Toe walking

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Toe walking
Toe Walking in Autism 1.jpg
Toe walking
Specialty Pediatrics

Toe walking refers to a condition where a person walks on their toes without putting much or any weight on the heel or any other part of the foot. This term also includes the inability to connect one's foot fully to the ground while in the standing phase of the walking cycle. [1] [2] Toe walking in toddlers is common. Children who toe walk as toddlers commonly adopt a heel-toe walking pattern as they grow older. If a child continues to walk on their toes past the age of three, or cannot get their heels to the ground at all, they should be evaluated by a health professional who is experienced in assessing children's walking. [3]


Toe walking can be caused by a number of health conditions. When there is no medical reason for toe walking and no underlying condition can be identified, health professionals will commonly refer to it as "idiopathic" toe walking. This is not a formal or recognized diagnosis; rather, it is simply a term indicating that there is no identifiable reason or causal factor for the toe walking. [4] Idiopathic toe walking should only be considered after all other conditions have been excluded. [5] Other causes for toe walking include a congenital short Achilles tendon, muscle spasticity (commonly associated with cerebral palsy) or genetic diseases muscle disease such as Duchenne muscular dystrophy. [6] Toe walking may also be caused by a bone block located at the ankle which prevents the ankle from moving. This may be as the result of trauma or arthritis. [7] Toe walking may also be one way of accommodating a separate condition, foot drop. Persistent toe walking in children has been identified as a potential early sign of autism. [8] [9] Toe walking is commonly found in children who have been placed on the autism spectrum. [10] [11] In a recent study, 68% of children on the autism spectrum report experiencing a walking abnormality. [12] [13]

It is estimated that 5% of healthy children have no reason for their toe walking (idiopathic toe walking). [14] Idiopathic toe walking has also been observed more in males than females when very large groups of children with toe walking are observed. One study looked for a family history of toe walking, and found a connection with family members all toe walking with no medical reason (idiopathic toe walking). This means there may be a genetic link with idiopathic toe walking. [15] Idiopathic toe walking spontaneously disappears over the years in the majority of cases and is most often not associated with a motor or cognitive issue. [16]


Idiopathic toe walking is always bilateral and has no orthopedic or neurological cause. It is diagnosed after if it continues past the age of three. [17] In this condition, children are able to voluntarily walk with the typical heel-toe pattern, but prefer to walk on their tip toes. In order for it to be considered idiopathic, the child's medical history should be clear of any neurological, orthopedic, or neuro-psychiatric conditions including other gait abnormalities. [18] [19] It is thought to be related to sensory processing challenges. [20] [21] Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the toe walking based upon kinematics and ankle rockers. [22] The Pomarino classification identifies the toe walking according to the individual's specific characteristics and characterizes them into three types based on the signs presented. [23]

Cerebral palsy

Studies have been performed to determine the source of the association between toe walking and cerebral palsy. One study suggests that the toe walking—sometimes called an equinus gait—associated with cerebral palsy presents with an abnormally short medial and lateral gastrocnemius and soleus—the primary muscles involved in plantarflexion. A separate study found that the gait could be a compensatory movement due to weakened plantarflexion muscles. [24] In people who have cerebral palsy and toe walk, there is greater plantarflexion force required for normal heel-to-toe walking than for toe walking. When typically developing children are tasked to perform different types of toe walking, their toe walking could not reduce the force to the levels that children who toe walking with cerebral palsy have when they walk. This suggests that toe walking associated with cerebral palsy may be due to abnormally weakened plantarflexion that can only manage toe walking. [25]

GLUT1 Deficiency Syndrome

Toe walking is a symptom in those with GLUT1 deficiency Syndrome. [26]


There are many health professionals who assess and treat toe walking. Family physicians, neurologists, orthopaedic surgeons, pediatricians, physical therapists, physiotherapists and podiatrists are all commonly consulted. Treatment will depend on the cause of the condition. [27]


For idiopathic toe walking in young children, health professionals may prefer to watch and wait: as the child may "outgrow" the toe walking with time. [28] There are limited treatments that demonstrate long term walking change. Many treatments instead focus on any tightness in the calf muscles that can be associated with the toe walking. [29] [6] Common treatments for idiopathic toe walking can include: [29]

For toe walking which results from other medical conditions, additional specialists may need to be consulted.

