Walking on the toes or the balls of the feet, also known as toe walking, is fairly common in children who are just beginning to walk. Most children will outgrow it. Children who continue toe-walking beyond the toddler years often do so out of habit. As long as your child is growing and developing normally, toe walking is unlikely to be a cause for major concern. Toe walking sometimes can result from certain conditions, including cerebral palsy, muscular dystrophy and autism spectrum disorder.
Toe walking is walking on the toes or the ball of the foot without the heels touching the ground.
Most young children who walk on their toes are able to walk flat-footed when asked to do so. However, many older children who continue to toe walk (usually those over the age of five) are not able to walk with their heels down. These children may complain about problems wearing shoes or participating in sports or recreational activities that involve wearing roller skates.
Some children who toe walk have no specific complaints, but their parents are concerned about the impact their walking pattern may have on their future function as teenagers and adults.
If your child is still toe walking after age two, talk to your doctor about it. Make an appointment sooner if your child also has tight leg muscles, stiffness in the Achilles tendon or a lack of muscle coordination.
Typically, toe walking is a habit that some children develop when they learn to walk. In a few cases, toe walking is caused by an underlying condition, such as a short Achilles tendon, cerebral palsy, muscular dystrophy or autism.
Achilles tendon: This tendon links the lower leg muscles to the back of the heel bone. If it’s too short, it can prevent the heel from touching the ground.
Cerebral palsy: Toe walking can be caused by a disorder of movement, muscle tone or posture caused by injury or abnormal development in the parts of the immature brain that control muscle function.
Muscular dystrophy: Toe walking sometimes occurs in this genetic disease in which muscle fibers are unusually prone to damage and weaken over time. This diagnosis might be more likely if your child initially walked normally before starting to toe walk.
Autism: Toe walking has been linked to autism spectrum disorders, which affect a child’s ability to communicate and interact with others.
Risk factors and diagnosis
Toe walking out of habit, also known as idiopathic toe walking, can sometimes run in families.
Toe walking can be observed during a physical exam when the doctor does a gait analysis or looks at the way the child walks. In some cases, the doctor may order an electromyography (EMG) to measure the electrical activity in the affected nerve or muscle. If the doctor suspects a condition such as cerebral palsy or autism, he or she may recommend a neurological exam or testing to make sure your baby is developing at the right pace.
Treatment for toe walking depends on a number of factors, including the age of the child and whether the child is able to walk flat-footed.
For children who are two to five-years-old and are able to walk flat-footed, initial treatment is always nonsurgical and includes observation, serial casting, bracing, Botox therapy and wearing an ankle-foot orthosis (AFO)
Observation: Your doctor may recommend simply monitoring your child with regular office visits for a period of time. If he or she is toe walking out of habit, it may stop on its own.
Serial casting: Your doctor may apply a series of short leg walking casts to help progressively stretch and lengthen the muscles and tendons in the calf and break the toe-walking habit. Serial casting is usually performed over a period of several weeks.
Bracing: Wearing an AFO can help stretch and lengthen muscles and tendons. An AFO is a plastic brace that extends up the back of the lower leg and holds the foot at a 90-degree angle. Typically, bracing is performed for a longer period of time than casting (months rather than weeks).
Botox therapy: For certain patients – usually those with a neurologic abnormality that leads to increased muscle tone – an injection of botulinum A toxin (Botox) may also be given to temporarily weaken the calf muscles. This will allow the muscles to stretch more easily during casting or bracing.
Ankle-foot orthosis (AFO)
Wearing an ankle-foot orthosis (AFO) can help stretch and lengthen the muscles and tendons in the calf.
If conservative treatments fail, the doctor might recommend surgery to lengthen the muscles or Achilles tendons at the back of the lower leg. In children over the age of five who toe walk, the calf muscles and Achilles tendons may be so tight that walking flat-footed with heel on the ground is not possible. For these patients, the doctor may recommend a surgical procedure to lengthen the Achilles tendons. Lengthening the tendons will improve range of motion and allow better function of the foot and ankle. Your doctor will talk with you about which technique is best for your child. The surgery is usually done on an outpatient basis and the child will have to wear a short leg walking cast for four to six weeks.
If the toe walking is associated with cerebral palsy, autism or other problems, treatment would focus on the underlying condition.
Persistent toe walking can increase a child’s risk of falling. It can also result in a social stigma.
• For more information or to see a podiatrist visit Bahamas Foot Centre Rosetta Street, telephone 325-2996 or Bahamas Surgical Associates Centre, Albury Lane, telephone 394-5820 or email email@example.com or visit www.apma.org.