Toe Walking Tips

What is toe walking?

Toe walking is an atypical gait pattern in which a child makes initial contact at the balls of their feet when walking instead of their heel. Toe walking is something that both occupational and physical therapists treat! So how do you know if OT or PT is the right route for your child?

When is it OT?

Occupational therapists become concerned with toe walking when it is present after the age of 2 years old, observed more than 50% of the time, and/or when other sensory processing concerns are present (such as but not limited to: hand flapping, resistance to messy play or specific textures, difficulty tolerating gross motor play, use of excessive force, hesitant or timid when playing on playground equipment, etc.)

When is it PT?

It is normal for a child to walk on their toes periodically when they are first learning to walk, especially within the first 6 months of independent ambulation. Children like to experiment different ways their legs and feet can help them explore their environment. This includes side stepping, stomping, and YES, walking on toes! However, if toes walking persists more than 50% of the time after 6 months of independent ambulation AND your child is 2 years of age or greater, a physical therapy evaluation is warranted.

What will an occupational therapist assess during an evaluation?

Subjective: birth history, medical history, developmental history, previous therapeutic interventions, family history
Physical exam: ROM, tone, posture
Sensory assessment: use of a sensory questionnaire or Sensory Profile Assessment in order to look at sensory preferences that may contribute to toe walking, hands on assessment of tolerance for varying types of sensory input including but not limited to
- Vestibular input: some children walk on their toes to help them understand where their body and head is in space
- Proprioceptive input: some children will walk on their toes for prolonged muscle contraction as way to meet their proprioceptive needs and improve their understanding of where their body is in space
- Tactile input: some children will avoid allowing their entire foot to touch the ground due to a sensitivity to how the ground feels on the skin of the bottom of their feet
- Retained reflexes: a retained Babinski reflex may contribute to toe walking in regards to involuntary response of tactile and proprioceptive input to areas of the foot or other retained primitive reflexes such as ATNR, STNR, and Spinal Galant may contribute to impairments with core strength and stability that contribute to toe walking

What will a physical therapist assess during an evaluation?

Your child’s physical therapist will conduct a subjective exam, physical exam, gait assessment, and other gross motor skills assessment.

Subjective: Birth history, medical history, developmental history, balance concerns, onset of toe walking, family history of toe walking, previous therapeutic interventions
Physical exam: symmetry between left and right legs, pain assessment, neurologic testing, muscle tone and reflexes, ankle dorsiflexion (DF) active AND passive range of motion (ROM), muscle length assessments, standing posture, lower extremity and trunk/core strength, skin assessment
Gait assessment: length of time/frequency toe walking occurs, Observational Gait Scale (OGS), ability to correct gait and achieve heel flat with verbal cues
Other gross motor skills: squatting and return to stand, single-leg stance, balance on compliant surfaces, jumping, stair ambulation, lower extremity coordination, need for standardized testing

What are some OT treatment interventions for toe walking?

Proprioceptive input activities (heavy work): use of vibration, deep pressure, weight bearing, and compression in order to improve body awareness and promote appropriate muscle activation
Vestibular input activities: use of change in head position and movement to improve overall body awareness and activation of postural control system. With improvement in body awareness and postural control, then we can improve balance and motor deficits that accompany toe walking
Tactile input activities: walking over various textures to reduce any sensitivities to input to the bottom of the feet, participation in messy play with the whole body
Reflex integration: a daily exercise protocol and use of various play positions to promote reflex integration that may be contributing to toe walking

What are some PT treatment interventions for toe walking?

While each child’s treatment will be unique, there are several common interventions that have proven to be effective for the majority of children who walk on their toes. These include:

Active and passive stretching 
Squat to stand and sustained squatted play
Heel-walking and other anterior compartment strengthening activities
Challenging balancing activities 
Repeated jumping
Animal walks, such as crab walks, bear walks, and frog jumps
Foot intrinsic muscle strengthening

When might an OT consider a referral to PT for toe walking?

Decreased balance
Joint instability
Impaired range of motion, especially at the ankle joint
Poor postural control
Abnormal muscle tone
Gross motor skill delay
Additional gait differences and abnormalities (inward toe-ing, pain with walking, fatigue with walking)

When might a PT consider a referral to OT for toe walking?

Caregiver reports sensory aversions, especially on the child’s feet. This often sounds like:
- “They hate wearing shoes”
- “They will only walk on hardwood but refuse to walk on our shag carpet or in the grass when barefoot.” OR “They walk on their toes more when they’re on different walking surfaces.”

Caregiver reports sensory-seeking behaviors. This often sounds like:
- “They’re always purposefully running into walls or throwing themselves on the ground.”
- “They frequently ask me to squeeze them tightly.”
- “They are constantly moving, jumping, spinning, etc.”

What if physical and occupational therapy intervention isn’t working? Is there anything else we can do?

In most cases, yes! Every child is different in their journey, and treatment should reflect that. Depending on the root cause of their toe walking (i.e. how long they have been walking on toes, ankle range of motion, or medical conditions such as cerebral palsy or muscular dystrophy), your child might benefit from further interventions. Some of these interventions include:

Change in footwear/shoes
Serial casting
Orthotics 
- Ankle-foot Orthoses (AFOs) are the most common bracing type for ITW
- Supramalleolar Orthoses (SMOs) may be prescribed for the child with hypotonicity and/or overpronation

Imaging, such as X-ray, CT, or MRI
Botulinum Toxin A (BoNT-A) Injections (most often used for children with CP)
Achilles Tendon Lengthening (ATL) surgery, or other lengthening/recession surgeries

What if we do nothing? Does it really matter?

Tiptoe walking is sometimes harmless; however, if not addressed, toe walking can lead to a variety of future problems. These may include:

Foot or leg pain
Muscle contractures (muscle shortening that cannot be corrected without extensive intervention)
Poor muscle and joint alignment in foot, ankle, knee, hip, and spine
Difficulty maintaining balance
Other gross motor delays
Impaired core muscle strength and stability
Retained reflexes which can impact further gross and fine motor development

Ask your pediatrician for a referral for physical therapy if most or all the following apply:

Toe walking occurs >50% of gait following 6 months of independent ambulation
Toe walking persists after age 2
Your child’s leg muscles are tight, especially their calf muscles
Your child’s lower leg muscles are weak or low-tone, often observed as overpronation or “flat arches” when standing still
There appears to be a lack of lower leg muscle coordination, or has a “funny walk/run”
Your child complains of foot or leg pain that may be a result of walking on their toes
Your child is not meeting age-appropriate gross motor milestones/abilities
Your child demonstrates sensory seeking or sensory avoidant behaviors