Children who walk on their toes for long periods of time are considered to be persistent toe walkers. Most children walk on their toes at some point in their development and generally cease to do so before long, but some children continue to walk on their toes into later childhood or even adulthood. Persistent toe walking may be a part of normal development in some children and may need to be addressed by a pediatrician or other healthcare provider. In other cases, toe walking can be indicative of underlying medical issues, and it can be secondary to other medical conditions.
Toe walking can have many different meanings. In toddlers who are learning to walk as part of normal development, toe walking is usually part of the child’s learning process. Children who walk on their toes as toddlers are exploring different ways to use their bodies to walk around. For most of these children typically start to walk heel to toe by the time they are about 2 to 3 years old and continue to improve their ability to walk as they get older. Children who continue to toe walk past this age may have some underlying issue that needs to be addressed by a health care provider (Morozova et al., 2017). As previously stated, some cases of toe walking are classified as being idiopathic, meaning that there is no known cause for the behavior. Research has said that although toe walking that is classified as idiopathic is usually benign, caregivers and health care providers need to keep a close eye on the child’s development as well as their gait (Pomarino et al., 2017; Engström and Tedroff, 2018).
Research demonstrates that toe walking can have serious physical consequences for children’ physical development, which can even create problems when children are older. For example, tight calf muscles and Achilles tendons of children who persist in toe walking can be a problem for their development of other skills that require running, jumping and general physical fitness. (Morozova et al., 2017)
In addition to physical effects to a child who persists in toe walking there are social issues as well. For example children who toe walk may be quite self-conscious of their own gait while children with normal gait patterns may tease children who toe walk in an attempt to embarrass them. When a child is embarrassed by the way that he or she walks and this embarrassment results in the child avoiding certain sports or games then this child’s opportunities for normal motor play are decreased which can result in lowered self esteem. Thus, in order to be able to better meet the needs of the children in your care it is very important that you have a good understanding of all of the possible reasons for a child’s persistence in toe walking and of the various effects that such behavior can have on that child’s development.
In some children who toe walk, there could be an underlying condition that needs to be evaluated. Therefore, healthcare professionals evaluate children with toe walking on a case by-case basis and consider the child’s age, development and whether the child has any other physical challenges such as problems with balance or other motor function skills. Children who toe walk are generally okay but about 10% of children who toe walk may have an underlying medical condition (Morozova et al., 2017).
Overall toe walking in children is normal part of growth and development, but of concern when it persists. Understanding causes of toe walking is key to monitoring development and possibly implementing interventions to promote typical development of walking.
Toe walking in children can be caused by a variety of factors, including their genetic makeup, neurological disorders, and even general developmental delays. Children with parents or siblings who were also toe walkers as children may be more likely to develop the condition. Neurological disorders, such as cerebral palsy and autism spectrum disorder, can also affect a child’s ability to control their muscles and develop balance, both of which can lead to toe walking. Finally, children with general developmental delays, including those that affect physical skills, may use toe walking as a temporary measure to help them cope with the challenges of movement.
Toe walking can impact the child’s physical growth and lead to issues within the child’s calf muscles and Achilles tendon. This in turn can create additional physical development issues. Furthermore, research has found that children who toe walk are physically delayed and can find it difficult to participate in physical activities with their peers. As a result of their physical difficulties children who toe walk can lack confidence in their ability to participate in social situations. Research by Williams and et al. (2014, found that there was a correlation between the age of onset of toe walking and the degree of physical developmental difficulties a child experiences. Children who start to toe walk at an early age are more likely to continue to experience difficulties with their walking in later years. This in turn can cause additional problems as the child attempts to master other movements such as running and jumping.
A further consideration for children who toe walk is that they may experience social impacts of their way of walking, e.g. feeling self-conscious, drawing attention to themselves. Children may notice that their peers walk differently, and feel that they are different from others. They may be the subject of teasing by their peers. Children who toe walk may be reluctant to participate in physical activities, e.g. sports, which require running, because they fear that their gait will be the subject of ridicule. The child’s reluctance to participate in certain activities can result in limited social interactions, decreased self-esteem and feelings of being an outcast. In turn, these social impacts can result in the child avoiding certain activities in an attempt to avoid ridicule, further limiting the child’s social interactions and causing decreased self-esteem.
This fear of being different may stop children who toe walk from participating in sports, games or other physical activities where they may draw attention to themselves by walking in an unusual way. Again, the child’s natural shyness may contribute to this feeling of apprehension and cause the child to be less inclined to interact with their peers and, therefore, experience a decline in self-esteem and a widening of developmental delay.
