Pediatric Orthopedic Surgeons treating a Hammer Toe

TOE WALKING

Toe walking is quite normal in children beginning to walk and it normally will go away. However, Toe walking sometimes can result from certain conditions, including cerebral palsy, muscular dystrophy, and an autism spectrum disorder.

At Medical City Children’s Orthopedics and Spine Specialists, our expert Toe Walking Doctors are dedicated to diagnosing and treating spinal problems in children and ensuring comprehensive care tailored to each patient’s needs. With advanced techniques and a compassionate approach, our team is here to diagnose, treat and care for children suffering from Toe Walking.

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Children who Toe Walk

Tow Walking Toe walking is a pattern of walking in which the toes of the feet are pointed toward the ground as opposed to the heels. This is a common gait pattern for children under the age of 2, but most people eventually adopt a heel-to-toe gait pattern. If your toddler is achieving developmental milestones, tiptoe walking is nothing to worry about. In many cases, it is unclear why your child continues to tiptoe walking past the age of 2. However, the calf muscles can become stiff, making it more difficult for children to learn the heel-to-toe walking pattern as they get older.

Neurological vs Structural Toe Walking: What’s the Difference?

When evaluating toe walking, your doctor will try to determine whether the cause is neurological or structural:

Neurological toe walking is often linked to underlying conditions that affect muscle control, such as cerebral palsy or muscular dystrophy. Signs of neurological involvement may include muscle stiffness, unusual muscle tone, or difficulties with balance and coordination.
Structural toe walking is typically due to anatomical factors. For instance, a short Achilles tendon or other physical restrictions in the foot or leg. In these cases, the child might have limited ability to flex the foot upward (dorsiflexion). Generally the child will have normal muscle tone and coordination.

Understanding whether your child’s toe walking is neurological or structural helps ensure the right treatment plan is chosen. If you notice persistent toe walking, especially with other symptoms like muscle weakness or delayed developmental milestones, consult your pediatrician—they can help identify the underlying cause and recommend next steps.

A Simple Home Assessment for Toe Walking

If you want to assess your child’s toe walking at home, try a simple check of ankle flexibility. Have your child lie on their back with knees straight. Gently flex their foot upward toward the shin. Then, bend the knee and repeat. Compare the foot’s movement with the knee straight versus bent.

This observation helps you notice any difference in ankle motion between both positions. If the foot doesn’t bend much, or there’s a large difference, tell your doctor.
These findings help your specialist determine if tight calf muscles affect your child’s walking. Always avoid forcing movements. Stop immediately if your child feels pain.
For a full evaluation and expert guidance, contact your child’s healthcare provider.

QUESTIONS AND ANSWERS

Why is my child walking on their toes, and is it a cause for concern?

Toe walking refers to a walking pattern where a child walks on their toes without putting their heels down. There are various potential reasons for toe walking, ranging from normal developmental variations to underlying medical conditions. In many cases, toe walking in toddlers is a phase of normal development. However, they eventually transition to a regular walking pattern. Yet, persistent toe walking, especially beyond the age of three is problematic. It can be associated with conditions such as tight calf muscles, sensory processing issues, or neurological conditions. A healthcare professional, such as a pediatric orthopedic specialist, can assess the child to determine the cause.

What can be done to address toe walking in my child?

The appropriate intervention depends on the underlying cause of toe walking. Common strategies include:

Stretching Exercises: If tight calf muscles contribute to toe walking, stretching exercises may be recommended to improve flexibility.
Physical Therapy: A physical therapist can work with the child to address muscle imbalances, coordination issues, and promote a more typical walking pattern.
Orthotic Devices: In some cases, orthotic devices, such as braces or shoe inserts, may be prescribed to encourage proper foot placement and walking mechanics.
Monitoring and Observation: For children with idiopathic toe walking (no known cause), close monitoring may be recommended, as some children naturally outgrow this behavior. However, if it persists, further evaluation may be necessary.

When should I be concerned, and when is it time to seek medical attention?

