At 2 years old, your adorable “ballerina” is cute now but when she is 8 and STILL tip-toe walking and now complaining about pain in her feet AND legs it won’t be so cute anymore. This blog post covers Toe Walking, its causes and how its NOT idiopathic, the importance of early intervention, and issues that will arise as your child ages if its never corrected.
Your little ballerina is cute now…
They will not “Just grow out of it”
Toe walking, tip-toe walking or equinus gait pattern as its referred to in the medical community is not an un-common condition in pediatrics and their walking development. Typically seen upon the onset of walking - these kiddos are typically destined to a life of being the perpetual “ballerina” if it isn’t corrected at a young age. A popular opinion from pediatricians and family care doctors is “oh they will just grow out of it.” The sad fact is most do not and because intervention was missed when they were little, many never fully recover or take months to years to begin walking normally without issue even with pediatric physical therapy intervention. While toe walking is never an easy condition to treat it is much easier to treat a child that has only been toe walking for 6 months or a year as compared to 7-10 years. The movement habits are far more engrained and the musculoskeletal changes that have occurred are often to some degree un-reversible.
I think my kid is a toe walker…
Toe walking is a gait pattern where at initial strike of the ground a child hits on the ball of their feet and their heels never touch the ground throughout the cycle. This results in a Toe-toe gait pattern as opposed to the typical heel-toe gait pattern of normal walking. Toe walking is categorized by a child that walks on his/her toes for over 50% of their steps during the day, stands “still” on his/her toes, and/or is unable to bring heels to ground even when asked by an adult. Toe walking typically presents within the first 0-6 months after a child begins walking upright either cruising or independently walking. (*A typically developing gait pattern demonstrates a consistent heel strike by 18 months of age or 22.6 weeks after onset of independent gait!) Sometimes toe walking can arise during later years between 3-5 years of age if its more associated with a sensory impairment. In the beginning, most toe walkers are “intermittent” toe walkers walking between 25-50% of steps on their toes but as they develop, this will increase to nearly 100%. If your 18+month old is spending a majority of his/her time on their toes when upright, it is cause for some concern and to bring it up with your pediatrician so they can be monitored or potentially referred. By 3 years of age and they are still toe walking, it is cause for definite concern and it is time for a referral for physical therapy evaluation.
Some toe walkers can “self correct” and walk “normally” if they are thinking about it but as soon as they are distracted immediately rise to their toes again. Some other characteristics of toe walkers include an inability to be “still” when standing- their feet are constantly moving even if their body isn’t, walking VERY quickly or nearly running every where they go, and older toe walkers may have issues with gross motor coordination tasks that challenge balance or single limb strength.
A consistent heel strike and arm swing should be present in typical walking by 3 years of age…
Toe walking IS a symptom of something greater
Toe walking can have a variety of causes. A thorough exam will rule out sinister neurological causes such as Cerebral Palsy, Muscular Dystrophy, or others. But once these causes are eliminated your child doesn’t just have an “idiopathic” version of toe walking. Idiopathic refers to a condition with no known cause. And let me stress KNOWN! Just because we don’t KNOW what is causing your child’s toe walking, doesn’t mean it doesn’t have a cause, we just need to test to find your child’s cause! Some underlying causes of “idiopathic” toe walking include: vision issues, hypo/hyper sensory issues, poor vestibular development, congenitally/acquired tightened achilles tendon, flat feet, and poor core strength to name a few. Your child could have just one or a few of these underlying causes that are contributing to the SYMPTOM of toe walking.
Many case-studies regarding toe walking often come up short on the goals originally set and pediatric therapists everywhere immediately cringe when they hear they have a toe walker on their schedule. But this is because if you don’t address the underlying CAUSE of the toe walking, no amount of stretching, retraining, or orthotics is going to change that child’s walking behavior. And I will admit, I WAS that therapist in the beginning - wasn’t getting the results I wanted with these kids and I knew something else had to be contributing to their gait patterns - at the time I just didn’t know what I could screen to figure it out though! After years of experience and courses later I now have a much better grip on determining each child’s exact recipe to getting better.
