When is Toe Walking Normal?

Toe walking is often considered a normal developmental variant before the age of two years. This developmental toe walking usually resolves by two years of age.

Toe walking not associated with neurological or orthopedic abnormalities that persists beyond two years of age is called idiopathic toe walking (ITW).[1]Children over the age of two years who walk on toes may benefit from medical evaluation for diagnosis of potentially associated conditions and for discussion of treatment options. Some younger children may also warrant evaluation, especially if contractures, excessive tone, unequal tightness, or other medical conditions are present.

What Patterns of Toe Walking Occur?

Toe walkers manifest varying patterns, from children who stand, walk and run on their toes to children who walk and run or walk only on toes but do not stand on toes.[2]Toe walking can be constant or intermittent.

Does Toe Walking Resolve Over Time?

Idiopathic toe walking may improve with time in some children, but persists in others. A 2022 review of idiopathic toe walking (ITW) in children found only one prospective natural history study.[3]Of children with ITW without contractures, 59% resolved by age 5.5 and 79% by age 10 years.

In 2000, Eastwood and colleagues in Australia published the largest series of children with idiopathic toe walking at the time with 136 patients.[4]At an average of 3.2 years of follow-up, only 6% of patients who received no treatment reported achieving normal gait, 45% reported partial improvement, and 49% reported no change.

Toe walking may be less likely to improve spontaneously in children with neurologic or neurobehavioral conditions. Referencing data from 2005 to 20016 in a national insurance database, Leyden and colleagues at Stanford reported that 63.6% of children with autism spectrum disorder who did not undergo medical treatment continued to toe walk within ten years, compared to just 19.3% of children without autism.[5]

Why Does Toe Walking Occur?

Evaluating why a child walks on his or her toes is important to diagnosis and treatment. Some children with no related orthopedic or neurological conditions walk on their toes after age two out of habit or perhaps because toe walking feels normal to them.

This condition is called idiopathic toe walking (ITW). Idiopathic is a medical term meaning that doctors do not know precisely why it occurs. Idiopathic toe walking without contracture typically does not result from any structural abnormality in the lower leg, foot, or ankle, but rather arises from excessive stimulation of the gastrocnemius and soleus muscles by nerves transmitting signals from the brain and spine.

ITW is a diagnosis of exclusion, meaning that the diagnosis is confirmed only when other possible causes have been ruled out. Sometimes, idiopathic toe walking may run in families.

Some children may walk on toes because of a musculoskeletal, neurologic or neurobehavioral condition. “Motor planning challenges and sensory processing differences” have been cited as potential factors in idiopathic toe walking, although research findings have been inconsistent.[6],[7]Evaluation by a neurologist or neuropsychologist may be recommended if findings are present that may suggest an underlying condition, or if toe walking is not improving in an otherwise healthy child.

How Do Achilles Tendon Contractures Develop?

Contracture of the Achilles tendon can develop over time in some children when the ankle persists in plantar flexion. This may occur because of habitual toe walking or because of excessive tone in the gastrocnemius and soleus muscles due to a neurological condition.

Asymmetric ankle tightness with one side notably tighter than the other in the absence of a known orthopedic cause may raise concern for an underlying neurological condition.

How Does an Achilles Tendon Contracture Affect Toe Walking?

Children with Achilles tendon contractures who cannot reach a neutral position of dorsiflexion at the ankle are obligate toe walkers. This means that they cannot bring their heel down due to a mechanical block. For these children, treatment needs to address the contracture, whether through stretching or surgery.

While an Achilles tendon or ankle contracture may not be the only reason a child walks on toes, achieving 10-15 degrees of ankle dorsiflexion is necessary for a normal gait. This is because the body’s center of gravity passes over the ankle in the stance phase of gait and requires some ankle dorsiflexion to achieve a normal stride length.

[Insert diagram here]

Children with normal ankle range of motion who toe walk do so for some reason other than fixed contracture. This is referred to as dynamic toe walking because it occurs as a result of excessive muscle contraction.