Parents should seek medical attention if:

Toe walking is persistent: If toe walking persists beyond the age of three without signs of improvement.
Other developmental issues are present: If toe walking is associated with other developmental delays, motor coordination problems, or if the child is frequently tripping or falling.
Pain or discomfort is reported: If the child experiences pain or discomfort while walking, especially if it affects their daily activities.

It’s important to remember that while toe walking can be a normal part of early childhood development, persistent or problematic patterns should not be overlooked. Early intervention can help address underlying issues and support your child’s healthy growth and mobility.

When should I be concerned, and when is it time to seek medical attention?

Parents should seek medical attention if:

Toe walking is persistent: If toe walking persists beyond the age of three without signs of improvement.
Other developmental issues are present: If toe walking is associated with other developmental delays, motor coordination problems, or if the child is frequently tripping or falling.
Pain or discomfort is reported: If the child experiences pain or discomfort while walking, especially if it affects their daily activities.

It’s crucial for parents to communicate openly with their child’s healthcare provider, who can assess the situation, conduct a thorough examination, and determine whether further evaluation or intervention is necessary. Early intervention can be essential in addressing the underlying causes of toe walking and promoting optimal development.

If your child toe walking, please give our office a call to make an appointment with one of our children’s specialists who will examine your child to find the cause so that it can be addressed early on.

Toe Walking Causes

Doctors often cannot find a reason why a child walks on their toes. They call this idiopathic toe walking. These youngsters can normally walk heel to toe, but they prefer to walk on their toes.

Idiopathic toe walking is seen in children over the age of three who continue to walk on their toes without any identifiable neurological, orthopedic, or mental illness. It’s quite common, affecting roughly 7–24% of kids. In many cases, it simply becomes a habit, while in others there may be a subtle or undiagnosed physical cause.
However, medical professionals have recognized a few circumstances when a kid could toe walk often.

Health Conditions

Occasionally, chronic toe walking may be an indication of one of the following medical conditions:

Cerebral palsy
Muscular dystrophy
A spinal cord abnormality
Neurological conditions

There is no clear connection between autism and toe walking, however children with disorders related to autism toe-walk more frequently than children who are developing normally. Instead, their toe walking may be sensory-related.

Cerebral Palsy

This circumstance influences muscle tone, coordination, and posture. People with cerebral palsy may walk clumsily or even on their toes. Their muscles could also be excessively rigid.

Muscular Dystrophy

A hereditary disorder called muscular dystrophy results in muscle loss and weakening. Toe walking is one of the possible adverse effects. A possible reason for toe walking in a youngster who has previously walked in a heel-toe pattern is muscular dystrophy.

Spinal Cord Abnormality

Abnormalities of the spinal cord, such as spinal cord attachments to the spine or clumps of the spinal cord, can cause toe-walking.

Is Toe Walking a Symptom of Autism?

Doctors have observed a higher incidence of toe-walking in people with autism spectrum disorders, a group of conditions that affect a person’s communication, social skills, and behavior. But doctors haven’t figured out exactly why people with autism tend to tiptoe.

Autism-related sensory issues, where a youngster may not enjoy the way their heels feel when they contact the ground, are some of the suggested causes of toe walking in persons with autism. Concerns about visual and vestibular (balance) function might also be a contributing factor.

Diagnosing the Cause of Toe Walking

If your child keeps toe walking, schedule a doctor visit. The doctor will check for any underlying conditions. Toe walking has many causes. Identifying the correct type helps guide effective treatment. The doctor starts with a detailed medical history. They may ask if the child was born full term or not. Doctors also ask about pregnancy complications and family history of toe walking.

Your doctor might ask if your child toe walks on one or both feet. They’ll check when your child reached developmental milestones like sitting or walking. The doctor may ask about leg pain, weakness, or the ability to walk heel-to-toe. Next, your doctor will perform a physical exam. They will observe your child walking, and then they check the growth and motion of your child’s feet and legs. They may also test muscle strength and neurological function. Knowing the cause of toe walking is critical for treatment.
Toe walking falls into two main types: neurological and structural.

