Idiopathic Toe Walking: A Parent’s Guide to The Many Causes

by Dr. Ali

Toe walking is something that is frustrating for many parents and their kids and our parents are often worried about their child’s balance or overall joint health of their feet and ankles as they age. The children are frustrated with always being told to walk on flat feet when they feel like they really can’t control how they are walking! We often hear “They’ll walk on flat feet when they’re thinking about it, but as soon as they stop thinking about how they are walking, they are back up on their toes again!” We hear this over and over again from parents. If you have been to another physical therapist for your child’s toe walking, often they just stretch, stretch, stretch them… your child is miserable and in pain AND there is often no change in their toe walking.

We look at toe walking a little differently. The body is a movement system if the system is not moving the way it is designed to, there must be a reason! The important question we therapists always ask is WHY! When a child walks on their toes, they are using a less efficient gait pattern than when a person walks with a heel to toe gait pattern. Our bodies are SMART and they are always trying to optimize their own movement efficiency naturally so that we can move with EASE. Basically all bodies take the path of least resistance, no matter what! That said, if a child is toe walking, it is DEFINITELY meeting an underlying need in their body, or else, they wouldn’t be walking that way. Toe walking IS their body’s path of least resistance. There is something blocking their body from walking with a heel toe gait pattern and making toe walking the easy way to move. THIS is where we pediatric PTs come in! There are many needs that their body might be trying to meet and we are here to help them fill in the little gaps that their body has not been able to do alone (up to this point). 

Postural and Biomechanical 

Sometimes, the origin of a child’s toe walking is related to their alignment and the way a child uses their core. When this is the primary reason for a child’s toe walking, we will often see the child leaning forward, belly out, with their whole center of mass (aka the middle of their body) positioned forward over their feet. If this is the primary driver of a child’s toe walking, then they need to re-learn how to use their belly muscles and how to re-align and control their whole body while moving before any changes are seen at their feet and ankles. 

Sensory

Sometimes toe walking can have a large contribution from the sensory system. Within this realm there could be multiple different sensory needs their toe walking may be meeting. Let’s look at these different needs a little more: 

• Tactile: Often the link between toe walking and tactile sensations (aka what you feel when something touches your skin) is related to something called tactile defensiveness. Simply put, if your child is tactile defensive, they dont like the way some sensations feel. If your child doesn’t like certain sensations and their toe walking changes when they walk on grass versus concrete or tile versus carpet, and etcetera, there could be something relating to their tactile system that is contributing to their toe walking.

• Visual: The development of the visual and visuomotor systems are tricky overall. As a child develops, their eye movements become more and more coordinated. By the age of three, most children have started to develop more mature visuomotor skills, like convergence (when the eyes work together to see things that are low and in the foreground). When we hear that a child did not start toe walking until about the age of three, we often suspect there is a visuomotor factor at play, though other factors may be present as well. If there is a visuomotor component, we typically refer the child to a professional called a Developental Optometrist who is the ideal healthcare provider to determine whether the eyes are coordinated and if eye movements are developmentally appropriate or if they are in need of a little help!

• Proprioceptive: when a child is trying to meet a proprioceptive sensory need by toe walking, they may be walking on their toes to gain extra sensory input from their feet. Proprioception is a sense we have in our muscles and joints that tells us where our body is in space. This is why proprioception helps us feel safe and grounded, because we can understand where our bodies are in relation to our environment. Sometimes, if a child has a proprioceptive system that is not accurately processing, such as with a child with low tone, the information the body is trying to give, the child may be unsure of where their feet are and their legs are in space when their feet are flat on the ground. Their innate solution for this is to rise up onto their toes to press the joints of the feet and ankles together, which then gives them more info about where their legs are.

Neuromuscular:

-Sometimes children who present with high tone or low tone can toe walk based on how their system regulates the tone in their muscles. High tone is frequently seen in children with Cerebral Palsy or children who have had a Traumatic Brain Injury, and in this sense, when the child moves or tries to walk, the tone in their calf muscles may increase to the point where they are walking up on their toes. In the case of low tone, similar to why children with impaired proprioceptive systems might toe walk, the child might be looking to stabilize joints which are more mobile. By toe walking, children with low tone are increasing their overall joint stability and thus the stability of their body while they move. Neuromuscular contributions to toe walking are more complicated as they require more time, patience, and retraining of the way the child regulates their tone while they move (which is often an automatic process and is only slightly understood by the medical community). The main reason why toe walking can be troublesome for this population, especially in the case of high tone, is that having the foot and ankle positioned in a pointed position while moving and likely while standing or resting too can create something called a contracture. A contracture is the term used when a joint loses movement in a certain direction to the point where it affects the intended function of that joint. When a contracture gets too severe, it might cause skin break down while a child is walking in certain shoes, which could lead to an infection down the line. Contractures are very hard to reverse once they occur and prevention is typically the preferred way to go!

If ANY of these descriptions (or a combination of these) sound like your child, they may benefit from physical therapy with the knowledge of how to treat idiopathic toe walking. Gone are the days of “stretching three times a day will make it better” because if you have done this with your child you KNOW that 9/10 time this does not work. At KidPT we treat idiopathic toe walking from the tummy out to the tips of the toes and don’t look over the potentially crucial contributing sensory factors. We will work with you and your child as a team to put the puzzle pieces together (and oh yeah did we mention they will have FUN while doing it). Stop stressing and start getting answers, come in to KidPT today for a Free Discovery Visit and see if WE are the right fit for YOU!