Children with dynamic toe walking are able to stand flat-footed and are less likely to benefit from surgical tendon lengthening. Tendon lengthening is not a reliable solution for toe walking when the cause is not that the tendon is too tight, but that the muscle is being overstimulated.

Out-toeing can predispose to Achilles tendon tightness and toe walking for mechanical reasons which will be discussed in another article.

What Are Associated Neurological Conditions?

A study conducted by Haynes and colleagues in Dallas reported that 62% (108/174) of patients referred by orthopedic surgeons to neurology were diagnosed with an underlying neurological condition.[8] The diagnoses included:

• 37% (40/108) previously undiagnosed cerebral palsy (CP)

• 16.7% (18/108) peripheral neuropathy

• 15.7% (17/108) autism spectrum disorder

• 13.9% (15/108) hereditary spastic paraparesis

• 8.3% (9/108) attention deficit hyperactivity disorder

• 5.6% (6/108) syndromic diagnosis

• 2.8% (3/108) spinal cord abnormality

This does not mean that 62% of children who toe walk have a neurological diagnosis. Orthopedists typically refer patients to a neurologist only when they have clinical suspicion of a neurological condition, and so this group represents only a subset of toe-walking children.

Whereas Achilles tendon contractures can occur in children with both idiopathic and neurologic causes, one-sided toe walking or asymmetric tightness can raise concern for neurological etiology. Haynes reported that of children referred to a neurology clinic by an orthopedist, 71% of children who toe-walked on only one side and 32% with asymmetric toe walking were diagnosed with cerebral palsy.[9]

Cerebral Palsy

Toe walking is common among children with cerebral palsy, an injury to the brain that occurs at or near the time of birth. Blood vessels in the brain are fragile in infants, and especially in premature babies who have an increased risk for intraventricular hemorrhage (IVH) or stroke that can lead to cerebral palsy.

The nerves that control the lower leg muscles, including the ankle flexors, are particularly susceptible to injuries resulting from bleeding or ischemia (lack of circulation) to the infant brain. This is due to their location in the parietal lobe near the central sulcus and lateral ventricles of the brain. These are watershed areas, border regions of the brain with limited blood supply which are more vulnerable to decreases in circulation. Their location is shown on the cortical motor homunculus, which depicts the body parts controlled by different regions of the parietal lobe.

Cortical motor homunculus. Source: Wikimedia Commons.

Cerebral palsy is typically diagnosed by a neurologist. While certain findings on a brain MRI or CT scan may demonstrate evidence of cerebral palsy, normal imaging studies do not necessarily rule it out. This is because nerve injury or dysfunction can occur in the absence of major anatomic disruption. At times, gait analysis studies including EMG (electromyogram) and multisegment foot model may help to diagnose mild forms of cerebral palsy.[10]

What Are Associated Neuropsychological Conditions?
A neuropsychologist or neurobehavioral specialist can assess for autism spectrum disorder, Asperger syndrome, Attention Deficit-Hyperactivity Disorder (ADHD), and other conditions.

Leyden and colleagues at Stanford University found that of patients in a national insurance database from 2005 to 2016 with autism spectrum disorder, 8.4% (484/5,739) were diagnosed with toe-walking.[11] A study from Virginia Commonwealth University published in 2011 reported on walking children seen by a developmental pediatrician for initial evaluation (n=954). Among children with autism (n=324), 20.1% had persistent toe walking and 12% had a tight Achilles tendon. Among children with Asperger syndrome (n=30), 10% had persistent toe walking and 3% had Achilles tendon tightness.[12]

What are the Limitations of Medical Research on Toe Walking?

