Toe Walking: Implications for Therapy

Toe walking is commonly observed in all children up to 2 years of age as they learn to navigate, explore and manage their environment in a dynamic upright position. When toe walking is either observed consistently or beyond the age of 2-3 years, it could implicate a neurological illness, a muscular illness, a congenital heel cord contracture (tightness) or a sensory processing deficit.

Children who walk on their toes either have existing muscle tightness or develop tightness/contractures in their ankle muscles. This tightness could lead to serious injury. Toe walking changes the position of each joint in the legs (ankles, knees, hips) and could also lead to additional orthopedic deformity. In order to perform motor skills appropriately, children require a balance of the muscles that flex and extend their bodies. This provides them with a stable base of support for movement. Children who toe walk often develop an imbalance in their flexion and extension muscles and therefore may have poor motor control, balance and coordination. This can also potentially impact further higher level motor skill development. It is essential to determine the underlying cause(s) for toe walking in order to implement the appropriate treatment. Three of the less common, but clearly understood causes of pediatric toe walking are congenital heel cord tightness, central nervous system damage or paralytic muscle disease. In the first case, the toe walking is caused by inherently tight ankle muscles. In the second case, toe walking is caused by spastic gastrocnemius and soleus (heel cord) muscles in a child’s calf that result from an injury to the brain or the part of the spinal cord that contains fibers from the motor cortex in the brain. Infants and young children with an injury to the central nervous system by either a lack of oxygen or bleeding in the brain are diagnosed with cerebral palsy. Depending on the extent and nature of the injury, these children will end up with spasticity in their antigravity muscles, including the muscles that plantar flex the foot (point the toes downward). This results in a toe walking gait.

Autism Spectrum Disorders

Toe-walking is frequently a behavior displayed by people with autism spectrum disorders (ASD). No definite cause for this behavior has been determined, but several possible explanations have been proposed. Several treatment options have likewise been suggested to address the various theoretical bases for toe-walking.

A popular explanation for toe-walking behavior is that it is a sign of tactile hypersensitivity, which is common in folks with ASD. Finding tactile input to the sole of the foot aversive, the person reacts by trying to avoid contact with the walking surface as much as possible. It should be noted that toe-walking is more often observed when the person is barefoot. Treatment based on this theory is aimed at reducing the sensory hypersensitivity, usually by therapeutic brushing and graded desensitization to tactile input.

A second theory is that toe-walking is an attempt to self-provide proprioceptive input. Proprioception is the unconscious awareness of body position in space, provided by receptors in muscles, tendons, and connective tissue when they are compressed or distracted. Since persons with ASD often have poor awareness of where their body is in space, the theory is that, by contracting the muscles and changing the position of the foot, the body receives extra proprioceptive input. In sensory integration theory, proprioception is also credited with being modulating, calming input, so people who toe-walk when excited may be attempting on an unconscious level to calm themselves. Treatment based on this theory would concentrate on providing the individual with proprioceptive input in other ways, such as jumping on a trampoline, stomping feet, walking in sand, providing traction, and other activities involving compression and traction.

Normal gait (walking)

A normal gait is called a heel-toe gait and that means that as one leg swings forward, it lands with the heel on the ground first. Then the body proceeds over that stance phase limb and finally the foot raises up on tip-toe right before it swings forward again. When the leg is on tip-toe, the other leg is on heel strike so in normal gait there is never a time when a child should be on both tip toes.

Toe walking Toe walking refers to a condition where a person walks on his or her toes without putting much weight on the heel or any other part of the foot.

What's muscle spasticity? Muscle spasticity Symptom Search Results : Healthline.com

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