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Idiopathic Toe Walking in Young Children

February 7, 2019 | by Joann Flaherty, graduate intern in Physical Therapy under the supervision of Kelly Walsh, DPT

Have you ever noticed your child tiptoeing around the house? Walking up on toes is a normal occurrence in children age 3 and under, as they continue to develop their ability to walk. However, if you are noticing that your child prefers to stay up on their toes while they are walking past the age of 3, they could have Idiopathic Toe Walking (ITW). ITW occurs in children between the ages of 3 and 7 years old, and is more commonly seen in males compared to females. ITW is not related to any specific diagnosis, and can present due to a variety of reasons (Ruzbarsky, Scher, & Dodwell, 2016).

The most common reasons children develop ITW are because of decreased stability or sensory involvement. If the child began walking later or earlier than typical, they may still be developing the lower extremity strength for balance, coordination, and stability during walking. For this reason they may resort to walking up on their toes, as this position locks out the lower extremity and provides them with additional stability. A child may also develop ITW if they have a sensory aversion or if they are sensory seeking. Walking up toes may allow the child to make less contact with the surface they are walking on, helping them avoid certain sensations on their feet. However, this position may also provide increased sensation input at the ball of the foot, allowing for additional stimulation if the child is sensory seeking.

Often times, children who present with ITW will prefer toe-walking, but with a quick reminder, can walk with flat feet and a normal heel strike. However, as ITW progresses, a
child may lose flexibility in their calf muscles, resulting in decreased ability to actively or passively dorsiflex, or bend their ankle so toes are lifted. Overtime, ITW may cause foot or ankle pain, compensatory walking mechanics, an increased risk of ankle sprains, and potentially a delay in certain developmental milestones. Toe-walking also requires more energy than typical walking, which may cause difficulty keeping up with peers. (Ruzbarsky et al., 2016).

At Pediatric Therapy Associates, we do a comprehensive evaluation of motor function and assess developmental milestones, with particular emphasis on gait mechanics in children with suspected ITW. The evaluation may be with an occupational therapist (OT) or a physical therapist (PT) depending on whether the ITW is thought to be more sensory or stability based. We can also further narrow down the cause of ITW, and determine the appropriate course of action during the evaluation. Children with more sensory based ITW will benefit more from a combination of OT and PT, whereas children with more stability based ITW will benefit more from PT.

A variety of interventions are used during PT to combat ITW and facilitate typical gait. We use active and passive stretching of the plantar flexor, or calf muscles. We do activities to actively strengthen and engage the dorsiflexor muscles, which oppose the plantar flexors. We also facilitate strength and stability throughout the lower xtremity, and practice balance, walking, stair climbing, running, and agility tasks, as appropriate, to help each child continue progressing with their developmental milestones. We can also assess the child’s potential need for additional support from a foot orthoses, which has been shown to also help combat ITW (Michalitsis, Murphy, Rawicki, Haines, & Williams, 2019).

Some research suggests that most kids will grow out of ITW naturally, however being evaluated and treated by a PT or OT will help facilitate this process and also ensure that all developmental milestones are met, and continue to be met, appropriately (Engström & Tedroff, 2018). A presentation of toe-walking can also be related to a variety of different diagnoses, therefore, in addition to determining the sensory or stability nature of ITW, an evaluation by a PT and/or an OT can also help rule out other diagnoses. Lastly, depending on the severity of the ITW, there are a few other treatment options that may appropriate in addition to PT or OT. Being evaluated by a therapist can further help determine which treatment routes are most appropriate for your child.

References:

Engström, 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.

Michalitsis, J., Murphy, A. T., Rawicki, B., Haines, T. P., & Williams, C. (2019). Full length foot orthoses have an immediate treatment effect and modify gait of children with idiopathic toe walking. Gait & Posture, 68, 227-231.

Ruzbarsky, J. J., Scher, D., & Dodwell, E. (2016). Toe walking: Causes, epidemiology, assessment, and treatment. Current Opinion in Pediatrics, 28(1), 40-46.