Toe walking

It is common for children to walk intermittently on their tip toes when they are learning to walk. Idiopathic toe walking (ITW) is an exclusionary diagnosis given to healthy children who persistently walk on their toes after they should typically have achieved a heel‐toe gait.

Common causes:

• Toe-walking is usually idiopathic and resolves with age. It may simply be a preference and/or a habit. Suspended walkers and door bouncers should be discouraged as they exacerbate the problem.
• Children may have tight, shortened calf muscles and limited ankle dorsiflexion
• Toe-walking may be seen in children with neurodevelopmental conditions, such as autism spectrum disorders and is related to sensory differences these children have.
• Toe walking may be due to an underlying neurological or neuromuscular impairment (e.g. cerebral palsy or muscular dystrophy)

Action: Key assessment points

• Observe gait pattern and ensure symmetrical
• Function checks:
  • can the child stand with their heels down and trunk straight
  • can they squat keeping their heels down
  • can they walk on their heels
• Check ankle dorsiflexion and calf muscle length and size
• Check for abnormal neurology in both the upper and lower limbs, including Gowers Sign and muscle tone/clonus.

Action: Referral not indicated

• Child is under 3 years of age (with no neurological signs and no muscle tightness)
• Educate/reassure parent/guardian, it is likely to resolve with age
• Give appropriate leaflet: Toe walking in children

Action: Refer to Paediatric Physiotherapy

• Reduced ankle dorsiflexion with calf muscle tightness
• If associated with pain
• If there are associated functional difficulties

Action: Refer to Paediatric Orthopaedics

• Not improved with physiotherapy input (stretches/serial casting etc.)
• Unilateral toe-walking, with no abnormal neurology
• Inability to dorsiflex foot beyond neutral or stand with heels down despite conservate intervention

Action: Refer to Community Paediatrician/Neurologist

• Abnormal neurology
• Signs of cerebral palsy e.g. asymmetry, increased ton/clonus
• Signs of muscular dystrophy: calf hypertrophy, positive Gowers and/or regression of milestones.