Related Research Articles

<span class="mw-page-title-main">Charcot–Marie–Tooth disease</span> Neuromuscular disease

Charcot–Marie–Tooth disease (CMT) is a hereditary motor and sensory neuropathy of the peripheral nervous system characterized by progressive loss of muscle tissue and touch sensation across various parts of the body. This disease is the most commonly inherited neurological disorder, affecting about one in 2,500 people. It is named after those who classically described it: the Frenchman Jean-Martin Charcot (1825–1893), his pupil Pierre Marie (1853–1940), and the Briton Howard Henry Tooth (1856–1925).

<span class="mw-page-title-main">Cerebral palsy</span> Group of movement disorders that appear in early childhood

Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation, vision, hearing, and speaking.

Spasticity is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.

<span class="mw-page-title-main">Ankle</span> Region where the foot and the leg meet

The ankle, the talocrural region or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

<span class="mw-page-title-main">Gait analysis</span> Study of locomotion

Gait analysis is the systematic study of animal locomotion, more specifically the study of human motion, using the eye and the brain of observers, augmented by instrumentation for measuring body movements, body mechanics, and the activity of the muscles. Gait analysis is used to assess and treat individuals with conditions affecting their ability to walk. It is also commonly used in sports biomechanics to help athletes run more efficiently and to identify posture-related or movement-related problems in people with injuries.

<span class="mw-page-title-main">Functional electrical stimulation</span> Technique that uses low-energy electrical pulses

Functional electrical stimulation (FES) is a technique that uses low-energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system. More specifically, FES can be used to generate muscle contraction in otherwise paralyzed limbs to produce functions such as grasping, walking, bladder voiding and standing. This technology was originally used to develop neuroprostheses that were implemented to permanently substitute impaired functions in individuals with spinal cord injury (SCI), head injury, stroke and other neurological disorders. In other words, a person would use the device each time he or she wanted to generate a desired function. FES is sometimes also referred to as neuromuscular electrical stimulation (NMES).

<span class="mw-page-title-main">Gait (human)</span> A pattern of limb movements made during locomotion

A gait is a manner of limb movements made during locomotion. Human gaits are the various ways in which humans can move, either naturally or as a result of specialized training. Human gait is defined as bipedal forward propulsion of the center of gravity of the human body, in which there are sinuous movements of different segments of the body with little energy spent. Varied gaits are characterized by differences such as limb movement patterns, overall velocity, forces, kinetic and potential energy cycles, and changes in contact with the ground.

<span class="mw-page-title-main">Foot drop</span> Gait abnormality

Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the deep fibular nerve, including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. Foot drop is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion). Foot drop may be temporary or permanent, depending on the extent of muscle weakness or paralysis and it can occur in one or both feet. In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along the ground.

Diplegia, when used singularly, refers to paralysis affecting symmetrical parts of the body. This is different from hemiplegia which refers to spasticity restricted to one side of the body, paraplegia which refers to paralysis restricted to the legs and hip, and quadriplegia which requires the involvement of all four limbs but not necessarily symmetrical. Diplegia is the most common cause of crippling in children, specifically in children with cerebral palsy. Other causes may be due to injury of the spinal cord. There is no set course of progression for people with diplegia. Symptoms may get worse but the neurological part does not change. The primary parts of the brain that are affected by diplegia are the ventricles, fluid filled compartments in the brain, and the wiring from the center of the brain to the cerebral cortex. There is also usually some degeneration of the cerebral neurons, as well as problems in the upper motor neuron system. The term diplegia can refer to any bodily area, such as the face, arms, or legs.

A selective dorsal rhizotomy (SDR), also known as a rhizotomy, dorsal rhizotomy, or a selective posterior rhizotomy, is a neurosurgical procedure that selectively cut problematic nerve roots of the spinal cord. This procedure has been well-established in the literature as a surgical intervention and is used to relieve negative symptoms of neuromuscular conditions such as spastic diplegia and other forms of spastic cerebral palsy. The specific sensory nerves inducing spasticity are identified using electromyographic (EMG) stimulation and graded on a scale of 1 (mild) to 4. Abnormal nerve responses are isolated and cut, thereby reducing symptoms of spasticity.

