Starfish Therapies

March 22, 2012

Toe Walking Revisited

I had written a post on toe walking a while back and since then I have learned some new things so I thought I would expand on what I had written.  I recently went to the APTA combined sections meeting in Chicago and took this great session on idiopathic toe walking (when the toe walking can’t be attributed to any other diagnosis or condition).  Here is some of what I learned:

  • Doctor’s often don’t refer soon enough because they think the kids will ‘grow out of it’
  • No where in the literature does it describe toe walking as ‘normal’
  • Usually heel strike (meaning the heel hits the ground first unlike toe walking where its the front of the foot or a flat foot) occurs at 22 weeks after independent walking and should definitely be there 50 weeks after independent toe walking
  • When we walk we have 3 ‘rockers’.  The first is when our foot hits the ground, the second is when our leg advances over our foot and the 3rd is when we push off.  Kids who are toe walkers almost never develop the 2nd rocker phase even if their heels drop down to the floor.
  • Often what looks like the kids coming down off their toes is that weight is helping them push their heels down onto the floor.
  • Without the second rocker phase they aren’t getting the normal loading of weight through the foot.  They can often develop a wide forefoot because they are putting more weight through that part of their foot.
  • They will usually over use their big toe extensors to clear their foot during walking because the muscle (anterior tibialis) that helps them to lift their whole foot doesn’t work as efficiently
  • As a result of toe walking these kids will usually have tight calves.  What’s interesting is that one study showed that if the kids got the range of motion back in their ankles, the timing of their ankle muscles improved and they were better able to use the muscles (anterior tibialis) that lifts their foot up
  • In addition kids who are toe walkers often have weakness of their hip extensors (butt muscles).
  • You will also see core weakness with these kids as well as trouble with standing on one leg and hopping on one foot.
  • Another thing you will notice with kids who are toe walkers is that they don’t play in squatting with their feet flat on the floor
  • Just because a kiddo can walk heel to toe when you are cuing them doesn’t mean that they have stopped toe walking.  We want them to do it automatically because how realistic is it for you to walk around telling them heel to toe every day, all day.

What does all this mean?  Well, if you have a kiddo that is a toe walker I would recommend having your doctor get you a referral for physical therapy sooner rather than later so that the PT can give you exercises to work on your child with so that they can develop a ‘normalized’ walking pattern which will help them as they continue to grow with running, walking, jumping, etc more efficiently.  For kids who are older (usually once they are older than 3) they will often have tighter muscles and may need some additional support to help them with their walking.  This can often look like serial casting to increase their ankle range of motion or a DAFO #9 for a night splint or using a hinged AFO (ankle foot orthosis), like the DAFO #2, that allows them to bend at the ankle but not to come up on their toes.

My biggest recommendation would be to get a consult with a pediatric physical therapist so you can find out if you should be concerned or not.  Usually its not a big deal but as with everything its a lot easier to change habits and motor patterns the earlier they are addressed.

I hope this was helpful!  If your PT has questions about what to do for idiopathic toe walking they can go to the clinical guidelines for toe walking developed by Cincinnati Children’s Hospital Medical Center on the National Guideline Clearinghouse.



  1. Very nice to know. I will keep an eye out for the walking pattern of my daughter.


    Comment by aaron — June 24, 2012 @ 2:59 pm | Reply

  2. Do you know if weak hip extensors would make it uncomfortable to sit on their bottom, I have a 3 1/2 year old who is a tiptoe walker and she will only maintain a ‘bottom sitting on a chair position” for a matter of seconds (maybe 10) before she changes to all sorts of other variations.
    (kneeling, one leg crossed, one leg hanging off) I have ped appt Monday for referral to p/t but am trying to have a bit more knowledge.

    Comment by Lara Campbell — July 28, 2012 @ 5:56 pm | Reply

    • Weak hip extensors shouldn’t cause that. Possibly weak core muscles or just that they don’t like to sit still, its hard to say without seeing them. They may just prefer mobility to stability. Is that the only position they have a hard time with?

      Comment by Starfish Therapies — July 28, 2012 @ 11:29 pm | Reply

  3. Who do you recommend for pediatric pt in chicago? My daughter is a chronic toe walker. She is almost three years old.

    Comment by jean — January 23, 2016 @ 3:58 pm | Reply

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