Toe Walking in Children

Toe walking is when your child continues to walk on their tiptoes beyond age 3. It does not cause them pain, but walking on the balls of their feet can sometimes be related to certain conditions.

At Banner Children’s, our caring team can help. Learn how toe walking may affect your child, symptoms to watch for and available treatment options.

What is toe walking?

Toe walking is a gait pattern where your child walks on their toes or balls of their feet without their heels touching the ground. They will often stand with their feet flat on the ground but will walk or run on their toes.

Toe walking can be temporary or ongoing and may happen in one or both feet.

Walking on tiptoes is relatively common in toddlers as they get their balance. However, they usually begin to walk in a normal heel-to-toe pattern within a few months of learning to walk.

Children who continue to walk on their toes past their toddler years often do it out of habit. However, sometimes it can be related to certain conditions.

Why do children walk on their toes?

In most cases, toe walking in children is idiopathic, meaning there is no known cause. Your child simply may get used to tiptoe walking.

In a small number of cases, however, toe walking can be a sign of other medical conditions, such as:

• Short Achilles tendon (equinus deformity) or calf muscles: The tendon and lower leg muscles connect to the back of the heel bone. When one or both are short, it may be hard for your child to put their heels on the ground or walk flat-footed.
• Autism spectrum disorder (ASD): In autistic children, the vestibular system (which helps control balance and body position) is underdeveloped or not working correctly. Children with autism may also have low muscle tone and use toe walking to feel stable when moving. Toe walking may also be sensory-related.
• Cerebral palsy (CP): Children with this disorder usually have tight and wound-up muscles.
• Duchenne muscular dystrophy (DMD): Children with muscular dystrophy walk heel-to-toe when they first walk. However, toe walking is usually seen as the disease develops.

What are the symptoms of toe walking?

Most young children who toe walk will have a pattern of walking where their heels do not touch the ground. They will remain on their toes for each step. However, they can walk on their heels when asked to do so.

Toe walking symptoms may also include:

• Difficulty or discomfort when trying to walk with flat feet
• Tight or stiff calf muscles
• Balance or coordination difficulties
• A noticeable difference in how your child moves, compared to their friends
• Delayed motor skills development (walking, running or jumping) or sensory processing difficulties (being easily overwhelmed by noise, light, itchy fabrics, strong smells or tastes)

Is toe walking bad?

Toe walking usually does not cause any pain or discomfort. If toe walking continues, however, it can cause foot and ankle issues.

The ankle joint can become stiff and the calf muscle and Achilles tendon (heel cord) can shorten. As a result, your child may have balance and falling issues.

This toe pattern can also cause the ball of the foot (forefoot) to widen due to extra weight on that part of the foot, and the heel bone may become smaller or narrower.

Early diagnosis and treatment are important to lower the chance of these problems.

How is toe walking diagnosed?

Your child’s health care provider will ask about your child's medical history, including developmental milestones and any family history of toe walking or related conditions.

Your provider will look at your child’s legs, feet and muscle tone.  Your child will be asked to walk while the provider watches for any issues. They’ll also check your child’s range of motion in their joints.

If your provider suspects a condition such as autism or cerebral palsy, they may perform some neurological tests. These tests will check your child's nervous system, reflexes and muscle strength.

Usually, imaging tests like X-rays are not necessary to diagnose toe walking, unless there are clear signs of issues in the muscles or joints.

How do you treat toe walking?

Treatment will depend on what is causing your child’s toe walking. For children between ages 2 to 5, treatment always starts with nonsurgical methods and may include:

• Observation: If your child is toe walking out of habit, treatment isn’t needed. They will likely outgrow the habit. Your provider will check their gait at their yearly checkup.
• Physical therapy: Exercises prescribed by a physical therapist can help stretch and strengthen the calf, hamstring and trunk muscles. Your therapist may also work with your child to walk slowly with their heels down or feet flat.
• A splint or leg brace: An ankle-foot orthotic can help stretch and lengthen muscles and tendons.
• Serial casting: Your child may wear a series of short leg walking casts to slowly strengthen and lengthen muscles and tendons in the calf and break the toe walking habit.
• Injections: An injection of Botox (botulinum toxin) may be given to help relax the calf muscles. This may be used with casts or braces to let the muscles stretch more easily.

Surgical treatment

Most children will not need surgery. However, if nonsurgical treatments do not work, your child’s provider may recommend surgery to lengthen the muscles or tendons at the back of the lower leg. This procedure is usually done on an outpatient basis.

Importance of early diagnosis and treatment

Early diagnosis is important for toe walking as it helps your child’s health care provider identify and treat any related health concerns for your child, as well as correcting walking and balance problems as your child grows.

What is the long-term outlook for children who walk on their toes?

Toe walking can affect a child's balance and coordination. If left unaddressed, toe walking may lead to physical limitations when your child runs, jumps, or participates in sports. However, early intervention and treatment can help improve these areas, allowing your child to move freely and with ease.

Your child’s outlook depends on the cause of their toe walking. When a cause is identified, treatment can allow most children to walk, run and play flat-footed.

How we care for toe walking at Banner Children’s

Contact Banner Children's if you have concerns about your child’s walking pattern. Our team of specialists offer complete care to cover all of your needs. We explain all treatment options to help you choose what’s best for your child.