Neurological causes include cerebral palsy, muscular dystrophy, or other conditions that affect coordination and muscle control. Structural causes involve physical issues, like a short Achilles tendon or unusual bone alignment in the foot or leg. Doctors usually skip imaging tests unless medical history suggests a specific cause. Many kids have idiopathic toe walking, which has no known cause or serious underlying condition.

How to Stop Toe Walking

Toe walking may be problematic because the majority of children with idiopathic toe walking past the age of five may experience difficulty walking with their heels down later in life. If your child often walks on his or her toes, it may be difficult for you to put their shoes on or have them engage in leisure activities like roller skating that need specific footwear.

Over time, ITW (idiopathic toe walking) can also lead to muscle tightness, improper bone growth, and joint discomfort if not addressed. These complications make it even more important to monitor your child’s walking patterns and speak with your doctor if you notice persistent toe walking. Early intervention can help prevent these issues and support your child’s long-term mobility and comfort.

How Successful Are Treatments for Toe Walking in Children?

The good news: most children outgrow toe walking or respond very well to treatment. For the vast majority of families, conservative options—like physical therapy, stretching exercises, and special footwear—lead to significant improvement without the need for surgery. Fewer than 1 in 10 children with toe walking require any surgical intervention at all.

With early intervention and a bit of patience, full recovery is not just possible—it’s the usual outcome.

Physical Examination

By seeing your child walk, the doctor will often begin the physical examination. This may be done even if your child isn’t aware that they are being watched, to prevent the ‘doctor’s walk’, which occurs when a patient tries to walk correctly when the doctor is looking. The doctor will next want to see your youngster walk both normally and then “best” when on their toes (walking as flat-footed as possible). In addition to seeing the toe walking itself at this time, the doctor will evaluate the walk’s smoothness as part of a neurological assessment. Our Children’s orthopedic specialist will examine your child by:

Check your child’s feet for anomalies, particularly discrepancies between the left foot and right foot.
Check for variations in thigh and calf size as well as leg length.
Asking your kid to move their feet and ankles in various ways will help you determine whether one or both of their calf muscles are tight.
Check the range of motion in your child’s hips and knees.
Look closely at the lower extremities and back for any skin or other abnormalities.

Toe Walking Treatment

Physical Therapy

It could be helpful to reduce the amount of toe walking over the course of several sessions to concentrate on stretching the tight muscles. Children should perform stretching activities at home as well.

Bracing

To encourage a flat foot when walking, certain kids may benefit from an ankle-foot orthotic (AFO). In order to stretch and promote a flat foot position during the day, the AFO is a customized brace. An AFO worn at night might aid in releasing tense muscles as your child sleeps.

There are different types of orthotic braces available to help with walking and foot alignment. An AFO, or Ankle-Foot Orthosis, is designed to support both the ankle and foot, helping correct alignment and improve walking patterns, especially in children who tend to walk on their toes. For children who need a bit more freedom of movement, a Supramalleolar Orthosis (SMO) might be recommended. SMOs are shorter than AFOs, offering support just above the ankle. They stabilize the foot while allowing more mobility than a full-length AFO.

Both AFOs and SMOs are commonly used to manage a variety of foot and ankle conditions in children, helping to improve stability, encourage proper movement, and promote overall function.

Serial Casting

A short leg cast is applied at 1-2 week intervals to gradually stretch tight muscles and improve foot and ankle position. Kids are able to walk in these casts. The addition of Botox injections to stretch the tight muscles in casts may be more effective in some children.

Achilles Tendon or Gastrocnemius Lengthening

If physical therapy and continuous casts are ineffective in correcting a tight ankle, surgery may be necessary to achieve a flat foot position while walking. A surgical procedure will increase the range of motion and function of the foot and ankle. The lengthening also makes it easier for the child to tolerate his or her AFO and achieve a flat foot position when walking.

