Idiopathic toe walking

--What is idiopathic toe walking?

When we are not sure why some children walk on their toes, this is called ITW.  We consider ITW a ‘diagnosis of exclusion’, which means that other causes must be ruled out. Thorough assessment by a team of appropriate health care professionals is necessary to determine the cause of your child’s toe walking. This will include assessment by a paediatrician, as well as an experienced paediatric physiotherapist or podiatrist. Other possible causes of toe walking include musculoskeletal issues (eg, leg-shortening—toe walking may be on only one side), neurological conditions (eg, cerebral palsy), or developmental disorders (eg, autism spectrum disorders). It is important to remember that there will be other signs and symptoms of these conditions (such as overall weakness or other developmental issues) if these are causing the toe walking. 

Once a diagnosis of ITW has been confirmed, treatment may include stretches to prevent or treat muscle tightness, exercises to strengthen any weakness, use of orthotics (a splint inside the shoe) or special shoes to encourage a heel-toe walking pattern, and strategies for breaking any habits that may have formed. A physiotherapist can assist you in creating a treatment plan for your child.

If the difficulties your child is having increase, or their toe walking becomes more significant, it may be an option to refer you in to a larger paediatric medical service or to see orthopaedic specialist. This may be to explore the options of serial casting (use of consecutive casts to obtain a stretch, usually completed by a physiotherapist) or surgery (which is used rarely but includes use of Botox injections or calf-lengthening).

Most children grow out of toe walking, however, we cannot predict those who will and those who won’t. Treatment focuses on preventing any complications (such as tightness, pain and falls) which would negatively impact on your child’s quality of life. 

--What causes idiopathic toe walking?

The cause of ITW remains unknown and it remains a ‘diagnosis of exclusion’ where other causes have been ruled out.

--Should I be worried if my child is diagnosed as an idiopathic toe walker?

Most children grow out of ITW by adolescence (when they become bigger and heavier), however, we cannot predict those who will continue to toe walk into adulthood. Children who are idiopathic toe walkers usually live a normal and full life. There are, however, some difficulties that may arise from ITW that are worth keeping in mind. These include foot and leg pain, falls, social isolation or embarrassment, not keeping up with their friends, fatigue with walking and shortening of the muscles in the backs of their legs (particularly their calf and hamstring muscles). Any of these issues would warrant treatment. It is also thought that there are some long-term potential side effects of ITW, such as foot pain in adulthood and development of some structural abnormalities, however, these have not been totally proven. 

Many parents are understandably concerned about a child who is an idiopathic toe walker, however, it is important to consider to what degree it is affecting their quality of life when deciding on what to do.

--How do I know if this is idiopathic toe walking or if I should be more concerned?

Walking on your toes is a common pattern seen in typically developing children in the early stages of walking (before the age of two). After this, it is recommended that children who toe walk are assessed to determine if this is a sign of a greater developmental concern. It is important to consider all aspects of your child’s development and think about whether there are other areas that are not typical.  

You should consult your doctor/physiotherapist if you have noted any of the following associated with your child’s toe walking:  toe walking persisting after the age of two years; only one leg is affected; excessive stiffness of the legs; generally weak in their muscles (eg, difficulty getting on and off the floor or sitting up from lying down); delayed development (across any or all areas including fine motor and speech and language development); narrow, fixated interests of repetitive behaviours or poor social interaction, or frequent falls or trips.

Conditions that may be associated with toe walking include cerebral palsy, peripheral neuropathy, muscular dystrophy, autism spectrum disorders or congenitally shortened tendo-achilles. Toe walking will not be the only sign and symptom of these conditions but may be the most obvious. A relevant health professional (paediatrician or physiotherapist) can thoroughly assess your child for these conditions. Once these other causes are ruled out, your child will likely receive a diagnosis of ITW. 

--How can physiotherapy help with toe walking?

Assessment

An experienced paediatric physiotherapist can assist with the diagnosis of ITW by completing a thorough assessment of your child. They will watch your child complete a variety of different tasks (such as walking, running, jumping and getting on and off the floor), and assess the amount of movement they have and how strong they are. This will help to determine the need for a referral on to another health care professional for ongoing assessment or whether a diagnosis of ITW can be made. This will also help to guide their physiotherapy management.

Management

If your child has been diagnosed with ITW, physiotherapy can be very effective in treating issues that may arise (eg, tightness, pain, falls) and, hopefully, improve your child’s ability to achieve a heel-toe walking pattern. Treatment options include: stretching, including calf muscles and hamstrings to improve muscle length and minimise pain and falls; motor control and strengthening exercises: this involves exercises for strengthening muscle groups so your child is more able to walk with a heel-toe pattern; habit-changing strategies, such as encouraging a normal walking pattern and retraining your child to walk with a heel strike; general advice on footwear that can minimise the toe walking pattern, and setting up a home program, as these treatments are best completed daily and within your normal life.

