Toe Walking

Toe walking is a gait pattern in which a child walks on the balls of their feet without the heel making contact with the ground. While it is common and often normal in children under 2 years of age who are just learning to walk, persistent toe walking beyond age 2–3 warrants evaluation.

It can be habitual (idiopathic) — a simple habit with no underlying cause — or it may be a sign of an underlying condition such as cerebral palsy, autism spectrum disorder, or tight Achilles tendons.

• Idiopathic (habitual) toe walking: The most common cause — no underlying abnormality. The child can walk flat-footed on request but prefers toe walking. Often familial
• Tight Achilles tendon / equinus contracture: The calf muscles and Achilles tendon are shortened, preventing the heel from touching the ground
• Cerebral palsy: Increased muscle tone (spasticity) in the calf causes toe walking — typically affects one or both legs depending on the type of CP
• Autism spectrum disorder: Sensory processing differences can lead to habitual toe walking
• Muscular dystrophy: Progressive muscle weakness can alter gait patterns including toe walking
• Spinal dysraphism: Tethered spinal cord or other spinal problems may present with toe walking

• Child consistently walks on toes or balls of feet, heels not touching the ground
• In idiopathic cases, the child can walk flat-footed when reminded or asked
• Tight calf muscles — reduced dorsiflexion range of motion (foot cannot bend upward beyond neutral)
• Calf muscle hypertrophy (enlargement) may be present
• Difficulty wearing flat shoes; prefers walking barefoot on toes
• In secondary causes: associated neurological findings such as spasticity, weakness, or developmental delays

• Clinical gait analysis and neurological examination to identify any underlying cause
• Ankle dorsiflexion range of motion measurement with knee straight and bent
• Assessment of lower limb tone, power, reflexes, and sensation
• Developmental screening and autism evaluation where relevant
• MRI of the spine if neurological cause is suspected (tethered cord, spinal dysraphism)
• Nerve conduction studies and muscle biopsy if muscular dystrophy is suspected

• Observation: For children under 3 with flexible, idiopathic toe walking — watchful waiting is appropriate as many resolve spontaneously
• Physiotherapy and stretching: Calf stretching programme, gait retraining, and sensory-motor exercises form the first line of treatment
• Serial casting: Plaster casts applied to the foot in a progressively corrected position over 4–6 weeks to stretch the Achilles tendon and improve range of motion
• Ankle-foot orthosis (AFO): Custom splints worn during the day or at night to maintain the corrected position after casting
• Botulinum toxin (Botox) injection: For spastic toe walking (cerebral palsy) — Botox is injected into the calf muscles to reduce tone and improve walking pattern. Often combined with casting or physiotherapy
• Surgical Achilles tendon lengthening (TAL): Recommended when conservative treatment fails or when a fixed equinus contracture is present. The Achilles tendon is lengthened under anaesthesia, followed by casting and bracing