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Tippy Toes

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.

20 replies
    • Joni Redlich
      Joni Redlich says:

      Thanks Barbara. I have had few parents willing to go the AFO route. I have also had children go through serial casting and AFOs for a 6 month period only to pop back up on their toes. I do like to try carbon reinforced shoe inserts. I didn’t include that in the post. It works for some kids to curb the toe-walking, but other kids will go even higher!

      Reply
  1. michelle
    michelle says:

    i have a six year old who walks on her toes all the time and has ever since she stared walking around 10 months. is this abnormal and should i get her into some kind of treatment to get her to stop?

    Reply
    • Dr. Joni Redlich, DPT
      Dr. Joni Redlich, DPT says:

      Hi there. There are many kids who walk on their toes and they have no other issues. This is called idiopathic toe walking. I typically leave it up to the parent whether they want to try to change it or “wait and see.” It oftens does go away on its own with age. The one important piece of the puzzle is making sure that kids have enough flexibility to stand flat and walk heel-toe, even if they are often up on their toes. Since she has been toe-walking for so many years it could be helpful to get a physical therapy evaluation to learn some stretches. If you e-mail me on the contact form I can give you some local referrals if you’re interested.

      Reply
  2. kristen morgan
    kristen morgan says:

    Hi there, i have a 14 month old who cannot walk un-assisted..She will only stand or walk on assisted on the very tips of her toes and cannot stand flat! Im am very concerned..I am going to make an appointment today to see a specialist.Is there any tips on stretching or shoe support you can give me? please help.Thanks in advance, kindest regards, Kristen

    Reply
    • Dr. Joni Redlich, DPT
      Dr. Joni Redlich, DPT says:

      Hi Kristen. Since I haven’t evaluated your daughter I can’t give you specific advice on stretches or shoes. It is more important to find out why she’s standing on her tiptoes at this point. I suggest talking to your pediatrician (or the specialist as your mentioned) and you can also call your local early intervention program. If you need help finding that information let me know and I’ll locate it for you. Early intervention is a program for children birth to 3 that will come to your home and look at any developmental concerns you have. Let me know how things go!

      Reply
  3. Juli Buccellato
    Juli Buccellato says:

    My 11 year old son still toe walks. He can walk heel first when reminded. It is just a habit now. Where can I get carbon reinforced shoe inserts to help correct this?

    Reply
    • Dr. Joni Redlich, DPT
      Dr. Joni Redlich, DPT says:

      The carbon reinforced shoe inserts are from http://www.dafo.com. I also highly recommend the TAAP program to help your son transition from walking heel toe hen he tries to making this an automatic skill. Its a great method to accomplish this and using a treadmill is an fun age appropriate way to approach it as well.

      Reply
  4. Robbie
    Robbie says:

    I have a 5 yr old son who has walked on his toes since learning to walk. I’ve taken him to a pediatric orthopedist who said that there is nothing physically wrong with him, and that it is just a habit. If you tell him to stop walking on his toes he will, but then automatically goes back to it. He doesn’t show any signs of stopping this habit any time soon. He is unable to stand up straight without standing on his toes, and this has me worried. Are there any shoes or anything that you can recommend that may help him?

    Reply
    • Joni Redlich
      Joni Redlich says:

      You mentioned that the orthopedist didn’t think there is anything physically wrong, but yet he can’t stand on flat feet. It sounds like he has gotten too tight in his calves to walk with a heel-toe pattern. He needs to get that flexibility back before anything else could help his walking pattern. Has he done a stretching program before?

      Reply
    • Dr. Joni Redlich, DPT
      Dr. Joni Redlich, DPT says:

      I would suggest working with a local physical therapist to set up a stretching home program. Regardless whether you do any additional intervetion he needs to attain and maintain appropriate ankle flexibility.

      Reply
  5. Robbie
    Robbie says:

    Thank you…I’ve made another appointment with the orthopedist to see if I can get a referral for a physical therapist.

    Reply
  6. Robbie
    Robbie says:

    Hello…We met with the orthopedist today, and he said that my son would need to have his muscles lengthened because of his inability to stand straight without being on his toes. He wants to do surgery in June. Do you have any thoughts on this?

    Reply
    • Staci
      Staci says:

      Did your son have the surgery done? My daughter is 9, Almost 10 we have done Splints. And pt. But as soon as they stop the splints she was right back on her toes. I was wondering how the surgery went and what you thought about it all? Shes been walking on her toes since the day she could walk.

      Reply
      • jonikidpt
        jonikidpt says:

        Hi Staci.I would suggest looking into the functional vision component. You could also work with an orthotist and/or PT do a wedged shoe that is slowly lowered. That would give her practice to adjust to a new gait pattern rather than the all or nothing of casting or braces.

        Reply
  7. Erica Farrell PT
    Erica Farrell PT says:

    HI there,

    I just went to a really good two day course on treatment of toe-walking (through Progressive Gaitways) with the some excellent ideas on treatment, especially for the kiddos that do it for sensory reasons…

    Reply
  8. Liz
    Liz says:

    Hello!

    I have a bright and sweet 24 month old who occasionally toe walks. Some days I don’t see him do it at all, while others I see him do it here and there. He can definitely walk on flat feet and does so most of the time. I am not sure if this is a new “habit” or cause for concern. I also worry that he still prefers to W sit most of the time. He will sit properly when reminded, but this is his position of choice when he is on the ground. No other “sensory” issues and is well in track in other developmental areas. Just wanted to know I should seek a PT eval or if there is anything I can do to work with him at home.

    Reply

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  1. […] Reprinted with the express permission of Joni Redlich, DPT, as originally appeared on her Kid PT Blog, September 11, 2010 […]

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