Persistent toe walking or persistent walking on the toes for long periods of time can occur in children for various reasons. Persistent toe walking can be part of a child’s normal development and then habituate. Children who persist in toe walking for long periods of time may require treatment to assist with addressing this behavior and impact on development. Treatment for toe walking on the toes for long periods of time for children includes several different interventions and strategies and understanding each of the interventions and strategies for addressing persistent toe walking in children are an important component for helping children to address the impact of toe walking on development.
A large amount of research has been completed on the physical therapy approaches used to treat persistent toe walking. The purpose of physical therapy for toe walking is to help improve the range of motion of the ankle as well as strengthen the muscles of the legs and feet to promote a typical walking pattern. Many children are motivated to perform physical therapy exercises for toe walking because the activities are completed during play. Physical therapy for toe walking can also help a child who walks on their toes to be confident in their ability to walk. Long-term effects of persistent toe walking can be prevented by participation in some children with the use of physical therapy for toe walking.
Another approach in treating persistent toe walking is through the use of orthotics. Orthotics are shoe inserts or braces, which support the foot and aid in promoting a natural walking pattern. They can be especially helpful in counteracting persistent toe walking by placing the foot in a flat position, thereby reducing the amount of time the child spends walking on their toes. However, orthotics must be monitored by a healthcare provider to confirm that they are indeed effective for the child and that they are being used correctly.
Developing a specific intervention plan for each child is important. A one-size-fits-all approach will not work and involves a team of health care providers including pediatricians, physical therapists, and sometimes occupational therapists. However, with a team of professionals, an individualized plan can be developed that not only is effective, but also fun for the child.
Another consideration is that ongoing research aims to explore and compare the most effective interventions for children with idiopathic toe walking. Bauer and colleagues (2022) and Engström & Tedroff (2018) recently conducted studies on this topic and identified the importance of early intervention. Children who start to walk on their toes at an early age benefit most from developmental interventions which promote typical walking in order to ensure well-developed skills for running and jumping and overall physical development in the long term.
New research is currently underway to investigate the most effective interventions for children with Idiopathic Toe Walking. Greater awareness of the long-term implications of Toe Walking as well as the ways in which this behavior can impact a child’s life means that there is a growing body of research exploring the most effective ways to treat and manage the condition.
Interventions to treat persistent toe walking typically include physical therapy and/or orthotics, and are often facilitated by a team of health care professionals including pediatricians, physical and/or occupational therapists and orthotists. A developmentally appropriate and individually tailored intervention approach that is engaging and fun for the child is necessary to ensure effective treatment of children with persistent toe walking.
Citations:
Bauer, J.P., Sienko, S. and Davids, J.R., 2022. Idiopathic toe walking: an update on natural history, diagnosis, and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 30(22), pp.e1419-e1430. https://journals.lww.com/jaaos/_layouts/15/oaks.journals/downloadpdf.aspx?an=00124635-202211150-00007
Pomarino, D., Ramírez Llamas, J., Martin, S. and Pomarino, A., 2017. Literature review of idiopathic toe walking: etiology, prevalence, classification, and treatment. Foot & ankle specialist, 10(4), pp.337-342. https://journals.sagepub.com/doi/abs/10.1177/1938640016687370
Morozova, O.M., Chang, T.F. and Brown, M.E., 2017. Toe walking: when do we need to worry?. Current problems in pediatric and adolescent health care, 47(7), pp.156-160. https://www.sciencedirect.com/science/article/pii/S1538544217301207
Williams, C.M., Tinley, P. and Rawicki, B., 2014. Idiopathic toe-walking: have we progressed in our knowledge of the causality and treatment of this gait type?. Journal of the American Podiatric Medical Association, 104(3), pp.253-262. https://japmaonline.org/view/journals/apms/104/3/0003-0538-104.3.253.xml
Engström, P. and Tedroff, K., 2018. Idiopathic toe-walking: prevalence and natural history from birth to ten years of age. JBJS, 100(8), pp.640-647. https://journals.lww.com/jbjsjournal/fulltext/2018/04180/Idiopathic_Toe_Walking__Prevalence_and_Natural.2.aspx
Caserta, A.J., Pacey, V., Fahey, M.C., Gray, K., Engelbert, R.H. and Williams, C.M., 2019. Interventions for idiopathic toe walking. Cochrane Database of Systematic Reviews, (10). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012363.pub2/abstract
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