<span class="mw-page-title-main">Orthotics</span> Medical specialty that focuses on the building and designing of artificial legs

Orthotics is a medical specialty that focuses on the design and application of orthoses, sometimes known as braces or calipers. An orthosis is "an externally applied device used to influence the structural and functional characteristics of the neuromuscular and skeletal systems." Orthotists are professionals who specialize in designing these braces.

<span class="mw-page-title-main">Parkinsonian gait</span> Type of gait due to Parkinsons disease

Parkinsonian gait is the type of gait exhibited by patients with Parkinson's disease (PD). It is often described by people with Parkinson's as feeling like being stuck in place, when initiating a step or turning, and can increase the risk of falling. This disorder is caused by a deficiency of dopamine in the basal ganglia circuit leading to motor deficits. Gait is one of the most affected motor characteristics of this disorder although symptoms of Parkinson's disease are varied.

<span class="mw-page-title-main">Management of cerebral palsy</span>

Over time, the approach to cerebral palsy management has shifted away from narrow attempts to fix individual physical problems – such as spasticity in a particular limb – to making such treatments part of a larger goal of maximizing the person's independence and community engagement. Much of childhood therapy is aimed at improving gait and walking. Approximately 60% of people with CP are able to walk independently or with aids at adulthood. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level, or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.

Children's feet are smaller than those of adults, not reaching full size until the ages of 13 in girls and 15 in boys. There are correspondingly small sizes of shoes for them. In poor populations and tropical countries, children commonly go barefoot.

A DAFO is a brand name for some lower extremity braces that provide thin, flexible, external support to the foot, ankle and/or lower leg. They have the particularity to fit firmly the ankle and correct concisely the foot deformity within special pressure points. It is stated to help in improving mobility and stability of the ankle joint on CP patients, evidence shows that immediate gross motor function improved with the use of DAFO's as well. Designed to help a patient maintain a functional position, a DAFO can improve stability for successful standing and walking.

<span class="mw-page-title-main">Ataxic cerebral palsy</span> Medical condition

Ataxic cerebral palsy is clinically in approximately 5–10% of all cases of cerebral palsy, making it the least frequent form of cerebral palsy diagnosed. Ataxic cerebral palsy is caused by damage to cerebellar structures, differentiating it from the other two forms of cerebral palsy, which are spastic cerebral palsy and dyskinetic cerebral palsy.

<span class="mw-page-title-main">Spastic cerebral palsy</span> Cerebral palsy characterized by high muscle tone

Spastic cerebral palsy is the type of cerebral palsy characterized by spasticity or high muscle tone often resulting in stiff, jerky movements. Cases of spastic CP are further classified according to the part or parts of the body that are most affected. Such classifications include spastic diplegia, spastic hemiplegia, spastic quadriplegia, and in cases of single limb involvement, spastic monoplegia.

Neuromechanics of orthoses refers to how the human body interacts with orthoses. Millions of people in the U.S. suffer from stroke, multiple sclerosis, postpolio, spinal cord injuries, or various other ailments that benefit from the use of orthoses. Insofar as active orthoses and powered exoskeletons are concerned, the technology to build these devices is improving rapidly, but little research has been done on the human side of these human-machine interfaces.

<span class="mw-page-title-main">Gait deviations</span> Medical condition

Gait deviations are nominally referred to as any variation of standard human gait, typically manifesting as a coping mechanism in response to an anatomical impairment. Lower-limb amputees are unable to maintain the characteristic walking patterns of an able-bodied individual due to the removal of some portion of the impaired leg. Without the anatomical structure and neuromechanical control of the removed leg segment, amputees must use alternative compensatory strategies to walk efficiently. Prosthetic limbs provide support to the user and more advanced models attempt to mimic the function of the missing anatomy, including biomechanically controlled ankle and knee joints. However, amputees still display quantifiable differences in many measures of ambulation when compared to able-bodied individuals. Several common observations are whole-body movements, slower and wider steps, shorter strides, and increased sway.

<span class="mw-page-title-main">Diane Damiano</span> American biomedical scientist and physical therapist

Diane Louise Damiano is an American biomedical scientist and physical therapist specializing in physical medicine and rehabilitation approaches in children with cerebral palsy. She is chief of the functional and applied biomechanics section at the National Institutes of Health Clinical Center. Damiano has served as president of the Clinical Gait and Movement Analysis Society and the American Academy for Cerebral Palsy and Developmental Medicine.


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