Understanding Idiopathic Toe Walking
Most children begin walking at about 12 to 15 months of age. As they learn to walk, they often try different foot positions, such as walking on tiptoes. By around 24 months, they should walk with their feet flat on the ground. By 3 years of age, children should walk with a heel-toe pattern.
Toe walking is a condition that occurs in childhood where only the ball of the foot rests on the ground while the child is walking. Toe-walking can vary from a mild condition which may be difficult to detect to a severe condition with obvious features.
Idiopathic toe walking is when a child continues to walk on their tip of toes above 3 years of age. It refers to the habit of tiptoe walking with no clear reason for it.
In nearly all cases, toe-walking is a habit that develops as a child learns to walk. It may also be a symptom of a more serious condition such as
Shortening of the tendon connecting the leg muscles to the heel bone (the Achilles tendon)
Brain, nerve or muscle disorders
Is it a problem?
For many children, toe-walking may only last for a short period of time with no long-term consequences. Walking on tip of toes generally does not cause the child any pain or discomfort and does not result in any type of deformity. Children are able to walk, run and jump on their toes without any problems.
However, it may lead to tightening of the calf muscle and shortening of the Achilles tendon which can lead to the child being unable to put their heel to the ground. Walking tiptoes for long can also put abnormal stress on the bones and ligaments in the knees, hips and lower back.
Over time, this can lead to a lot of biomechanical foot problems and risk for injuries and joint pain as they grow older.
How can you help your child?
Toe walking is common in children who begin walking and usually resolves by the age of 2 years.
For young toe-walking children without Achilles tendon contractures, watching and waiting is an option, though some benefit from physical therapy. For children with Achilles tendon contractures, a home exercise program may help stretch and strengthen the leg muscles to help encourage a heel-to-toe walking pattern.
A splint can also be used at night to keep the calf muscle flexible. A high cut shoe with wide rigid, stiff firm sole with or without orthotics can be helpful. Some shoes have flashing light in the heel to encourage heel strike.
When toe-walking is due to an underlying condition or when it does not respond to the above treatments and causes problems with function, a series of leg casts (serial casting) followed by bracing may be used to help stretch the leg and foot muscles. Rarely, surgery is necessary to lengthen the Achilles tendon or calf muscle.
A daily home exercise program can be helpful in stretching the calf muscles and strengthening the muscles on the front of the legs for children with idiopathic toe-walking. This will help your child to walk with a heel-to-toe pattern. This type of exercises will be dependent upon the child’s age.
Remember to have fun while doing these exercises and encourage them to use these muscles.
Stretches and strengthening exercises under 6 years of age:
Place your child on their back with the knee straight and leg supported on a comfortable surface.
Bend the ankle and bring the foot upwards towards the head. The stretch should not cause pain.
Hold the stretch for 15-30 seconds and bring the foot back to the normal position and repeat 10 times on each leg daily
Achilles tendon stretch
Place your child on their back with the knee bent and brings your child’s foot upwards towards the head bending the ankle. The stretch should not cause pain.
Hold the stretch for 15-30 seconds and bring the foot back to the normal position and repeat 10 times on each leg daily.
Sit to stand
Sit your child on a children’s sized chair or stool.
Place your hands below their knees and apply a constant downward pressure to help keep the heels on the floor.
Ask your child to practice standing up while keeping the heels on the floor.
Make this a fun exercise by playing a game to stand up to reach objects, high five etc.
Stretches and strengthening exercises 6 years and over:
Position your child approximately two feet from a wall or door. Place both of their hands at shoulder height against the wall.
Ask them to step towards the wall with their left foot while keeping their right knee straight. Make sure the heel of the right foot stays on the ground. They should lean into the wall until a stretch is felt on the back of the right calf.
Hold the stretch for 15-30 seconds then repeat the stretch 10 times on each leg daily.
Other exercises include marching on the spot, bring your knees up high and then back down with a flat foot, walking uphill, walking on uneven surfaces, walking on heels only and practicing squats.
Active Stretches and Strengthening:
Encourage the child to squat during play activities. It is important to help the child keep his or her heels on the floor in order to stretch the calf muscles. Sometimes performing activities on a low table will encourage squatting.
Squatting can also be encouraged by sitting on a small ball (playground ball, etc) while keeping both heels down on the ground. The child can practice standing up and sitting down on the ball while keeping his/her heels down.
Make strengthening your child’s ankles fun! Scooter races on a smooth surface are a great way to make your child stronger. Have the child sit on the scooter and use their heels to propel themselves forward.
Incorporating heel walking into your child’s day can be an excellent way to strengthen their ankles. Have the child walk, keeping their toes pointed in the air, and solely utilizing their heels. Some ways to make it part of the day include heel walking to dinner, heel walking during play time, heel walking to and from the car, etc.
Reward your child for walking with their heels down
Think of ways in which you can reward your child. You can include blowing bubbles, tickling or providing lollies. Tokens, which can be exchanged for a preferred item, can also be used.
Select a setting where there will be minimal disruption, where your child has plenty of opportunities to walk barefoot on a surface they are familiar with and where you are able to supervise them for about 10 minutes.
With your child standing, say “Heels down” and prompt your child by placing your hands on their shoulders and gently pushing downwards until their feet are flat on the ground. Reward your child and say “Good walking, heels down”.
Reward and praise your child frequently if they are walking appropriately. The time between rewards can be extended as your child is observed to walk appropriately for longer periods. These reward sessions should initially last for up to 10 minutes and then gradually increase to 20-30 minutes.
To help reinforce reward sessions aim to praise good behaviour as often as possible at other times. Gradually decrease how often you praise or reward your child so they are not motivated just by rewards.
If your child is observed to toe-walk, instruct your child by saying “No walking on toes - heels down.” If necessary, place your hands on their shoulders and gently push downwards until their feet are flat on the ground. As your child learns the instruction you can gradually reduce the amount of pressure on their shoulders.
Another approach is to make it a general rule around the house that everyone must walk properly and rewards are given out to those who do. Children who see their siblings get rewards for walking properly are often motivated to improve their own walking.