Toe walking in children

Daniel Smit | APA Titled Paediatric Physiotherapist

What it can mean, when to seek advice and how physiotherapy may help

Toe walking is when a child walks on the balls of their feet with their heels lifted. It can be part of early walking exploration, but a frequent or ongoing pattern is worth looking at in context. A physiotherapy assessment can check how your child moves, whether their heels can come down comfortably and whether another health professional should be involved.

What is toe walking?

Children learning to walk may sometimes rise onto their toes as they practise balance and explore movement. Many settle into a heel-to-toe pattern during the early years. If toe walking continues, it does not automatically mean there is a serious problem. The pattern, the child’s age and development, and any effect on comfort or everyday activities all matter.

When toe walking continues without an identifiable medical or developmental explanation, clinicians may use the term idiopathic toe walking. This is a diagnosis made after assessment has considered other possible explanations. Toe walking can also occur alongside a range of neurological, muscular, orthopaedic or developmental differences. A child’s walking pattern alone cannot identify the cause.

When should I seek advice?

Consider arranging an assessment if toe walking is frequent or ongoing, continues past age two, or has lasted more than six months after your child began walking independently. It is also reasonable to ask for advice whenever you are concerned about your child’s movement or participation.

Please seek medical advice sooner if toe walking is mainly on one side, has started after your child had been walking with their heels down, or is accompanied by pain, a limp, frequent falls, weakness, reduced ankle movement, or difficulty standing with the heels down. These features do not diagnose a particular condition, but they may mean that a medical review is needed.

Contact your GP or seek prompt medical advice if the change is sudden, worsening, painful, or occurs with weakness or a limp. If your child is acutely unwell or suddenly unable to walk or bear weight, seek urgent medical care.

What happens in an assessment?

A paediatric physiotherapist will ask about when the pattern began, how often it happens, whether it affects one or both sides, and what your child can do in play and daily activities. If it is helpful, a short video of your child walking at home can show what the pattern looks like in a familiar setting.

The assessment may include observing walking, running and balance; checking whether your child can stand with their heels down or walk on their heels; and looking at ankle movement, calf muscle length and size, strength, coordination and the spine. The physiotherapist will also consider your child’s overall development, medical history and your family’s priorities. If findings suggest another cause, they can recommend review by your GP, paediatrician or an appropriate specialist.

How can physiotherapy help?

Support is tailored to the child rather than to the toe-walking pattern alone. Some children may be monitored over time, while others may benefit from physiotherapy or medical input. If appropriate, physiotherapy may work on comfortable ankle movement, strength, balance, coordination and practising useful walking skills through activities the child enjoys. Strategies should be based on the assessment and linked to goals that matter to the child and family.

Depending on the findings and goals, the care team may discuss other options such as orthoses or serial casting. These need individual clinical consideration. More intensive treatment is not necessary for every child, and families should have a clear discussion of expected benefits, burdens and alternatives before making decisions.

What does the evidence say?

The evidence for treating idiopathic toe walking is limited. A Cochrane review found only four small studies with 104 participants, and the results were too uncertain to show whether adding botulinum toxin injections to serial casting improves outcomes compared with casting alone. This means treatment choices should be made carefully, based on assessment findings, the child’s function and comfort, and the family’s goals.

In one observational study, 79% of children who had toe walked at age five had stopped by age ten without treatment. This finding is reassuring, but it does not predict what will happen for an individual child or remove the need to assess concerning features.

A few helpful things to note

• When did the toe walking begin, and was it present from the first steps?
• How often does it happen, and is it on one side or both?
• Can your child stand with their heels down, even briefly?
• Have you noticed pain, falls, fatigue, tightness or changes in walking?
• Does it affect play, running, shoes, stairs or other activities your child enjoys?

You do not need to correct every step or make your child practise stretches before an assessment. Keep play comfortable and let your child move in ways that feel safe. If you are unsure, start with your GP or a paediatric physiotherapist.

If you would like to talk through your concerns, contact Little Strides Physiotherapy to arrange an assessment. We can help you understand your child’s movement and agree on practical next steps.

Download the toe walking in children handout (PDF)

References

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Explore Little Strides paediatric physiotherapy in Narre Warren. Selected appointments are available in Nunawading. View appointment and booking information or ask us about your needs.

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