Toe walking in children

What is "toe walking"?

The toes are the tips of the toes. Some children prefer to walk on their toes instead of on their whole foot, that is, walking with their heels not touching the floor. Toe walking is called “Toe walking” in professional language.

Is toe walking "normal"?

Toddlers begin walking around the age of one to one and a half years. Some of them prefer to walk on their toes during the first weeks or months. Later, when walking is more stable and confident, most toddlers will stop stepping on their toes and walk while stepping on the entire surface of their feet.
The prevalence of toe walking in 5-year-old children with normal development is 2% (that is, two out of every hundred healthy children will step on their toes by the age of five), but up to 40% of children with developmental difficulties.
Most children who continue to walk on their toes beyond the age of two are healthy, and in fact, toe walking is a type of behavioral habit for them. Professionals call this condition Habitual toe walking or Idiopathic toe walking or Dynamic toe walking.

What causes toe walking in children?

As we said before, many toddlers initially walk on their toes and later pass away. Even in older children, at the age of 3-5 years, toe walking is in most cases a behavioral habit and does not indicate a disease. It is possible that toe walking in healthy children results from a disorder in the sensory processing of the sense of balance (Vestibular sensory processing) or the sense of touch (Tectile sensory processing), but there are too few studies on the subject and there is no unequivocal proof of this.
In a small number of children, toe walking may be related to abnormal medical and developmental conditions, and in such cases, clarification or treatment is necessary.
Medical problems that may cause toe walking on only one leg: unequal leg length, hemiplegic cerebral palsy.
Medical problems that may cause toe walking on both feet: Diplegic or Quadriplegic cerebral palsy, autism, dystonia, spinal cord problems (such as structural, genetic, or inflammatory disorders of the spinal cord), diseases involving nerves or muscles, and metabolic disorders (i.e., deficiency or excess of various substances, such as vitamin B12 deficiency).

Why is there toe walking in a child with cerebral palsy?

In spastic cerebral palsy (CP), a rigid contraction of the ankle tendon (Equinus contracture) develops because the spastic muscles in the heel and foot grow more slowly than the non-spastic muscles. When the child tries to maintain a stable stance while the hip and knee are bent (Flexion) and the ankle is at a right angle to the shin (Plantigrade), he is forced to bear weight on the ball of the foot and toes to avoid falling forward.
In dystonic cerebral palsy (also called extrapyramidal), the feet may “go into” a tense position during stimulation of the foot, such as standing and walking. Cerebral palsy is often mixed and combines spasticity and dystonia simultaneously.

Why is there toe walking in a child with autism?

Toe walking can be seen in 30% of children on the autism spectrum. The reason for this is unknown, probably due to tactile (touch) and proprioceptive (body sense in space) sensory regulation. Toe walking is more common in children who have not acquired speech at all (non-verbal) than in those who speak (verbal). However, there is no difference in the severity of autism between those who walk on their toes and those who do not.

When should you worry?

It is advisable to seek evaluation from a pediatric neurologist when a child continues to walk while stepping only (or mainly) on the toes of both feet beyond the age of two, and some professionals recommend consulting after the age of four.
Situations of toe walking in which it is recommended to consult a neurologist at an early stage (at any age):
1. If a toddler regularly walks on the toes of only one foot, while the other foot steps on the entire foot.
2. If there was a significant complication during pregnancy or birth (such as prematurity, low Apgar score, need for resuscitation after birth, etc.).
3. If there is weakness in the legs, or of an arm and leg on one side of the body.
4. If there is a developmental delay in the motor area (strength, mobility and balance), verbal (understanding and speech) or communication (sociality and attitude towards others).
5. If the child suffers from leg, back or head pain over time.
6. If the child has a sensory disorder in the feet, such as: paresthesia (when the foot “falls asleep” frequently and for a long time) or numbness.
7. If toe walking does not improve or worsens.
8. If there are family members with walking problems, disability, muscle disease, nerve disease, or autism.

What happens at the pediatric neurologist?

When a pediatric neurologist is consulted with a child who walks on their toes, he will ask detailed questions about the course of pregnancy and childbirth, the child’s health, his development in various areas (language, communication and motor skills), the family background of the child and parents, and of course about the walking itself and whether there are any additional complaints.
In addition, the neurologist will examine the child with a careful physical and neurological examination, which will include the functions of the brain, spinal cord, nerves and muscles, as well as the back from the neck to the tailbone (because certain findings on the skin in the midline of the back may indicate a problem with the spinal cord).
After questioning and examination, the neurologist will determine whether the condition requires investigation. Sometimes the neurologist will refer for an evaluation by a pediatric orthopedist or physiotherapist. In most cases, no further investigation or treatment will be necessary. If a problem is still suspected, an MRI of the brain or spinal cord will sometimes be necessary, but it is very rare that other tests (blood and urine tests, EMG or genetic counseling) will be needed.

What is the treatment for a child with toe walking?
If a specific cause is found, then the treatment will be directed at that cause. For example, asymmetrical leg length will be treated by an orthopedist, vitamin deficiency will be treated accordingly, and cerebral palsy and many other diseases will require multidisciplinary rehabilitation.
But as we said, most children with toe walking do not have an illness or problem. Do these children need to be treated? Well, studies have shown that about 80% of them will improve and their gait will become normal even without any treatment or intervention. However, it is common for the doctor to refer a healthy child with toe walking to a pediatric physiotherapist, with the goal that the treatment will help promote normal walking and prevent shortening of the Achilles tendons in the ankles and worsening of toe walking.
Other treatments that have not been proven to be unequivocally effective:
1. Verbal cueing: It will not help to tell the child to “stop walking on the tips of the toes” or to remind him to “step on the whole foot”.
2. Sole inside the shoe – not enough information. A rigid splint inside the shoe – forces the foot to remain in a 90-degree position while it is put on. However, both the splint and the sole stop helping when they are taken off, and the child returns to stepping on the toes.
3. Serial casting of the foot and ankle with a plaster cast (serial casting): helped in one study, and other studies were conducted without a control group, meaning there is no clear scientific proof.
4. Botulinum toxin injection into the ankle: May weaken the muscle and even cause it to become stiff, so it is not given to children with toe walking, but only in certain cases of cerebral palsy.
5. Surgery to lengthen the gastrocnemius muscle tendon in the calf: Only performed if the tendon is already shortened.

In conclusion,
Toe walking (on the tips of the toes) is common in toddlers up to 2 years of age as an initial gait and usually goes away on its own within a short time. Toe walking in most children up to 5 years of age is habitual (and is also called bitual, idiotic or dynamic toe walking) and will usually go away without treatment or intervention, but it is common to refer these children for evaluation and treatment in physiotherapy. In a minority of children, toe walking is caused by a disease or disorder in the brain, spinal cord, nerves, muscles, or bones. It is important that any child with toe walking see a pediatric neurologist to understand their condition and, if necessary, refer them for testing and treatment as needed.