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What is toe walking?

Toe walking is defined as an observed absence or limit of heel contact with the ground during walking. Walking happens predominately on the balls of the feet with the ankle in a pointed position. It is more often seen in children, yet can progress into an adults walking gait if left untreated.

What does toe walking look like? 

Children who toe walk will walk predominantly on their toes and have a ‘bouncy’ gait. They will take twice as many steps and have a much shorter stride length. This makes their walking pattern quite inefficient as they need to compensate elsewhere in order to gain momentum whilst walking. It is often described as ‘controlled falling’ as the child may look like they are leaning forwards. 

Toe walking on force plate

When is toe walking expected to be seen?

Children under the age of 3 will commonly toe walk at some point in their early days of walking. It is thought that this happens for a variety of reasons. Reasons for toe walking are suggested because children are trying to make themselves taller, to reach higher objects, to keep up with siblings or to simulate play equipment like a jolly jumper. If there are no underlying conditions (eg cerebral palsy, muscular dystrophy etc), toe walking will resolve 3-6 months after it started and can be considered a normal part of their development. In these stages toe walking is considered idiopathic – which means there isn’t a real reason why it occurs.

When toe walking persists for children over the age of 3 years of age, the research suggests that treatment intervention should then happen. Further assessments and tests should be considered to treat the toe walking, and encourage a normal heel to toe gait. It is important the child is assessed by a professional to determine any alternative reasons for the toe walking, and to ensure the child is able to bend their ankle in order to get their heel on the ground. 

Cerebral palsy and muscular dystrophy are neurological conditions that are diagnosed at birth and will cause weakness, shortening and contractures of muscles particularly in the lower limb. These muscle changes will be the cause of toe walking in affected individuals and will generally be picked up quite early in addition to other noticeable milestone differences too.

Autism spectrum disorder and toe walking

There is no evidence to suggest that autism spectrum disorder (ASD) causes toe walking. However, there is a greater prevalence of toe walking in children with ASD compared to children without and more children with ASD who toe walk will require treatment compared to children who toe walk without ASD. Therefore, it is reasonable to assume that there is a strong correlation between the two and a contributing factor must exist. 

Sensory processing disorder 

Our sensory systems rapidly develop through childhood and allow us to make sense of our external environment in order for us to choose the correct movement pathway to suit our needs. This includes the 5 main senses that everyone is consciously aware of (feeling, hearing, tasting, seeing and smelling) as well as the hidden senses, vestibular and proprioception. These sensory pathways are responsible for our balance and letting our brain know where our limbs are in space so we don’t fall over. 

When these sensory pathways are disrupted, it is classified as a sensory processing disorder. The brain will not process or regulate the input of sensory information in a way that gives the child precise information about themselves and their environment. Everyday sensory information is misinterpreted and they can feel overwhelmed and want to avoid certain sensory inputs. Some children find sensory inputs uncomfortable and even painful. This leads to difficulty with tasks such as washing hair, sleeping, bath time, dinner and wearing shoes. 

The link between sensory processing disorders, ASD and toe walking 

The literature suggests that children who have a sensory processing disorder are inclined to toe walk to avoid the pressure of the ground against their heel and to better control their sensory input by increasing the pressure on their forefeet. As sensory processing disorders often exist with ASD, this is most likely the cause of toe walking in children with ASD. 

What are the long term consequences of toe walking?

If toe walking persists beyond 3 years of age and well into late childhood it can result in ramifications later in life such as shortened and tight muscles in the back of the legs. This can lead to an imbalance with the muscles on the front of the leg, making the individual extremely prone to injuries and pain in adulthood. 

Assessment and management 

If a child is toe walking beyond 3 years of age and there is no obvious reason as to why, they should see a professional (podiatrist, physio, GP) for an assessment. It is important that the cause of the toe walking is defined in the assessment, so the management can be tailored accordingly. Children with sensory concerns respond well to having a foam heel lift stuck down in their shoe to ‘bring the ground up to their foot’. Custom orthotics can be prescribed to encourage heel contact with the ground. The clinician will most likely prescribe calf stretches or exercises to lengthen the calf muscle to ensure it doesn’t become tight and shortened. 

biomechanical assessment ankle range

If your child has been toe walking for a while and you aren’t exactly sure why, book in with one of our podiatrists for an assessment. We would love to get to the bottom of it and help your little ones stay active and healthy!

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