Early Intervention is KEY
At some point with these blogs I am going to sound like a broken record… But early intervention IS key! The longer a child toe walks, the more negative changes can occur in their muscles and developing skeleton. Their poor motor patterns become more engrained in their system (bad habits essentially). Thus leading to increased difficulty in making a full recovery for that kiddo! A young toe walker - I am talking 2-3 years old or younger - has not developed stiff joints or muscles, has not developed engrained motor patterns and bad habits, and has an easy potential to reverse the entire trend with some physical therapy intervention, addressing underlying causes, and potentially special braces to promote typical walking patterns.
Now, not just any physical therapist is going to do! I highly recommend seeking a pediatric physical therapist who has experience with and the express desire to work with toe walkers. Not only will a pediatric provider be able to engage your child in therapy better, but will have more drive to research and access to intervention tools that are specific to toe walkers. I am not saying that a traditional orthopedic physical therapy provider won’t be able to help your child in some way but likely they will not have read the research papers, taken the courses, or have the interest in treating the complexities of pediatric toe walking (returning to that idea of all they need is stretched out right?").
How bad could it really be if I don’t get my child treated?? They are a kid after all!
Alright, so your doctor said your child will grow out of it and you are inclined to believe them. Before you make your final decision please heed a few warnings… As a toe walker ages several things happen to their developing musculoskeletal system.
The skeletal structure in their feet changes. Without getting too anatomical, a bone called the navicular (our arch bone basically) gets really big because of the stresses the feet are taking and a bone called the calcaneus (our heel bone) and heel fat pad does not develop because weight is not being bore through them. This leads to eventual difficulty with heel-toe pattern by limiting the heels ability to absorb shock and the navicular will potentially block adequate dorsiflexion for walking.
Their core gets REALLY weak. By walking in the way they do, their gluteal muscles do not fire, their belly muscles turn off, and they end up utilizing ligaments to hold themselves in standing- which doesn’t work well by the way. And they use gravity to move- the traditional “Leaning Tower of Pisa” look that toe walkers display as their trunk becomes more and more forward of their feet.
They could get PAIN. Many older toe walkers I treat complain about foot or lower leg pain or fatigue by the end of the day, end of playing, or walking for long distances. Because of the altered gait mechanics, toe walkers send abnormal stresses up their feet and legs resulting in pain or muscle fatigue from improper biomechanical use.
Their muscles get really tight EVERYWHERE. Think this is just a foot problem?? Nope. Not only does their calf muscle become tight, so does their hamstrings, their hips, their lower back… And a tight muscle is a WEAK muscle.
Their balance is horrible. Depending on how bad their range of motion is, some toe walkers are unable to place their heel on the ground to balance on one foot. Imagine trying to balance on one foot with your heel in the air? You’d have to have the skills of a ballerina to accomplish that… and your 5 year old does not. Even if they can get their heel on the ground many have not developed the appropriate foot and ankle strategies to maintain their balance appropriately.
Their gross motor and coordination skills can become delayed. When they are little, many toe walkers can “hide” their issues with gross motor development. But as a toe walker ages, the increasing tightness and weakness present throughout their system starts to truly reduce their ability to run as fast, jump as far, or participate in typical childhood activities as well as their peers. Depending on research you read, this could have detrimental impact on social development and even education.
Trust me when I say a few months of intervention at an early age are far easier on your child, you as the parent, and your wallet compared to potential years of intervention in an older child. Now if your child IS the older toe walker- don’t beat yourself up! But get them into PT so they can be helped and hopefully avoid many of the issues named above. The key to success in toe walking management is early intervention and individualized care to your child’s underlying cause for toe walking. I promise your child won’t have to be a ballerina forever…unless they choose to be!