Children toe-walk for various different reasons. Medical causes such as cerebral palsy and muscular dystrophy must be ruled out. Many children on the autism spectrum will also toe-walk. Additionally, children without any other diagnoses have been called idiopathic toe walkers. It is important to understand that toe-walking is a MOVEMENT problem, not just an ANKLE problem. This is why toe-walking can be challenging to parents and therapists alike. A whole body approach is needed to achieve great results!
During a physical therapy evaluation, we first rule out any red flags. Did toe-walking develop over time as the child got older? Does the child have any stiffness or responses to a rapid stretch? Both of these situations will lead to referrals to a neurologist. There is also some research linking toe-walking with language disorders and other neurodevelopmental disorders. I always look at the child as a whole and ask parents about speech and school concerns as well.
Next we want to know if the child can stand flat? If they don’t have enough ankle flexibility to walk heel-toe, that is a priority to address. The most effective options for increasing flexibility are stretching, night splints , serial casting , and surgery. An excellent overall approach if the ankles are too tight to stand flat is to wedge shoes and slowly lower the wedges over time, so that the child can gain ankle flexibility and improve overall movement abilities at the same time!
Let’s say the child has adequate ankle flexibility to walk heel-toe. Next we look at the child’s sensory-motor system. We look at their visual skills and where the child holds their gaze. A child who always looks up will also toe-walk! We will look at the child’s vestibular (inner ear balance system) and the child’s somatosensory (touch and joint and muscle position) systems. We will look at a child’s postural symmetry and movement strategies, include their use of rotation and variation. Does the child move in 3D patterns during play or are they always moving in one plane?
All of these components are assessed and a plan can then be put together to work with the child and family to minimize the frequency of toe-walking.
Toe-walking can be a persistent, but with the right intervention we can minimize it and improve a child’s overall abilities!