Children walk on their toes for various different reasons. Medical causes such as cerebral palsy and muscular dystrophy must be ruled out. This link is a good overview of toe-walking in general. I want to address some of the physical therapy specific aspects of toe-walkers.
When a child who toe walks comes to me, I first rule out any red flags. Did they always toe walk or is this new? Does the child have any stiffness or responses to a rapid stretch?
There is also some research linking toe-walking with language disorders and other neurodevelopmental disorders. Therefore, I always look at the child as a whole and ask parents about speech and school concerns as well. If I don’t see any red flags, the first thing I want to know is the child’s ankle flexibility. Can the child stand flat? If they don’t have enough ankle flexibility to walk heel-toe, that needs to be addressed first. The options for increasing flexibility are stretching, night splints , serial casting , and surgery.
Let’s say the child has adequate ankle flexibility to walk heel-toe. Muscle groups that are commonly weak are the abdominal obliques (rotators), gluteals, shoulder stabilizers and ankles. Weakness in these muscles can put a child in a forward leaning position. Once the child starts walking he would naturally walk on his toes. Strengthening these muscle groups improves postural control and helps to create a more neutral posture. Activities that strengthen these muscle groups include: wheelbarrow walk , bridges (roll a car or ball underneath), climbing on playground equipment, crawling over a mountain of sofa cushions and pillows, and standing on the bed playing catch.
Another big piece of the puzzle with children is sensory processing. Children who toe-walk should have their vestibular (inner ear balance system) system assessed. The vestibular system mediates tone, anti-gravity muscle activity and some reflex activity that affects walking, balance, and ankle control. Some signs that a child has a vestibular disorder is that they dislike swings, never get dizzy, get carsick easily, and have difficulty with ball play. Tactile defensiveness can worsen toe-walking, but isn’t likely to be a sole cause. Toe-walking increases the amount of proprioceptive (feedback from the muscles and joints) input the child is getting as they walk. Children who crave deep pressure may use toe-walking to increase that input that they seek.
Toe-walking can be a persistent habit. I used to be much more aggressive in my treatment of toe-walking, but at the moment I feel that as long as appropriately flexibility is attained/maintained and balance reactions/gross motor skills are developed, then I will let it be. There are often many other priorities to focus on.