Toe Walking

Toe walking is a gait pattern in which a child walks on the balls of their feet, keeping their heels off the ground. It is common in toddlers who are just learning to walk and often goes away on its own. When toe walking continues beyond early childhood, it may need to be evaluated. With early assessment and the right treatment, most children can develop a normal, heel-to-toe walking pattern.

What Causes Toe Walking in Children?

Toe walking can have several causes, including:

• Habitual toe walking
• Tight calf muscles or Achilles tendon
• Neuromuscular conditions, such as cerebral palsy or muscular dystrophy
• Developmental or sensory processing differences
• Autism spectrum disorder

In many cases, no clear cause is found (idiopathic toe walking), and the child is otherwise healthy.

What Are the Symptoms?

Toe walking is usually easy to recognize and may include:

• Walking primarily on the toes
• Difficulty placing heels flat on the ground
• Tightness in the calves
• Tripping or balance issues
• Foot or leg pain with activity in older children

Some children can walk flat-footed when asked but return to toe walking naturally.

When Should My Child See a Specialist?

You should consider seeing a pediatric orthopedic specialist if:

• Toe walking continues beyond age 2–3 years
• Your child cannot place their heels flat on the floor
• Toe walking is getting worse
• Your child has pain, stiffness, or balance problems
• Toe walking only occurs on one foot (not both)
• Your pediatrician expresses concern

Early evaluation helps rule out medical causes and guide appropriate treatment.

How Is Toe Walking Diagnosed?

Diagnosis begins with a physical exam and review of your child’s development and walking pattern. The specialist will evaluate:

• Gait pattern
• Ankle range of motion
• Muscle strength and tone
• Balance and coordination

Imaging tests are usually not needed unless another condition is suspected.

How Is Toe Walking Treated?

Treatment depends on:

• Your child’s age
• How long toe walking has been present
• Ankle flexibility
• Whether an underlying condition is identified

Treatment goals focus on:

• Encouraging a normal heel-to-toe walking pattern
• Improving ankle flexibility
• Preventing muscle tightness or contractures
• Supporting safe movement

Nonsurgical Options

Most children improve with nonsurgical treatment, which may include:

• Stretching exercises for the calves and ankles
• Physical therapy to improve gait and balance
• Night splints or ankle-foot orthoses (AFOs)
• Serial casting to gradually increase ankle motion
• Sensory-based therapy if sensory factors are involved

These treatments are often very effective, especially when started early.

Surgical Options

Surgery is rarely needed, but may be considered if:

• Toe walking is severe
• The Achilles tendon is significantly shortened
• Nonsurgical treatment has not been effective

Surgical treatment typically involves lengthening the tight tendon or muscles to restore normal ankle motion.

What Are the Risks of Surgery?

If surgery is needed, potential risks may include:

• Infection
• Overcorrection or undercorrection
• Weakness in the calf muscles
• Need for additional treatment as your child grows

All risks will be discussed carefully by your child’s surgeon.

What Does Recovery From Treatment Involve?

Recovery depends on the treatment used and may include:

• Temporary casting or bracing
• Physical therapy
• Gradual return to full activities

Parents play an important role in helping children follow stretching and bracing plans.

How Long Does Recovery Take?

With nonsurgical treatment, improvement may be seen within weeks to months.

After surgery, the initial recovery period typically lasts 6–8 weeks, followed by continued therapy.

What Is the Outlook for My Child?

The outlook for children who toe walk is excellent. Most children respond well to treatment and develop a normal walking pattern without long-term problems. It is also important to note that toe walking is not a dangerous or dysfunctional condition. Some children will persist in toe walking despite treatment. As long as significant contractures do not exist, no pain or limitations in activities/sports are expected.