Tippy Toes: The Deal with Toe-Walking

Toe-walking is exactly how it sounds, when a child primarily walks on the balls of their feet or on their toes, instead of using their whole foot. This is typical when a child is learning to walk independently. Children usually outgrow it before 3, as they develop a consistent stride and heel strike.

However, some children continue to toe-walk for no immediate reason at all. This is known as idiopathic toe-walking. This means that, though a child frequently walks and balances on their toes, they can still physically keep up with their peers, walk with straight knees, and can stand with their feet flat on the ground. Idiopathic toe-walking has been estimated to occur in 7% to 24% of the childhood population.

As long as your child does not have a medical diagnosis such as Cerebral Palsy, Muscular Dystrophy, or ASD (Autism Spectrum Disorder), a doctor may tell you that they may grow out of it, and most of the time they do. However, if they don’t, they may have a tactile or sensory issue and are most likely compensating through toe-walking.

In some cases, idiopathic toe-walking after the age of 3 is part of a deeper underlying issue. But for this blog, we will just be talking about the causes and treatments from an OT perspective.

Why is it an issue?

If a child is walking on their toes all the time, they may develop muscle stiffness/cramping in their calves.
Their Achilles’ tendon (the connective band that links the lower leg muscles to the heel bone) may shorten over time, preventing their heels from touching the floor.
Abnormal stress is also placed on the bones and ligaments, and can cause low back, hip, and/or knee pain as the child grows.
Coordination is also affected as the child is relying heavily on the small surface area of their toes to balance, rather than their whole foot.

What can cause toe-walking?

Although it is not truly clear what causes a child to walk on their toes, a few things may attribute to it:

Sensory issues – If a child has difficulties processing sensory information, walking on their toes may heighten their sensory input. Kids who experience low arousal levels throughout the day may stiffen their bodies so that they are in a constant state of extension. This is similar to when a person is hand writing and they press down really hard. The tension and pressure feel good and secure.

Another identifier is they may also try to maintain alertness by bouncing on their toes.

They may also be trying to limit the amount of contact to substances/textures on their feet by walking on their toes, like we discussed in last week’s post.

Primitive reflexes – Primitive reflexes are a series of involuntary movements a baby is born with to respond to their new environment. Although each reflex if short-lived, they later serve as fundamental training for voluntary motor skills.

One primitive reflex that is responsible for toe-walking is called Tonic Labyrinthine Reflex (TLR). This reflex helps the newborn gain muscle tone throughout the body. When a baby moves and stiffens, flexing and contracting all their muscles at once, that’s the TLR. When a toddler is throwing a temper tantrum and they do backbends out of your arms, that is the TLR.

If this reflex does not go away by the age of 3, the child will associate “comfortable posture” with a straight body and pointed toes.

They may have jerky and stiff movements, a fear of falling, and will attempt to grip the ground with their toes as a method of maintaining equilibrium.

What can I do to help my child?

Massage the legs and feet – After a warm bath, get the lotion out and gently massage the back of the legs and feet. Not only does this help relax the muscles, but the lotion adds a sensory component as well. If they don’t prefer lotion, that’s okay too.

Stretch it out – Stretching helps elongate and build muscle. Simple stretches for calf muscles like Downward Facing Dog or a seated toe touch are helpful. Make sure your child holds these stretches for 7-10 seconds. You can also incorporate arms, twisting movements, and standing toe touches to give them a “workout” and use up some of that excess energy.

We also like the books Good Night Yoga and Good Morning Yoga. These books walk your child through a short, fun yoga cycle that makes stretching easy and part of their routine.

Make it fun:

Have them walk like a duck where they are walking on only their heels.
Put a long, wide piece of painters tape on the floor as a “balance beam” or a “tight rope”.
Have them test their balance on a (safe) wobbly surface and see how long they can stand without falling. Too easy? See if they can balance on foot. Do this at the playground, not places where they could easily fall and get hurt.
When walking around the neighborhood, use a curb where your child can experiment with different ways of walking. Can they balance on the curb without falling? Can they walk side to side with only their heels on the curb? While you’re there, have them do a quick calf stretch or a heel-drop stretch.
Does your neighborhood have hills? Walk up the hill with your child. Not only will this passively stretch your child’s lower leg muscles, but it will also promote walking on heels.

If you feel there is a concern, always talk to your pediatrician. If there is an underlying issue, they will refer to other medical professionals like an Orthopedist, or other services such as Physical Therapy or Occupational Therapy.

Sources:
“Toe Walking in Children”, The Mayo Clinic. http://www.mayoclinic.org.
Toe Walking, Children’s Healthcare of Atlanta. Patient and Family Education.
“Toe Walking, Idiopathic”, SickKids Staff. AboutKidsHealth.ca
“Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness?”, Raoul Engelbert, Jan Willem Gorter, Cuno Uiterwaal, Elise van de Putte & Paul Helders (2011). BioMed Central.
Goddard, Sally. (2002). Reflexes, Learning, and Behavior: A Window into the Child’s Mind.
Delaney, Tara, MS, OTR/L. (2008). The Sensory Processing Disorder Answer Book: Practical Answers to the Top 250 Questions Parents Ask.