Toe walk­ing is sim­i­lar to tip­toe­ing. It’s where a per­son walks on their toes or the balls of their feet with­out their heels touch­ing the ground. In adults, tip­toe­ing is nor­mal and rep­re­sents an ef­fort to walk qui­et­ly, where­as in chil­dren it may be ab­nor­mal. Most of the time, it is nor­mal. So, for ex­am­ple, it’s nor­mal in some tod­dlers. It oc­curs in about one in every 200 tod­dlers and usu­al­ly dis­ap­pears by the time they are three. Some­times it be­comes a habit and per­sists past three. This re­quires eval­u­a­tion.

Most toe walk­ing in chil­dren over the age of three is called id­io­path­ic. Id­io­path­ic is the term doc­tors use when there is no or­thopaedic or neu­ro­log­i­cal cause and we don’t know why it is hap­pen­ing. It makes us doc­tors ap­pear in­tel­li­gent. Eighty or 90 per cent of the time, id­io­path­ic toe walk­ing dis­ap­pears spon­ta­neous­ly by age 10.

Id­io­path­ic toe walk­ing runs in fam­i­lies, so it’s a fa­mil­ial ten­den­cy to walk on the toes. Some­times it’s due to the fact that these fam­i­lies have short­ened Achilles ten­dons, the ten­don that rais­es the heel off the ground, so they have a prob­lem putting their feet flat on the ground.

Toe walk­ing can be­come a habit and per­sist, to some de­gree, in­to adult­hood. The oth­er long-term ef­fect, if the heel sel­dom makes con­tact with the ground over a long pe­ri­od, is that the calf mus­cles tight­en and you have per­ma­nent­ly short­ened Achilles ten­dons.

What to do? Usu­al­ly noth­ing ma­jor. All tod­dlers who toe walk should have a more de­tailed de­vel­op­men­tal as­sess­ment than the one they should be hav­ing at every vis­it to the doc­tor or Health Cen­tre, and pro­vid­ed this is nor­mal, every­one re­lax­es. You can cer­tain­ly try to urge the child not to toe walk, but that sel­dom hap­pens spon­ta­neous­ly be­fore three, when the toe walk­ing mys­te­ri­ous­ly dis­ap­pears. Of course, if you or the phys­io­ther­a­pist have been try­ing to do ten­don-length­en­ing ex­er­cis­es, you will con­clude that your ef­forts have paid off. But, as hap­pens with most mi­nor child prob­lems, the age­ing process solves most of them. Any­way, it’s al­ways nice for you or the ther­a­pist to be­lieve that you have “saved” the child. It’s not al­ways nice for your bank ac­count.

The alarm­ing thing about toe walk­ing is that it is as­so­ci­at­ed with two not very nice con­di­tions, cere­bral pal­sy (CP) and autism spec­trum dis­or­der (ASD). CP oc­curs when there is dam­age to the part of the brain that con­trols the mus­cles. This usu­al­ly hap­pens dur­ing preg­nan­cy or birth. It of­ten re­sults in spas­tic­i­ty or in­creased mus­cle tone, lead­ing to a short­ened Achilles ten­don and toe walk­ing. The child can­not phys­i­cal­ly flat­ten their heels to the ground when stand­ing. Uni­lat­er­al toe walk­ing is ab­nor­mal and can be a sign of CP and may be ac­com­pa­nied by fre­quent trip­ping and falling. A child with CP usu­al­ly has oth­er de­lays in de­vel­op­ment, such as speech and fin­ger agili­ty.

Toe walk­ing is much more com­mon in chil­dren with ASD and oc­curs in about one in every 10 cas­es. Since ASD be­came pop­u­lar among teach­ers, this is what brings most chil­dren with toe walk­ing to the doc­tor’s at­ten­tion these days.

It’s im­por­tant to re­alise that most chil­dren with ASD do not toe walk, and toe walk­ing is not char­ac­ter­is­tic of chil­dren with ASD or any oth­er sen­so­ry pro­cess­ing dif­fi­cul­ty. Some autis­tic chil­dren, how­ev­er, do use toe walk­ing as a form of stim­ming (self-stim­u­la­tion) to gain ex­tra feed­back about their bod­ies or calm their ner­vous sys­tems.

There are some oth­er caus­es of toe walk­ing, and it’s good to know about them. Chil­dren with pain in their heel walk on their toes to re­lieve the dis­com­fort. Heel pain can oc­cur when the heel be­comes ir­ri­tat­ed from sports, run­ning, rapid growth and even in­jury.

An­oth­er cause is flat feet or fall­en arch­es. This can cause heel pain and is part of the ex­am­i­na­tion of any child with heel pain or toe walk­ing.

Most toe walk­ing is there­fore harm­less and re­solves spon­ta­neous­ly. Oc­ca­sion­al­ly, there is an un­der­ly­ing prob­lem, so toe walk­ing should not be dis­missed. It may need eval­u­a­tion by a pae­di­a­tri­cian and neu­rol­o­gist and some­times an or­thopaedic sur­geon. But most of the time, there is no re­al dif­fi­cul­ty in func­tion­ing. Since it is not a ma­jor prob­lem and most of the time it re­solves spon­ta­neous­ly, lit­tle re­search has been done on it, and this ex­plains the pauci­ty of in­for­ma­tion for par­ents, but it al­ways needs to be eval­u­at­ed.