A systematic review of studies published between 1966 and 2013 of idiopathic toe walking in children between two and eighteen years of age found only one randomized controlled trial and eighteen observational studies.[13] In 2012, Dr. Frederick Dietz summed up the state of knowledge regarding idiopathic toe walking:

• “The natural history and optimal treatment for idiopathic toe walking are unknown. The literature is full of poorly documented treatment regimens with few even medium term follow up studies.”[14]

Some limitations of published medical research on idiopathic toe walking include the following:

• - Primarily retrospective studies with less robust levels of evidence (LOE) than prospective research;

• - Small numbers of patients;

• - Lack of range of motion measurements and other outcome measurements in some studies;

• - Different methodologies, and data points that make comparisons difficult; and

• - Inconsistencies of definitions and nomenclature.

Nomenclature and definition inconsistencies include the designation of patients with neurobehavioral conditions as idiopathic toe walkers in some literature. Toe walking associated with a neurobehavioral condition cannot be idiopathic, which means that no underlying diagnosis is known. The lumping of neurobehavioral toe walking with true idiopathic toe walking in some research studies confounds results and makes them difficult to interpret, as the two have been shown to have different natural histories and responses to treatment.

Subsequent studies have provided additional insights and clarification. Yet the quality of research findings for treatment of idiopathic toe walking remains very limited and controversies persist.

Treatment of Toe Walking

The nature and role of treatment in idiopathic toe walking is controversial. Some common treatments include observation, cueing, stretching, casting, bracing, and surgery. A pediatric orthopedist can evaluate your child, listen to your goals and expectations, and discuss options and recommendations.

Nonsurgical options include observation, cueing, stretching, serial casting, and bracing. Surgical treatment lengthens the Achilles tendon or gastrocnemius muscle.[15]

Observation

Some children may not require treatment for toe walking. If a child has normal or near-normal range of motion at the ankle and is not experiencing pain or limitations, monitoring the condition without intervention may be reasonable. Sometimes toe walking may improve in time, although it may also persist. The child’s functional status and the family’s desires and expectations are important in deciding whether to pursue active treatment.

Cueing

Cueing refers to the use of a word or phrase to remind a child without contractures who habitually toe walks to come down off the toes to a normal heel-toe gait. Some children are able to walk normally when reminded, but return to toe walking soon after. This may occur in any child, but is particularly common in children with ADHD, autism, or other neuro-behavioral conditions. These conditions may limit the ability to maintain focus.

Stretching Exercises

Stretching can be helpful to improve ankle range of motion to facilitate a heel-toe gait. Stretching exercises may be done as a home exercise program with or without the assistance of a physical therapist. Exercises can be helpful in stretching the Achilles tendon.

[Insert diagram here]

An incline or slant board can also be helpful. Several inexpensive commercial slant boards are available, or one may be made from material in the home.

Stretching exercises are most helpful for toe-walking children with mild Achilles tendon tightness. Published medical studies have shown little success in correcting large Achilles tendon contractures in toe-walking children with exercises alone.

Casting with or without Botox

Stretching casts have sometimes been used to stretch mild to moderate contractures. The protocol typically involves gentle stretching of the Achilles tendon with cast changes at one to two week intervals. Casting may continue for four to six weeks, depending on the contracture severity and rate of progress.

Caution is required with stretching casts. As stretching casts rely on the cast to achieve and hold a position beyond the child’s normal range of motion, there is an increased risk of pressure sores. This especially the case in children with neurological or neuro behavioral conditions who may have altered sensation, and/or diminished ability to perceive and express pain.

The medical literature has shown little evidence of sustained efficacy from casting for toe walking. A systematic review of toe walking studies by van Kuijk and colleagues cited evidence of some improvement in gait with serial casting, but noted that “normalization does not occur” and that casting did not lead to sustained improvement beyond one year.[16]The Australian study by Eastwood and colleagues found that casting had similar outcomes to no treatment.[17] They reported that “cast treatment did not alter the natural history.” A 2012 literature review of ten studies by van Bemmel and colleagues reported a minimal 3.1° improvement in ankle dorsiflexion with casting three years after treatment, but without evidence of functional difference.[18]

The use of Botox (Botulinum toxin A) injections as an adjunct to stretching casts is controversial. The literature review study by van Kuijk found no benefit to Botox with casting. A randomized study of 47 children with idiopathic toe walking conducted in Sweden by Engström and colleagues also found no benefit to augmenting cast treatment with Botulinum toxin A (Botox).[19] An Italian clinic treated 22 children with toe walking and autism spectrum disorder with Botox and casting and reported short-term improvement.[20]However, there was no long-term follow-up and no control group of casting without Botox.