Other healthcare professionals that may be helpful

Your physiotherapist will also be able to guide you on referral to other professionals. These include:

• podiatrists or orthotists for consideration of orthotics (a splint worn inside the shoe), which minimise your child’s ability to come up onto their toes. These can only be used in children with adequate calf muscle length. There is some limited evidence around the use of these orthotics, however, many families find them very helpful.
• orthopaedic specialists for consideration of surgery (Achilles tendon lengthening) or Botox injections. Surgery is reserved for those children who cannot flex their ankle to attain a heel-toe walking pattern and will only be decided on with careful consideration.
• serial casting is used to gradually stretch a child’s calf muscle over a prolonged period of time and involves your child being in below knee casts for up to a few weeks at a time (this is usually completed at major paediatric centres by a physiotherapist).

Difficulties encountered

Some of the difficulties encountered with the treatment of ITW include that completing stretches on a daily basis can be time consuming and difficult to incorporate into your life and routine, and that tightness can fluctuate with the growth of your child. There may be times where toe walking improves and then other times when a child is up on their toes more. 

ITW can be a hard movement pattern to change and can take time and perseverance.  Always remember to consider the impact the toe walking is having on your child’s quality of life when deciding on ongoing management.

--I’ve Googled this and there are some really scary causes of toe walking—what do I do to rule these out?

If your child continues to walk on their toes after age two, it is worth a review with a relevant health professional to ensure that more serious conditions are ruled out. Your first point of call should be either your maternal and child health nurse or your GP. From there, further assessment may be warranted by a paediatrician or experienced paediatric physiotherapist. Always remember to consider your child’s overall function and development when thinking about their toe walking, as this can help with making a diagnosis and ruling out more serious causes.

--Does my child have an autism spectrum disorder? 

Autism spectrum disorders (ASD) can be a cause of toe walking and needs to be ruled out by a health professional in a child over the age of two who continues to walk on their toes. This assessment will look to see if there are other signs of ASD in addition to toe walking. Other signs of ASD include poor social skills and communication, fixed interests or repetitive behaviours, and sensory signs such as seeking or avoiding sensory experiences. 

--Does my child need surgery?

Surgery is one treatment that may be considered for more severe cases of ITW where other treatments have failed and the toe walking is significantly impacting on the quality of life of your child. Surgery involves lengthening of the Achilles tendon at the back of the ankle, and has been shown to be an effective treatment in children with ankle joints with extremely limited range of movement. The decision to go ahead with surgery will be made with an orthopaedic surgeon and should be considered very carefully as it can have effect muscle power.

--Would massage be helpful?

There is no current evidence that massage improves toe walking in children. Massage may help with reducing muscle tension and allow for more affective stretching of the calf muscles. It may also help to reduce pain and discomfort in some children. 

--Should I tell my child to come down off their toes?

There is limited evidence regarding verbal prompts to reduce toe walking, however, it is likely that encouraging a heel-toe pattern encourages more active and typical muscle activity in the legs which can assist with maintain length of the calf muscle and strengthening the leg muscles. 

--Will this be detrimental to my child long term?

Evidence does show that there can be some longer-term effects of toe walking. These include: more-regular falls; developing structural abnormalities to the bones, muscles and ligaments in the legs as they get older; tightness in the calf and thigh muscles; increased risk of ankle injuries; foot pain or issues in adulthood that may have a negative impact on walking, function and quality-of-life; and impact on play (eg, standing on one leg, jumping or hopping and coordination activities).

--My child is a toe walker. Will they still be good at sport?

Like all children, the physical skills of idiopathic toe walkers vary greatly. Some children are very capable with their physical skills despite being a toe walker (toe walkers can be fast runners as they use their calf to generate power). Other children are less-capable. Continue to encourage your child with their physical activity and direct them into activities that highlight their strengths.

--What else can we do? What if this treatment doesn’t work?

Once your child has been diagnosed as an Idiopathic toe walker, you may try a variety of the treatments outlined in this fact sheet. It is important to consider the impact the toe walking is having on your child’s life when considering the most appropriate treatment and how hard to persevere with altering their walking pattern. If treatment doesn’t work and your child is having ongoing issues, you may decide to seek further opinions from either an orthopaedic specialist or podiatrist. This is something that you should discuss with your physiotherapist and GP.