Nonsurgical Treatment

The first course of therapy is always nonsurgical for kids between the ages of 2 and 5 who do not walk flat-footed. The nonsurgical cure may include:

Observation. The doctor for your child could advise watching your youngster for a while with routine office visits. If your child is habitually toe walking, they could decide to stop on their own.
Serial casting. To gradually stretch and lengthen the muscles and tendons in the calf and break the toe-walking habit, your child’s doctor may use a series of brief leg walking casts. Serial casting often takes place over a few weeks.
Bracing. Wearing an ankle foot orthosis (AFO) allows you to stretch and lengthen your child’s muscles and tendons. AFO is a plastic brace that extends behind the lower leg and holds the foot at a 90° angle. Bracing is usually done over a longer period (months instead of weeks) than casting.
Botox therapy. For certain people (usually those with neurologic abnormalities that cause increased muscle tone), botulinum toxin injections may be given to temporarily relax the calf muscles. This allows muscles to stretch more easily during continuous casting or tensioning.

Surgical Treatment

Children over the age of 5 who walk on their toes can develop too much tension in their calf muscles and Achilles tendon to walk correctly, even if they try. For these patients, the surgeon may recommend a procedure to stretch the Achilles tendon. Stretching the tendons improves the range of motion and improves foot and ankle function. Which part of the tendon is stretched depends on whether the patient’s foot can be laid flat at the ankle with the knee bent. There are different techniques used to stretch different areas of the tendon. Your surgeon will tell you which technique is best for your child. Surgery is usually done in an outpatient setting (no overnight stay). After stretching the tendon while your child is still asleep, your doctor will put a short leg cast on your child’s leg. These bandages are typically worn for 4 to 6 weeks.

Recovery

After both surgical and nonsurgical treatment, physical therapy is typically advised to assist the patient in learning to walk flat-footed more regularly. After surgery, physical rehabilitation normally doesn’t start until the walking casts are taken off. Recovery often involves an initial period in a cast for about two weeks, followed by transitioning to a walking boot for another two weeks. Physical therapy generally begins around six weeks after surgery, once the foot has had sufficient time to heal and the patient is ready to safely begin movement exercises.

How Successful Are Treatments for Toe Walking in Children?

With early intervention and a bit of patience, full recovery is not just possible—it’s the usual outcome.

Real-Life Success Stories: Children Overcoming Toe Walking

When families seek care for toe walking, other patients’ experiences offer both reassurance and hope. Many children regain flat-footed walking and the confidence to enjoy the activities they love.

Take Julian, for example. He struggled with toe walking for years before receiving a specialized tendon lengthening procedure. He then followed a customized physical therapy plan and progressed from toe walking to pain-free running. Now, he participates fully in school sports. His story inspires younger patients to believe in their own progress.

Jacob’s family recalls feeling anxious before his surgery. Years of therapy hadn’t corrected his persistent toe walking. With strong guidance, education, and follow-up support, Jacob quickly adjusted to a heel-to-toe walking pattern. Today, he runs beside his soccer teammates and proudly walks tall with confidence.

Ari began toe walking as a toddler. Time and therapy didn’t resolve it. His medical team conducted a thorough evaluation and prioritized non-surgical care first. Ultimately, his treatment plan included Achilles tendon lengthening. With consistent follow-ups and family support, Ari now walks flat-footed and confidently.

These stories show what’s possible with patience and the right care team. If you’re concerned about your child’s walking, we’re here to help every step of the way.

Outcome

Most patients experience a gradual improvement and can engage in daily activities and sports. Studies suggest that some kids will toe-walk even after many castings or surgeries, so parents must be patient. We are experts at toe walking and invite parents to give us a call to schedule an appointment at one of our five convenient offices in Dallas, Arlington, Flower Mound, Frisco, and McKinney, TX are a board-certified, fellowship-trained orthopedic group that uses both surgical and non-surgical techniques to treat children. As such, our specialists provide cutting-edge and comprehensive care in diagnosing and treating children with toe walking. Also, we use the latest state-of-the-art treatment methods to return children, adolescents, and adults to their active lifestyles.

Finally, speak to one of our compassionate and expert surgeons to learn more about your child’s toe walking and the specific treatment procedure to reduce and eliminate this problem.

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Footnote:

American Academy of Orthopaedic Surgeons: Toe Walking

Call 214-556-0590 to make an appointment.

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