Toe Walking

What is toe walking?

Toe walking is a pattern of walking in which your child walks on their toes and balls of their feet. Their heels don’t make contact with the ground.

In children under the age of 2, toe walking is common as they’re learning how to walk. It isn’t normally a cause for concern. Your child will usually begin to walk with a heel-to-toe pattern as they get older. No treatment is usually necessary.

If your child continues to walk on their tiptoes after the age of 2, it may be a sign of an underlying medical condition.

How common is toe walking?

Toe walking is fairly common. At the age of 5 and a half, 2% of typically developing children still toe walk. In children with developmental disorders or delays, 41% were toe walkers at the same age.

What are the symptoms of toe walking?

The main and most noticeable symptom of toe walking is your child walks on their toes and balls of their feet. When asked to walk in a regular, flat-footed pattern, most young children can do so. But if your child continues to walk on their toes, you may also notice:

• Decreased balance and coordination.
• Frequent falls.
• Problems wearing shoes.
• Difficulty participating in sports or other recreational activities.
• Complaints of pain.
• Difficulty heel walking (walking with their toes up in the air).
• Tightness in their heel cords.

Why do kids walk on their toes?

In most cases, persistent toe walking is an idiopathic condition. That means the cause is unknown.

A shortened Achilles tendon (equinus deformity) may cause toe walking. Your calf muscles merge at the base of your calf, where they turn into your Achilles tendon. Your Achilles tendon then joins your heel bone. When you use your calf muscles, your Achilles tendon pulls on your heel.

In some kids who toe walk, this muscle-tendon combination may have been shorter at birth. (This isn’t typical unless your child has a club foot or other congenital bone deformity.) It may also shorten over time. This can prevent your child from touching their heels to the ground and walking flat-footed, which is problematic and abnormal.

Some older children who toe walk may be doing it out of habit. They may also be doing it because the muscles and tendons in their calves have tightened over time. This makes it painful to walk in a heel-to-toe manner (normal gait mechanics).

In very rare cases, toe walking may be a sign of an underlying medical condition. These conditions may include:

• A brain disorder, such as cerebral palsy.
• A muscle or nerve disorder, such as muscular dystrophy.
• A spinal cord abnormality.
• Autism spectrum disorder (ASD).

Toe walking with autism

Toe walking happens more frequently in children with autism spectrum disorder than in children who don’t have ASD. One large study found that 9% of children on the spectrum were toe walkers. The same study found that less than 0.5% of children without an autism diagnosis were toe walkers.

The causes for this increased rate are unclear because there’s no direct link between autism and toe walking. It may be that tightened heel muscles restrict the range of movement in your child’s ankles.

Toe walking with autism may also be sensory-related. Many children with autism have a dysfunctional vestibular system. The vestibular system is responsible for providing your brain with feedback about motion, position and spatial orientation. It may be responsible for toe walking. Scientists need to do more research to understand how sensory processing may cause toe walking in children with autism.

Toe walking in adults

Some people walk on their toes into adulthood. They may have tried to correct their toe walking as a child but never outgrew it or treatment was ineffective.

Other times, walking on your toes as an adult begins for unknown reasons. Certain health conditions affecting your feet can sometimes cause toe walking. Corns, calluses and peripheral neuropathy may all cause toe walking.

How is toe walking diagnosed?

Your child’s healthcare provider will talk to you about your child’s medical history and perform a physical examination. As part of the exam, your child’s provider will observe how your child walks. They’ll look for any issues with your child’s feet or legs. They’ll also check for any limitations with your child’s range of motion.

Your child’s provider may perform neurological tests to see if your child has a problem with their nervous system. These tests may include:

• Checking your child’s reflexes.
• Measuring their ability to feel sensations in their arms or legs.
• Testing their muscle strength.

How do you stop toe walking?

Treatment to stop toe walking depends on various factors, including:

• Your child’s age.
• How severe your child’s toe walking is.
• The underlying cause of the condition.

Your child’s healthcare provider will likely recommend nonsurgical treatments first, including:

• Physical therapy: Your child may work with a physical therapist to help stretch their calf and foot muscles. This can help release tension and increase their range of motion. Traditional physical therapy may include serial casting. With this approach, your child wears a series of walking casts over several weeks to stretch and lengthen their calf muscles and tendons.
• Ankle-foot orthotics (leg braces): Your child may wear a plastic leg brace that keeps their foot at a 90-degree angle to stretch and lengthen their calf muscles and tendons while they walk throughout the day. This would be coordinated with a physical therapist and an orthotist (a healthcare provider that specializes in making splints and braces).
• Observation: Your child’s provider may recommend a “wait-and-see” approach to see if the condition improves on its own. They would use this approach for no more than six months.
• Botulinum A toxin (Botox®): Your child may receive Botox injections to weaken their calf muscles and make them easier to stretch.

If your child is older than 5, their healthcare provider may recommend surgery to loosen and lengthen their calf muscles and Achilles tendons. This surgery will help improve their range of motion and foot and ankle functioning.

Vestibular-sensory therapy may also help your child. During this therapy, your child may see an occupational or a physical therapist to stimulate their vestibular system.

Can toe walking be prevented?

Yes. However, you need to bring it to the attention of your child’s pediatrician so they can address the condition.

As your child grows, you can help reduce the likelihood of toe walking by stretching their Achilles tendons. You can also help by selecting footwear that fits and has good support.

What is the outlook (prognosis) for children who walk on their toes?

Your child’s outlook depends on the cause of their toe walking. In idiopathic toe walking, most children recover fully with treatment and learn to walk flat-footed. They’re typically able to participate in sports and other recreational activities. However, some children will continue to walk on their toes even after treatment or surgery. That’s why leg braces may be necessary and beneficial to prevent toe walking.

What complications are associated with toe walking?

Persistent toe walking may cause your child’s calf muscles and Achilles tendons to tighten even further. This can make it difficult or even impossible for your child to walk flat-footed. In addition, your child may have less range of motion in their feet and ankles or may have difficulty wearing shoes or footwear for certain sports, like ice skating. Other musculoskeletal problems and pain may arise as they grow into adulthood if they don’t manage their toe walking.

What questions should I ask my child’s healthcare provider about toe walking?

If your child continues to walk on their toes after the age of 2, you should ask their provider:

• What specialist should my child see to treat this?
• Will my child need casts or leg braces?
• What tests are necessary to rule out other medical conditions, such as cerebral palsy?
• Should I watch for signs of another condition, such as autism spectrum disorder?
• If this condition persists, what will the effect be on the rest of my child’s life?

A note from Cleveland Clinic

Toe walking is a common condition in younger children, especially as they learn to walk. Most children grow out of toe walking and eventually walk in a heel-to-toe pattern. Rarely, toe walking can be a sign of an underlying medical condition. If you’re concerned about your child’s toe walking, talk to their healthcare provider. They can determine if your child’s toe walking is an issue and find the correct treatment option.