Ah, toe walking. At first is can be the cute little ballerina toddling around the house, that funny little way he walks, so sweet! But after a couple of years, as the child gets older, it can be a source of frustration and angst for parents with accompanying constant reminders to "stop walking on your toes!" It is not uncommon for toddlers and young children to occssionally go up on their toes, but for those that consistently continue this gait pattern, there can be one or a combination of reasons that is the cause. The most important first step is to determine why he or she has adopted this walking pattern in the first place.
From a pediatric PT perspective, we look for a handful of things:
- Limited ankle range of motion
- Sensitivity on the bottom of the feet (Sensory Processing issue)
- An active primitive reflex (the Tonic Labyrinthine Reflex)
- Balance/Core stability and control issues
- Visual deficits
- Habit or conditioning (often called Idiopathic Toe Walking)
Once we identify why a child is walking on the toes, it makes it easier to treat the underlying cause and correct the gait pattern. Let's briefly look through each.
Limited range of motion in the ankle, or not being able to move the foot up and down, can be the cause or the effect of toe walking. A child who walks on the toes for long periods can cause shortened calf muscles that will reduce the ability to pull his or her toes up for a heel to toe gait pattern. Stretching the tight muscles is recommended in this instance. Reciprocally, if the bones of the ankle are not moving correctly or the muscles are shortened, the only option a child would have to successfully walk would be on the toes. The treatment here would be for the PT to free up the ankle joint so the bones move correctly then stretch out the muscles. Sometimes children will begin toe walking after breaking a leg bone which indicates that there is an ankle joint issue that needs to be addressed.
Sensory Processing or Sensory Integration deals with the way the body and mind process sensory information coming in from the environment. In the instance of toe walking, we are talking about the tactile or touch sense. Children with tactile sensory processing issues may not like the feel of certain textures on their feet- carpet, hardwood floors, tile, grass, sand, etc. and will walk on their toes to avoid touching those textures. A good clue for parents is if the child stops toe walking when wearing shoes and only walks on the toes when barefoot. We treat sensory processing in PT by integrating the response to the sensory input.
Babies are all born with a host of reflexes. Certain reflexes are present when a baby is born and then go away or integrate. Others develop as the child grows. In this instance, the reflex that plays a part in a child walking on his or her toes is the Tonic Labyrinthine Reflex or TLR. Babies are born with this reflex and it is supposed to integrate, or go away, by 3 to 4 months of age. Simply stated, the TLR causes the body to curl in a ball, or flex, when the head is bent forward, and the body to extend, legs straighten, toes point when the head is bent back. If it remains active it can cause a child to toe walk. In PT, we assess if the reflex is active then integrate it to bring the child back down on the heels.
Often times when little ones walk early, at 9 or 10 months old, with a very short period of crawling or no crawling at all, they tend to have a weak core and are not able to balance as well. These children go up on their toes for stability to compensate for the weakness and less than great balance. They begin walking in a more "falling with style" pattern than a controlled manner. Momentum pulls them forward and the last thing to leave the surface is the toes so that becomes the adopted walking pattern. These kids often are on-the-go in the beginning, either stopped or running with no in between. Treatment focuses on regaining core control and stability, improving balance, and yes, getting the kids on the floor to crawl in an all-four pattern to recapture all the benefits that come along with crawling.
Vision plays a big part in how we perceive the world and also in our ability to balance. A Visual Midline Shift can cause a child to toe walk. An interruption in the spacial visual processing will cause a weight to shift forward thus pulling a child up on his or her toes. As you can probably guess, the treatment is to address the visual midline shift which in turn returns a child to his or her heels on the ground.
In some instances, kids walk on their toes out of habit or conditioning. We may see this when a parent or older sibling walks on the toes. It is what the child sees so what the child replicates. In addition, toe walking can continue to some degree after the issues stated above are addressed out of sheer habit. If that is the gait pattern of choice from one year old to five years old, that is alot of years of laying down the movement pattern. In this instance, we need to lay down new patterns to break the habit.
It is also possible for children to have more than one of these things happening at once. They may have limited ankle range of motion and a sensory processing issue, or an active TLR and a visual midline shift. Whatever the underlying cause, or causes, to be most successful at getting your kiddo to walk with the heels down is to first figure out what is driving the toe walking then you will have much better luck at getting it resolved. That sure beats an endless stream of verbal reminders!
Have questions? Feel free to email me at stephanie@compassptinc.com