Your four year old son walks on his tip toes. Not all the time, but a lot of the time. He will walk on flat feet when you ask him to, but before you know it he is running about on his toes again. It makes you nervous – is this normal? Will he just grow out of it? Will other children tease him? Is it going to cause problems down the track? Maybe it’s the result of the 17 mins he spent in a Jolly Jumper at a friend’s house when he was six months old, massive parenting fail. You googled it once, but by the third click you were fairly sure he had some terrible illness, and decided to file it in the back of your mind under "Things to keep me awake at 2am".
Toe walking is a really common presentation during the first few years of life. Persistent toe walking is a bit trickier to quantify, but studies suggest as many as 5% of 3-4 year olds and 2% of 5 year olds still persistently toe walk. Most children will spend some time walking on their toes during their first couple of years of life. It is a part of normal development and exploration of gait and balance, and usually integrates by the age of 2-2.5 as their walking pattern matures. So when is toe walking developmentally normal, and when is it a problem?
When should I check in with a health professional?
Over 3 years in age and walks on toes >20-25% of the time
Under 3 years in age but only walks on toes
You are concerned - always a valid reason!
Most cases of toe walking are not related to anything sinister or serious and fall under the diagnosis of Idiopathic Toe Walking (ITW). That means toe walking with no particular cause. However, toe walking is associated with a number of more serious diagnoses, and these need to be ruled out before settling on the more benign diagnosis of ITW. Conditions that are associated with toe walking include those which affect the nervous system, the musculoskeletal system and behavioural development. If your child persistently toe walks, they should be assessed by a Paediatrician or a Paediatric Physiotherapist who will look for any underlying causes. Signs that could warrant further testing include
Only affecting one foot
Toe walking 100% of the time
History of potential neurological injury
Neurological changes on assessment such as spasticity or clonus
Very significant shortening of the calf muscles
More global muscle weakness
Bladder and bowel changes
Delays in language and social skills
Idiopathic Toe Walking
ITWs are older than 3, walk on their toes more than 20% of the time, can walk on a flat foot if asked to and have both feet equally affected. About half the time there is a family history of toe walking. They may lack muscle control and stability, and often have postural and balance weaknesses. They may have difficulty modulating their pace and like to move quickly. Over time, their calf may get quite tight and their gait and posture may change, leading to longer term musculoskeletal changes. ITWs may have sensory processing difficulties when screened.
What does treatment for toe walking look like?
This will depend on
The age of your child
If they have lost any movement at the ankle
How much time they spend walking on their toes
If they have sensory difficulties identified on assessment.
Treatment can include
Serial casting to stretch the calf out
Splinting and orthotics
Sensory activities to improve sensory integration (may involve referral to an OT)
Posture and gait activities
Will toe walking go away on its own or do I need to see a health professional?
Persistent toe walking should be investigated to rule out any serious health issues. There is not enough evidence to clearly say whether all children with ITW need treatment. Some families opt for observation to see if it resolves on its own. We do know that if your child is walking on their toes most of the time for a long period, they will get secondary changes to their muscles, biomechanics and posture that may persist into later childhood. A good assessment by a paediatric physiotherapist will help to identify whether there are motor, sensory or biomechanical issues that should be addressed, or whether a little bit of time and a few targeted play ideas might be the most appropriate strategy for your child.