Toe walking is a pattern of walking in which a child walks on balls of his or her feet, with no contact between the heels and ground. Toe walking is common in children who are learning to walk. After the age of 2, however, most children outgrow toe walking and begin to walk with a normal heel-to-toe pattern.

In very rare cases, continuing to toe walk after age 2 may be a sign of an underlying medical condition. In the vast majority of cases, however, persistent toe walking is “idiopathic,” which means that the exact cause is not known. Older children who continue to toe walk may do so simply out of habit or because the muscles and tendons in their calves have become tighter over time.

Treatment for persistent toe walking often involves a period of casting or bracing to help stretch the muscles and tendons in the calves and encourage a normal gait.

Anatomy

Your calf is formed by two major muscles. They are:

• Gastrocnemius muscle. This is the larger calf muscle. Its two parts form the bulge that is visible beneath the skin.
• Soleus muscle. This smaller, flat muscle lies underneath the gastrocnemius muscle.

Both muscles merge at the base of the calf, where they transition into becoming the Achilles tendon. The Achilles tendon then inserts into the calcaneus (heel bone). When you contract your calf muscles, the Achilles tendon pulls on your heel

In some children who toe walk, this muscle-tendon combination may be shorter at birth, or may shorten over time, which prevents the child from touching his or her heels to the ground and walking flat-footed. However, in most children who toe walk, the muscle-tendon combination is long enough that the child is able to walk with his or her heels down if reminded to do so.

Cause

In the vast majority of children, toe walking is “idiopathic,” which means that the exact cause is unknown. When these children are evaluated by a doctor, their physical exams and neurological tests are normal.

Medical Causes

In a smaller number of cases, persistent toe walking can be a sign of an underlying medical condition, such as:

• Cerebral palsy
• Muscular dystrophy
• A spinal cord abnormality

Although children with autism-related conditions toe walk more frequently than children who are developing normally, there is no direct link between the two conditions, and their toe walking may be sensory-related.

Symptoms

Most young children who walk on their toes are able to walk flat-footed when asked to do so. However, many older children who continue to toe walk (usually those over the age of 5) are not able to walk with their heels down. These children may complain about problems wearing shoes or participating in sports or recreational activities that involve wearing roller skates or ice skates Some children who toe walk have no specific complaints, but their parents are still concerned about the impact their walking pattern may have on their future function as teenagers and adults.

Doctor Examination

Your doctor will begin by asking a number of questions, including:

• Were there any pregnancy complications or was your child born prematurely?
• How old was your child when he or she reached developmental milestones such as smiling, sitting, and walking?
• When did the toe walking start? (For example, did it begin when your child started to walk independently or at an older age?)
• Is the toe walking on both sides or only on one side? (Toe walking on just one side may be morenconcerning to your doctor since it can sometimes indicate a neurological problem.)
• Is there a family history of toe walking?
• What percentage of time is spent walking on the toes?
• If asked, is your child able to walk flat-footed?
• Does your child complain of foot or leg pain, weakness in the legs, or difficulty keeping up with children the same age?

Physical Examination

The physical exam will typically begin with your doctor observing your child walk. In order to avoid the “doctor walk” (the patient does his or best to walk properly when the doctor is watching), this may be done even before your child realizes that he or she is being watched.

Your doctor will then ask to see your child’s typical walk (on the toes), followed by his or her “best” walk (walking as flat-footed as possible). In addition to observing the toe walking itself during this time, your doctor will also be evaluating the smoothness of the walk as part of a neurological evaluation.

During the physical exam, your doctor will also:

• Check your child’s feet for abnormalities, including differences between the left foot and right foot.
• Look for differences in leg length and in the size of the thighs and calves.
• Assess if one or both calf muscles are tight by asking your child to move his or her feet and ankles in a number of different ways.
• Check range of motion in the hips and knees.
• Look for any skin abnormalities in the lower extremities and lower back.

Tests

Neurological exam. Some simple neurological tests will help determine if abnormalities in your child’s nervous system could be contributing to toe walking. The exam will be tailored to your child’s age, developmental level, and ability to cooperate.

During the exam, your doctor will:

• Assess if there is any contracture or excessive tightness of the muscles in the arms or legs.
• Check the strength of the major muscles.
• Check your child’s reflexes by tapping a small rubber hammer or a fingertip on different points on
  the body.
• Test sensation, or feeling, in the arms and legs.

Other tests. Idiopathic toe walking is a diagnosis of exclusion, meaning that no other problems can be identified from your child’s medical history and physical exam. For this reason, specific tests—such as X-rays, CT and MRI scans, and nerve and muscle tests involving electrode patches or needles—are not usually ordered.

Treatment

Treatment for toe walking depends on a number of factors, including:

• The age of the child
• Whether the child is able to walk flat-footed

Nonsurgical Treatment

For children who are 2 to 5 years old and able to walk flat-footed, initial treatment is always nonsurgical.

Nonsurgical treatment may include:

• Observation. Your doctor may recommend simply monitoring your child with regular office visits for a period of time. If he or she is toe walking out of habit, it may stop on its own.
• Serial casting. Your doctor may apply a series of short leg walking casts to help progressively stretch and lengthen the muscles and tendons in the calf and break the toe-walking habit. Serial casting is usually performed over a period of several weeks.
• Bracing. Wearing an ankle-foot orthosis (AFO) can help stretch and lengthen muscles and tendons. An AFO is a plastic brace that extends up the back of the lower leg and holds the foot at a 90 degree angle. Typically, bracing is performed for a longer period of time than casting (months rather than weeks).
• Botox therapy. For certain patients—usually those with a neurologic abnormality that leads to increased muscle tone—an injection of botulinum A toxin (Botox®) may also be given to temporarily weaken the calf muscles. This will allow the muscles to stretch more easily during casting or bracing.

Surgical Treatment

In toe-walking children over the age of 5, the calf muscles and Achilles tendons may be so tight that walking flat-footed is not possible. For these patients, the doctor may recommend a surgical procedure to lengthen the Achilles tendons. Lengthening the tendons will improve range of motion and allow better function of the foot and ankle.

The specific part of the tendon that is lengthened depends on whether or not the patient’s foot can be positioned flat at the ankle with his or her knee bent. There are several techniques used to lengthen different areas of the tendon. Your doctor will talk with you about which technique is best for your child.

The procedure is usually done on an outpatient basis (no overnight stay). After the tendons are lengthened, while your child is still asleep, your doctor will place his or her legs in short leg walking casts. These are typically worn for 4 to 6 weeks.

Recovery

Physical therapy is usually recommended after both surgical and non-surgical treatment to help the patient learn to walk flat-footed more consistently. Physical therapy after surgery typically does not begin until the walking casts have been removed.

Outcome

Most patients improve over time and are able to participate in normal activities and sports. However, studies show that some children will continue to toe walk—even after serial casting or surgery.