Idiopathic toe walking is when your child continues to walk on their tiptoes beyond five years of age. Learn stretches and strengthening exercises, and about proper shoes to help your child.
Key points
Toe walking is when a child lacks a heel strike during walking. Initially, it is a common variation of normal gait development in children under eight years of age.
Idiopathic toe walking is diagnosed when a child has persistent toe walking beyond five years of age and all other underlying medical conditions (i.e., sensory disorder, neurological, musculoskeletal or other conditions) have been ruled out.
Idiopathic toe walking can lead to tight calf muscles and decreased movement of the ankles.
Treatment for children younger than six years of age includes calf stretches, Achilles tendon stretches and sit-to-stand exercises.
Treatment for children six years of age and older includes calf stretches and other exercises, including marching on the spot, walking uphill and on uneven surfaces, heel walking and squats.
Introduction
Most children begin walking at 12 to 14 months with their feet flat on the ground. However, there are some children who begin walking on their tiptoes instead. This pattern normally disappears within three to six months of learning how to walk. It almost always is completely gone by age five. About 80% of toe-walkers resolve without treatment by age 10.
Idiopathic toe walking is when a child continues to walk on their tiptoes beyond five years of age. They will often stand with their feet flat on the ground, but when walking or running will prefer to be on their toes. If your child does not outgrow tiptoe walking by age five, take them to see their health-care provider.
Signs and symptoms
Features of idiopathic toe walking
Although we do not really know why some children prefer to walk on their toes, we do know that idiopathic toe walkers:
walk on tiptoes on both sides
are constantly balancing on their toes
are physically able to keep up with other children their age
walk with straight knees
will often be able to stand with their feet flat on the ground
often have a family history of toe walking
Treatment
Help your child with a home exercise program
If your child has idiopathic toe walking, a daily home exercise program can be very helpful. The goal is to stretch the calf muscles and strengthen the muscles on the front of the legs. This will help your child to be able to successfully walk with a heel-to-toe pattern.
If your child's calf muscles are tight, or ankle motion is limited, you will be shown stretches to do at home with them. These stretches should be followed with activities to help them use their muscles in their new lengthened position.
These exercises will be necessary and beneficial if your child demonstrates a tiptoe walking pattern. The exercises will vary with their age. The most important part of the exercise program is to remember to have fun with your child!
Stretches and strengthening exercises for children under six years of age
Calf stretch
Have your child lie on their back on a comfortable surface such as a firm bed.
With their knee straight and leg supported on the bed, bring your child's foot upwards, toward their head, bending their ankle.
Hold the stretch at the end of the movement (that is, as far as your child's range of motion will permit) for 15 to 30 seconds. This should not be painful for your child.
Bring your child's foot back to a normal position. Repeat the exercise 10 times on each leg, daily.
Achilles tendon stretch
Have your child lie on their back on a comfortable surface such as a firm bed.
With their knee bent, bring your child's foot upwards, toward their head, bending their ankle.
Hold the stretch at the end of the movement (that is, as far as your child's range of motion will permit) for 15 to 30 seconds. This should not be painful for your child.
Bring your child's foot back to a normal position. Repeat the exercise 10 times on each leg, daily.
Sit to stand
Have your child sit on a children's sized chair or stool.
Place your hands below their knees, providing a moderate, constant pressure downwards as a cue to keep their heels on the floor.
Have your child practice standing up while keeping their heels on the ground.
Make this exercise fun by playing a game of high five, blowing bubbles, reaching for objects, working in front of a mirror or singing songs.
Exercises suitable for children ages six years and up:
Calf Stretch
Have your child stand approximately two feet from a wall. Place both of their hands at shoulder height against the wall.
With their right knee straight, have them step towards the wall with the left foot. They should lean in until a stretch is felt in the back of the right calf. Make sure they keep the heel of the right foot on the ground.
Hold the stretch for 15 to 30 seconds.
Repeat the exercise 10 times on each leg, daily.
Other exercises include:
Squats
Marching on the spot. Have your child bring their knees up high and then land with a flat foot.
Walking uphill.
Walking on uneven surfaces such as in a playground or sand.
Walking on the heels only. Always keep the toes off the ground.
Practicing squats. With feet flat on the floor, hip width apart, have your child slowly lower their body all the way to the floor by bending at their knees and hips but keeping their chest upright.
Complications
Identify toe walking early to prevent muscle problems
Children who walk on their toes can develop tight calf muscles on the backs of their legs and have decreased movement of their ankles. In addition, the muscles on the front of their legs may become weak. If there is tightness and weakness, your child will have difficulty walking on their heels. Early identification of toe walking can help lead to the prevention of these muscle problems.
Helping your child
Shoes for your child
Wearing shoes may not correct toe walking. However, appropriate footwear can help your child bring their heels further down. When selecting shoes for your child, keep in mind the following criteria:
Choose a high cut shoe with a wide sole that provides good foot support.
The shoe should be rigid or firm, not flexible in the middle section.
The back of the heel should be firm.
Other treatments
Idiopathic toe walking in children is not a serious condition. It often resolves spontaneously and does not cause the child significant problems apart from the cosmetic appearance. Normally, your child will not need surgery. In addition to stretching and strengthening, treatments may include repeated casting of feet and ankles, bracing devices (ankle foot orthoses [AFO]), or a combination of the two. These are typically started around four to six years of age if idiopathic toe walking has not resolved. It is important to understand that even though your child may achieve short-term improvement in muscle length and ankle range of motion, these treatments may not always guarantee a normal heel-to-toe walking pattern.
When to seek medical attention
When to see a health-care provider
If your child does not outgrow tiptoe walking by age five, take them to see a health-care provider. Their health-care provider can complete a neurological and musculoskeletal exam to assess range of motion and muscle length and rule out other medical issues.
References
Reference
Engstrom, P., & Tedroff, K. (2018). Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age. The journal of bone and joint surgery. American volume. 100(8), 640-647. https://doi.org/10.2106/JBJS.17.00851
