Toe walking is a condition where a person walks on his or her toes without putting much, or any, weight on other parts of the foot—especially the heel. This condition is composed of multiple aspects of functional development working together to create change over time. As a parent, you might identify toe walking in your toddler as they learn to navigate, explore, and manage their environment in a dynamic, upright walking position.
Parents who discover their children toe walking often wonder what caused it and how they can help. I hope to answer a few of these questions, but more importantly to explain the importance of physical therapy in recovery.
Let’s start with a few causes, looking beyond just the “muscles and bones.” Doctors have yet to identify a known cause for habitual, or idiopathic, toe walking. Biomechanical involvement due to congenital shortening of the Achilles tendon (which is often hereditary and is the result of abnormal foot structure) causes the tendon to shorten if its full length is not being used. Neurological diagnoses include muscle spasticity associated with cerebral palsy and paralytic muscle disease, or as a sign of autism. Last, but not least, there’s a sensory component that can be affected by a vestibular/visual dysfunction, a sensory processing disorder (SPD), or retained infant reflexes (ATNR/STNR) associated with development delay.
A pediatrician can advise you on further medical testing and treatment. They may prefer to wait and see if the child will “outgrow” the condition. However, other treatments include:
- Physical therapy
- Night splints or bracing
- Ankle-foot orthosis (AFO) or serial casting used to promote progressive stretching of naturally shortening tissues
- Botox therapy used to help relax the calf muscle allowing the patient or a healthcare practitioner to stretch the musculature. The goal would be to lengthen the muscle allowing flexibility through the heel during gait.
If conservative measures fail to correct the toe walking after about 12–24 months, surgical lengthening of the tendon is an option.
Let’s talk about what you can expect from physical therapy in the treatment of toe walking.
Beyond just muscles and bones
A physical therapist can assess the “muscles and bones” of the condition: the length of the musculature, range of motion (ROM), strength, balance, palpation of the sensation and gait.
Immediate treatment focuses on improving range of motion and flexibility. The patient is asked to actively participate in stretching areas of tightness, working on imbalances of the skeletal system from right to left and front to back as part of a strengthening program. This teaches the body how to adjust to new positions and muscle lengths, changes in proprioception (the receptors that help your brain and body know where they are in space), how to adapt to balancing on different surfaces and textures, and how to re-educate their neuromuscular system.
The sensory of it all
When toe walking is related to vestibular and visual dysfunctions, the inner ear may be to blame. The vestibular system, inside the inner ear, is responsible for feeding the brain information on position and movement. This correlates eye, head and body positioning. If this information is skewed or perceived incorrectly, the brain may not be aware of how the feet are moving or if they are not functioning in the most effective way. In this case, the physical therapist works on vestibular habituation exercises, activities in which we move the eyes, head, neck and extremities separately or together, while working on balance training and coordination.
If your child is sensitive to touch and different textures or has an aversion to shoes, socks or bare feet, this may indicate a sensory processing issue, or even sensory processing disorder, for which the child may walk on their toes to avoid overstimulation. In this instance, therapy can help by implementing tactile techniques. Desensitizing the bottom of the foot is an important part of improving tolerance for walking with the whole foot, from heel to toe.
Last, but not least, Facilitate New Gait
Historically, toe walking has been treated through the instruction and repetition of stretching, followed by more stretching. Treatment of only the “muscles and bones.” However, treatment is much more effective when it focuses on providing the best conditions for the body to work how it is intended. The goal is to find the missing pieces in therapy, work on the sensory of it all, and facilitate new, fine-tuned gait patterning. Think of tweaking the old movement patterns as facilitating a new gait pattern rather than trying to actually stop the toe walking. To do so, the physical therapist is tasked with creating an environment to which the toe walkers are asked to adjust. This means investigating and adjusting the patient’s center of mass, the weight shifting and reaching out of their base of support, stability, the transition from heel strike to pushing off through the toes, quality of gait, stride length, cadence, transition from one foot to the other, and sensory systems, how the child perceives sensations and pressure.