Pediatric Toe Walking
Chanda Strzyzewski, PT
I attended a workshop titled “Effective Evaluation, Assessment, and Treatment of Pediatric Toe
Walking. Toe walking is a fairly common pediatric problem. This course was quite PT-specific,
but did include some information that others might find interesting.
Many people feel that children will outgrow the toe walking when they are young. However,
research shows that the foot becomes formed with history of use, and the bones and shape are
not complete until approximately 6.5 years old. Therefore, it is important to start treating
these kids as early as possible, preferably before 3 years, to avoid improper bone formation.
Many toe-walkers actually use a “controlled fall” when walking, where they move quickly and
somewhat stumble, in order to hold themselves up against gravity. When they are up on their
toes, their center of mass is pushed forward, but they often don’t have the strength in their calf
muscles to hold them upright and slow themselves down. Toe walkers also do not develop
active pronation and supination of the foot (rotating of the foot sideways up and down),
therefore they often have to develop other compensation strategies to maintain their balance
when reaching or when on unstable surfaces. In addition, in normal gait, as you step forward,
your lower legs moves forward over a flat foot, causing it to flex approximately 10 degrees. In
toe walking, these muscles are often tight, not allowing such progression.
There are many methods out there for treatment of a child that toe walks. Sometimes a brace
is used to get the foot flat. However, this has to be looked at closely, because some will impair
range of motion instead of help it. In addition, oftentimes if the brace is kept on all the time,
the child will become dependent on the brace and lose more strength. Therefore it is
imperative that a strengthening program be included with this. In many instances, giving a
child a heel wedge will finally give them some contact to the floor, thus giving the calf muscles
more feedback. This often naturally strengthens the muscles and the heel wedge can then be
gradually decreased and allows the foot to become flat during gait.
Botox is another method that is used to treat toe walking. Essentially it is meant to decrease
the spasticity in the calf muscles in order to allow the front of the leg to strengthen and allow it
to flex. However, it does not address the reason for the movement disorder in the first place.
It will often weaken an already weak muscle, and on its own does not teach the dominated
muscle to function. Again, a strengthening program is imperative with muscle re-training to
reduce the toe walking.
Some children also undergo surgery to correct this problem. However, the result is that these
muscles are often over-weakened and over-lengthened. In addition, the scar tissue that is
formed is also weaker then the surrounding muscle tissue. A lot of work is required before and
after surgery to strengthen the surrounding and then affected muscles to get the maximum
benefit.
In many instances, strengthening in functional activities and manual therapy to increase the
range of motion can help retrain the muscles and get a more natural gait pattern. If we just
lengthen the shortened muscle group without effective retraining, the gait pattern will not be
corrected.
The Muscle Balance Theory explains that the altered muscle length affects function. Muscular
imbalance leads to the chronic use of one muscle group, with a detriment to the others. Then
the dominant muscle eventually loses functional length and/or extensibility. Lengthening the
shortened muscles only depletes the effectiveness of the pathologic strategy. When not
replaced with an alternate strategy, the established patterns continue and lead to recurrence of
contractures and/or tightness. Treatment options to retrain the gait pattern include core
strengthening and posterior load line training (walking on heels, standing with toes up an
wedge or dowel to direct their weight backwards or performing squats). It is also important to
teach hip and ankle co-activation for balance control. This can be accomplished by walking on a
balance beam, standing on unstable surfaces, and sometimes playing Wii. In addition, working
with the child in a staggered stance that is greater than the usual step length will increase the
dynamic stability of the child. Neuromuscluar electrical stimulation has also been shown to
increase the number of muscle fibers during a contraction, thus increasing strength. This does
not require a high level of cognitive function to benefit the child, however can typically only be
worked on in a clinical setting.
Sensory Processing Dysfunction can also lead to toe walking, which requires entirely different
treatment techniques, including a sensory diet. Children with this disorder are typically either
sensory seeking or sensory avoiding. “Sensory seeking” children often benefit from joint
compressions, which will help for approximately 2 hours, as it gives the joints and ligaments
more information to process where they are in space. Vestibular activities will also help for
approx. 4-6 hours. “Sensory avoiding” children may state that walking with their feet flat on
the floor feels like it is walking on hot sand. This is because of the heightened state of the
tactile receptors in the soles of their feet. A brushing protocol or Kinesio tape will often benefit
these children.
Prematurity is a good indicator that a child may toe walk. This is because, during the last four
weeks of gestation, the human fetus is confined in a tight space, which decreases the amount
of movement and promotes ankle flexion, thus lengthening the calf muscles. Those children
that are born premature, have more space to move around, and don’t get this stretch on their
calves, thus causing shorter muscles when they are born.
Other things to consider when a child toe walks include GI function and vision. A child with a
lot of reflux or stomach pain may go into an exaggerated extensor pattern, which will bring
them up on their toes.
There has also been research explaining two different types of visual fields. Focal vision is the
central visual field and is independent of other body systems. Ambient vision is the entire
visual field and is integrated with the other body systems. It has been found that most autistic
children have a lack of attention to their ambient vision, giving decreased neurofeedback to the
other body systems. This decreases their ability to process information in the areas involving
speech, thought, posture and movement. Prisms are sometimes used to treat these kids as it
alters their visual field and stimulates active reorganization of visual processing.
Treating toe walking is important because this altered position of gait changes all of the
biomechanics of the skeletal system. It often causes impaired function, multiple joint pain,
degenerative arthritis, knee instability, osteoarthritis, increased frequency of injury, and
incompatibility with foot wear.