Bulletin of Orthopaedic and Neuromuscular Education Series

Toe-Walking and the Benefits of Therapy

When children consistently walk on their toes, this is a condition known as toe-walking. This condition can happen for many reasons such as decreased flexibility of the calf muscles, increased spasticity in the calf muscles, decreased core and ankle strength, and/or sensory reasons. While it may seem like your child’s toe-walking is not a big deal, there are risks that your child could develop foot abnormalities or weaknesses and if left untreated could result in increased bone or callous growth on the balls of their feet and may require more intensive interventions like serial casting or surgical intervention.

Visiting a pediatric physical therapist can help determine the root cause of toe walking for your child and tailor an exercise program individualized for your childs needs. Until you can speak with a specialist, get started with the basic stretching exercise routine we’ve provided below.

Because the child’s muscles may be tight, it might be difficult for those muscles to be stretched when first beginning the routine. This is all the more reason to continue working on stretching! As range of motion increases, the child will have more range to utilize during walking.

If the muscle are tight, try small intervals of stretching time more often during the day (5-10 seconds 3-5 times per day), and gradually work up for longer periods of time (30-60 seconds only 2 times per day). You should start noticing more range of motion the more you stretch the muscles. Consistency is key!

  1. Gastrocnemius stretch: This exercise helps to increase flexibility of the gastrocnemius muscle in the calves, which can be tight in toe walkers.
    Make It Fun! Have them sing their favorite song while you stretch them.
  2. Soleus stretch: This exercise helps to increase flexibility of the soleus muscle in the calves, which can be tight in toe walkers.

  • Hamstring stretch: This exercise helps to increase flexibility of the hamstring muscles, which can be tight in toe walkers.
    Make It Fun! Allow them to watch their favorite music video while you stretch them.
  • Downward dog stretch: This exercise helps to increase flexibility of both the hamstring and calf muscles.
    Make It Fun! Do it with them and make it a challenge to see who can do it longer.
  • Deep squat stretch: This exercise helps to increase flexibility in their calf muscles in a functional way.
    Make It Fun! Have them do a puzzle on a low table while in a deep squat position.

Improving flexability and range of motion is a great start to address toe walking, but strengthening the muscles is also needed in order to provide the child with enough strength to use the range of motion achieved through stretching. Below is a suggested strengthening program for you and your child to perform together. In all of these exercises, make sure that the child’s heel is down as much as possible to make use of the range of motion they have.

  1. Penguin walks: This exercise helps to strengthen the ankle dorsiflexors which can be weak in toe walkers.
    Make It Fun! Print out pictures of all the animals we mention and have them choose which one they want to do first.
  2. Frog jumps: This exercise helps strengthen lower extremity and core muscles that may be weak in toe walkers.
    Ask them to make their best frog noise every time they jump like a frog.

  • Bear walks: This exercise helps to strengthen lower extremity and core muscles that may be weak in toe walkers.
    Make It Fun! Have them try to scare people in the house like a bear.
  • Squatting: This exercise helps to strengthen lower extremity and core muscles that may be weak in toe walkers.
    Make It Fun! Have them play hide the bean bag around the house and look for the missing bean bags. When they find one, cue them to squat for each bean bag rather than bend at the hip.
  • Climbing ladders/stairs: This exercise helps to strengthen lower extremity and core muscles that may be weak in toe walkers.
    Make It Fun! Go to the park and have them climb all the ladders and stairs in order to slide down the coolest slide.

Frequently Asked Questions:

  • When should I be concerned about my child’s toe walking and contact an orthopaedic specialist like Growing Bones

    1. Your child may need more individualized help with their toe walking and that’s okay. Some reasons to be concerned and contact Growing Bones would be the following:

    1. If you notice that the toe walking has been happening for longer than a few months and/or the toe walking seems to be getting worse.
    2. If you have tried these exercises and you’re not seeing any change.
    3. If you notice that no matter how much you tell them to walk on their feet, their walking does not change.
    4. If you see that there are other changes that are going on as well (i.e. you notice that their feet look different, there is significant weakness on one side versus the other or this week versus last week, etc.).

  • What are sensory reasons for toe walking?
    1. In terms of sensory input, there are 3 main systems that we look at

    1. Tactile: The system that lets us understand the feeling of touch
    2. Vestibular: The system that controls our sense of gravity and movement
    3. Proprioceptive: The system that provides information of the speed of muscle stretch and perception of the body in space

    2. Some children seek these types of sensory input and some children avoid these types of sensory input, which can manifest in toe walking (i.e. your child is seeking proprioceptive input so they bounce when they toe walk, your child is avoiding tactile input so they pull away from the sensation of the ground on their feet and toe walk, etc.).

  • What exercise program should I start with?1. If your child can tolerate it, they can try both the stretching and strengthening exercise programs within the same day or week. However, starting with the stretching exercises and then slowly adding the strengthening exercises as your child can tolerate them is acceptable as well.

References:
Ruzbarsky JJ, Scher D, Dodwell E. Toe walking: causes, epidemiology, assessment, and treatment. Curr Opin Pediatr. 2016 Feb;28(1):40-6. doi: 10.1097/MOP.0000000000000302. PMID: 26709689.