopedic deformity. In order to perform motor skills

appropriately, children require a balance of the muscles that flex and extend their bodies.

This provides them with a stable base of support for movement. Children who toe walk

often develop an imbalance in their flexion and extension muscles and therefore may

have poor motor control, balance and coordination. This can also potentially impact

further higher level motor skill development. It is essential to determine the underlying

cause(s) for toe walking in order to implement the appropriate treatment.

Three of the less common, but clearly understood causes of pediatric toe walking

are congenital heel cord tightness, central nervous system damage or paralytic muscle

disease. In the first case, the toe walking is caused by inherently tight ankle muscles. In

the second case, toe walking is caused by spastic gastrocnemius and soleus (heel cord)

muscles in a child’s calf that result from an injury to the brain or the part of the spinal

cord that contains fibers from the motor cortex in the brain. Infants and young children

with an injury to the central nervous system by either a lack of oxygen or bleeding in the

brain are diagnosed with cerebral palsy. Depending on the extent and nature of the injury,

these children will end up with spasticity in their antigravity muscles, including the

muscles that plantar flex the foot (point the toes downward). This results in a toe walking

gait.

Children with Duchene’s muscular dystrophy also have the tendency to walk on

their toes. This results from the pattern of muscle fibrosis that occurs in the children’s

lower extremities. As their muscles become fibrotic, there develops an imbalance of

muscle strength at the knee and ankle. The children lose strength in their quadriceps

femoris muscles which makes it harder for them to keep their knees straight. When they

stand on their toes, it makes it easier to do so. Also, the strength of the muscles around

the ankles becomes disproportionate, and as a result the relatively stronger plantar flexors

cause the children to go up on their toes.

Finally, the majority of children who walk on their toes are said to have what is

termed in the medical community as “habitual” toe walking, or idiopathic (def. having no

known cause) toe walking. This term does not implicate a disease or dysfunction

underlying the atypical gait. There are a small number of children who habitually walk on

their toes and have no other significant deficits. These children will often develop a

typical heel-toe gait with verbal instruction and reminding to walk with their feet flat.

However, habitual toe walking is often related to a vestibular-visual dysfunction.

Children with sensory processing disorders and autism are often observed walking on

their toes.

Toe has been qualitatively linked to a vestibular deficit alone in some children. In this

situation, a rigorous vestibular program alone can help a child walk with a typical heel-

toe gait. The vestibular mechanism in the inner ear receives information from sensory

receptors in different parts of the body to gain an accurate picture of the child’s position

in space. It receives information from the eyes, neck and shoulders, fingertips and palms,

jaw muscles, the front part of the tongue, and the soles of the feet. Children with poor

vestibular processing are often observed running their hands along the walls, chairs, etc.

in an effort to increase the information being sent to the vestibular system. In a similar

effort, these children will also toe walk. Theoretically, this increases the child’s ability to

perceive where they are in space.

 A number of medical professionals attribute toe walking to possibly either a vestibular

dysfunction or a visual-vestibular dysfunction. There is a great deal of qualitative research

in which children have undergone prism work with a developmental optometrist and

subsequently stopped toe walking. It has been shown that children can have an anterior

visual shift in midline in which the child perceives the center of their body to be more

forward in space than it actually is. From that standpoint, it can be theorized that a child

may perceive that the floor is sloping downward and so the child will walk on their toes

to “keep from falling forward.” Additionally, a study entitled “When is Vestibular

Information Important during Walking?” in The Journal of Neurophysiology (April 2004)

was able to conclude that changes were noted in foot placement during typical heel-toe

gait when vestibular stimulation was administered. The study states that (appropriate)

walking is clearly dependent on visual, vestibular and somatosensory (light and deep

touch) information together.

It is essential that a child receive a thorough neuromuscular examination to assess a

potential underlying cause. This will enable a child to receive appropriate treatment for

their atypical gait, and ensure that the child does not have additional impairments

(habitual toe walking has also been linked to language delays often not picked up until

later in the child’s development). Depending on the cause, appropriate treatment may

include physical therapy, occupational therapy, and possible intervention by a pediatric

orthopedist and/or orthotist.  Therapy will address muscle tightness, weakness, muscle

imbalances, the need for orthotic intervention, and deficits in sensory processing, balance

and coordination. If you have any further questions, or would like to arrange an

evaluation, please contact us.