Because the lack of evidence of benefit for casting, and because of the risk of pain and pressure sores and the need for multiple casting sessions, minimally invasive techniques for lengthening the Achilles or gastrocnemius tendon may offer improved risk-benefit profiles for some patients with contractures.

Bracing

Bracing with an ankle foot orthosis (AFO) or similar orthotic has been shown to reduce toe walking when children are in the brace. However, patient numbers have been small and follow-up limited. Some studies have reported that children tend to revert to toe walking when bracing is discontinued.[21]

Optimally, a brace should prevent or discourage excess plantarflexion at the ankle while still allowing ankle dorsiflexion to strengthen the respective muscles.

Bracing can only be used for toe walking when the ankle is able to reach neutral or near-neutral dorsiflexion. This is because a brace placed on a contracted ankle Is an accommodative brace, which merely holds the ankle in its contracted position, rather than achieving heel strike. Occasionally, a small heel wedge may be placed if there is a minor contracture of only a few degrees. However, patients with larger contractures are usually not candidates for bracing and are more likely to benefit from surgery to achieve a plantigrade ankle.

Daytime bracing in children with mild to moderate Achilles tendon tightness can improve gait while worn and help keep the ankle stretched out. The role for a nighttime stretching brace in toe walking is unclear. Daytime braces help children when they are actually walking, and because most children need a break from bracing at night.

In some cases, bracing may be helpful after surgery, especially the case when the ankle dorsiflexors are weak or when ankle contracture coexists with habitual toe walking.

A study reporting on 204 children between age 4 and 7 years at diagnosis of idiopathic toe walking treated between 2008 and 2015.[22]The authors report that only 59.3% of children (121/204) attended at least one follow-up visit and that among those who followed-up, just 45.5% had a successful outcome with improved gait. Among various treatment modalities, only bracing with AFOs (ankle-foot orthosis) was statistically associated with improved short-term outcome with unadjusted and adjusted odds ratio of 3.97 and 4.81, respectively.

One study reported meaningful improvement with a circular subtalar blocking orthosis in two-thirds of patients, although the study was retrospective with only twenty-two patients and follow-up was limited to two years.[23]

Surgery

Surgical lengthening of the gastrocnemius or Achilles tendon can result in improved ankle dorsiflexion, although this does not always correlate with resolution of toe walking.[24]

The systematic review by van Kuijk noted improved gait with surgery which was sustained beyond one year, but not full normalization.[25] A systematic review by Van Bemmel and colleagues reported a 14.2° improvement in ankle dorsiflexion three years after surgery, but cautioned that they were unable to draw definitive conclusions regarding functional improvement due to methodological limitations of published studies.[26]

Some of the medical research is confounded by a lack of clear differentiation between children with contractures of the Achilles tendon and those without. In the Australian study by Eastwood, among patients who underwent Achilles lengthening for toe walking, 22% reported normal gait, 50% reported partial improvement, 26% reported no change, and 2% reported worsening.[27]Surgery had very limited benefit, with only 16% more patients (approximately one in six) in the surgical group reporting normal gait compared to those without. No pre- and post-operative range of motion figures were reported in their study. The limited benefit may relate to patient selection issues including operating patients without significant contractures.

Surgery can benefit selected patients with toe walking due to ankle contractures, but has been shown to have little if any benefit for idiopathic toe walking without contracture.

Disclaimer

This material is presented for educational purposes only and does not constitute medical advice. Every patient’s condition is different. Providers vary in their preferences and experience. Resources and availability may vary by region. Medical knowledge is constantly being updated with new research which may not be reflected here. We recommend consulting with a board-certified orthopedic surgeon for specific recommendations for your child.