What can cause toe walking, either unilateral or bilateral, and what can a physical therapist do to help the child?
When a child has a tight heel cord, this makes it difficult for him to bring his foot into a neutral or flat position. As a result the foot favors a pointed position and “toe-walking” develops.(3) The development of a tight heel cord can occur due to improper positioning, ineffective motor control or an inherent problem with the muscles and tendons of the foot and ankle.
Children who learn to walk in a walker or spend a lot of time in an exersaucer maintained at the incorrect height tend to develop a pointed toe position so that their feet can touch the ground. This positioning causes the foot and ankle to develop in such a way that lends itself to toe-walking. Besides the risk of injury, this is one of the reasons why walkers are not recommended for children.
There are some children that normally walk on their toes. (4) When this occurs interventions such as wearing high top shoes or work boots, performing ankle stretching exercises and physical therapy are recommended to help remedy the situation. These measures are recommended in order to stretch the tight heel cord, restore normal foot position and prevent contractures.(2)
Children with toe-walking need to be evaluated and monitored by a Doctor or Nurse Practitioner at regular intervals. Repeat evaluations should be performed in order to determine the child’s progress and to monitor the child’s development. Doctors and Nurse Practitioners become concerned with toe-walking because in some cases it may be a sign of a more serious condition.
Persistent and consistent toe-walking after a child has started to walk independently may be a sign of a musculoskeletal disorder such as Spastic Cerebral Palsy or Muscular Dystrophy.(1,4) Muscular Dystrophy is a degenerative disorder of the skeletal muscles. Children with Muscular Dystrophy tend to walk like a duck, experience clumsiness, sway from side to side when walking, have a waddling gait, have persistent toe-walking, can only walk fast and are unable to run. They have difficulty going up steps and have problems going up a sidewalk curb. (1). Cerebral Palsy is a non-progressive disorder of motion and posture. Children with Cerebral Palsy experience persistent toe-walking, rigidity of the extremities, difficulty in making purposeful movements and movements which are abrupt, jerky, uncontrolled and uncoordinated. (3) Toe-walking can also be due to a congenital shortening of the Achilles tendon and may be a sign of Autism. (4).
It is important to remember that just because a child develops one symptom of a serious condition does not mean that the child has that condition. Medical conditions such as Cerebral Palsy, Muscular Dystrophy and Autism encompass a cluster of many different problems, not just one isolated symptom. It is common for a parent to fear the worst when they see that their child has a symptom that is commonly found in a serious condition or syndrome. Good communication with your child’s Doctor or Nurse Practitioner can keep you abreast of your child’s progress, clarify any misunderstandings and alleviate your fears.
From my experience, most cases of toe-walking ended up being normal behavior due to positioning and not related to any underlying condition. Once identified, most children require the institution of stretching exercises, proper footwear and in some cases physical therapy in order to help them walk flat on their feet. I found that that the symptoms resolved in time with no residual effects in the the majority of the children who were compliant with therapy.
In order to prevent your child from learning to walk on their toes, make sure the height of the exersaucer is low enough so your baby’s feet are positioned flat on the ground, do not put your child in a walker and make sure your child wears shoes for walking. High top shoes or work boots prevent the child’s foot from pointing and keeps a child from toe-walking. If you notice that your child begins to toe-walk bring it to your Doctor’s attention so that the proper interventions can be initiated early.
(1)Ashraf A, El-Bohy D, Wong B. The Diagnosis of Muscular Dystrophy. Pediatric Annals. 2005. 34(7):525-530.
(2)Mandigo C, Anderson R. Management of Childhood spasticity: A Neurosurgical Perspective. Pediatric Annals. 2006. 35(5):354-362.
(3) Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis Missouri: Mosby –Yearbook, Inc. 1992:148-152.
(4) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:861.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice For Healthy Children