Toe walking in toddlers is often seen as part of their learning process and, at times, even considered charming. Who doesn’t love a toddler ballerina on their tiptoes? It’s estimated that up to 5% of toddlers walk on their tippy toes, with some studies reporting rates as high as 24%. But as pediatricians, it’s our job to determine when toe walking is part of typical development and when it requires further investigation.
For most young children with normal ankle range of motion, toe walking resolves on its own. But “most” isn’t always good enough – before diagnosing idiopathic toe walking (which is typically benign), it’s essential to rule out any underlying etiology that may be causing the gait abnormality.
What Is Toe Walking?
Technically and medically speaking, toe walking is defined as when a child’s first foot contact with the ground is their forefoot, rather than the normal heel strike.
When to Worry: Three Types of Toe Walking That Need Further Evaluation
- Persistent toe walking (beyond the age of 3.)
- Unilateral toe walking.
- Toe walking with a rigid ankle range of motion, often caused by an Achilles tendon contracture.
Historical Red Flags to Consider
- When did the child start walking?
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- Delayed walking may be a sign of other underlying developmental delays.
- Has toe walking been present since they started walking?
- New onset or progressive toe walking is more concerning for underlying pathology.
Key Physical Exam Pearls
A comprehensive physical exam should include the foot, spine, general gait, range of motio,n and neurologic exam.
- Remember to utilize all parts of the clinic! Have the child walk down the hallway several times, focusing on different aspects of their gait with each pass. Is there ataxia? Is there a Trendelenburg gait? Is there arm posturing while walking/running? This may be a sign of cerebral palsy. Is there a positive Gower sign? This, along with any calf hypertrophy, may be a sign of muscular dystrophy.
- Assess the feet in the standing and seated positions. When seated, watch for cavus (high arch), which might indicate peripheral neuropathy.
- Range of motion is incredibly important as it relates to the popliteal angle of the knee (assesses for hamstring tightness) and the dorsiflexion of the ankle (watch when the knee is extended and flexed for the most accurate range of motion assessment).
- Gauge the child’s ability to walk in a heel-to-toe manner. This confirms whether they have normal motor control or if a plantar flexion contracture is preventing heel contact.
Common Causes of Toe Walking
- Developmental/idiopathic
- Autism: Many children with autism have sensory sensitivities and simply do not like the feeling of their hind foot on the floor
- Neuromuscular disease
- Tight Achilles tendon
Work Up and Management
Treatment depends on the underlying cause and the child’s ankle range of motion. If concerning signs are present (high arch, unilateral toe walking, developmental delays, etc.), referrals to specialists such as neurologists, geneticists, orthopedists, or physical therapists may be necessary. But, as with so many things in pediatrics, shared decision-making with the family is important. What are the family's goals and expectations for management and treatment?
Management Considerations Based on Range of Motion
- Observation and Reassurance: If the child is younger than 3-5 years and has a full range of motion, reassurance is typically sufficient.
- Physical Therapy: If the child is older than 5 and still toe walking with normal range of motion, physical therapy, home stretches, or braces may be recommended. Physical therapy strengthens muscles and improves gait mechanics, while braces (worn above the ankle) can limit plantar flexion.
- Serial Casting: Reserved for children with less than 10 degrees of ankle range of motion, often managed by orthopedics or physical therapy.
- Surgical Intervention: Considered for patients with more than 10 degrees of contracture.
- Botox: Sometimes used to reduce spasticity in children where muscle tightness drives toe walking.
By combining careful evaluation, shared decision-making with families, and appropriate interventions, we can ensure that each child receives the care they need, whether they’re outgrowing toe walking or need more targeted treatment.