The Curious Case of Toe Walking

Written by Kent McCuistion

Why physical therapists look for heel strike, and when it’s worth changing.

Two six-year-olds walk into the clinic on their toes. One has done it since her first steps. She walks with her heels down when asked, keeps up at recess, and has no pain. The other used to walk heel-to-toe and recently started rising onto his right forefoot. Both referrals say toe walking. My first question for either family is “Has your child always walked this way?” A longstanding, symmetrical pattern and a new, one-sided change send the exam in different directions. British consensus on idiopathic toe walking · Neurology referral study · Spinal MRI referral study

Why is PT so obsessed with heel-to-toe walking?

“Walk heel to toe” might be one of the easiest cues to give in PT. You can see whether it worked from across the room. The harder question is whether it helped.

There’s a good reason we watch the heel. In typical level walking, the heel contacts first and acts as a pivot while the muscles at the front of the shin control how quickly the forefoot lowers. Watching that transition tells us something about how the person accepts weight and controls the foot. When a child who usually walks on their toes can bring their heels down on cue, we also learn that they can access that movement in the moment. Gait mechanics · AAOS on toe walking

The trouble starts when the cue becomes the goal. A child can give you ten beautiful heel-to-toe steps down the clinic hallway. Did anything get easier? If their calves hurt halfway through recess, I want to know whether they can play longer with less pain. If they have an ankle contracture and can’t stand with their heels down, I want to know whether they gain enough motion to do it. Those are changes I can explain to the child and family. British consensus on treatment goals

What about autism, ADHD, and developmental delays?

Persistent toe walking is more common in autistic children. A 2024 study of nearly 285,000 children ages 3–17 found documented persistent toe walking in 6.3% of autistic children versus 1.5% of children without autism. That’s about four times the adjusted odds. An earlier insurance-claims study found the same direction of association. A child’s gait on its own tells you little about whether they’re autistic. 2024 health-system study · 2019 insurance-claims study

The evidence for other developmental differences is thinner. One clinical study found toe walking in 20.8% of 312 children with ADHD after excluding children with autism. Small referral studies have also found speech, language, and motor delays in children who toe walk. These findings give me a reason to ask about milestones and coordination during the history. They leave plenty of uncertainty about how common those differences are in the wider population. ADHD study · Developmental evaluation study

Sensory processing may play a role for some children, and studies of idiopathic toe walking show substantial variation. I’d ask when the family notices the pattern and whether it changes barefoot, in shoes, or across surfaces. That can help describe when the child uses it. The 2024 British consensus allows autism and ADHD to coexist with idiopathic toe walking. Sensory processing systematic review · British consensus

Clinical findings and treatment emphasis

Clinical finding. Where I’d put the emphasis. Bilateral toe walking since first steps, heels down on request, and no pain or activity limits. Compare spontaneous and cued gait. Check developmental history, strength, ankle range, and the neurologic screen. If the exam supports asymptomatic idiopathic toe walking and there’s no contracture, reassurance is reasonable. Limited passive ankle dorsiflexion. Measure with the knee flexed and extended and the heel neutral. Check whether the child can reach a flat-foot position. A contracture changes the management discussion and can occur with either idiopathic or neurologic toe walking. Pain or difficulty with an activity the child cares about. Measure that problem directly. If calf pain cuts recess short, track how long the child can play and how their legs feel afterward. New onset after a period of heel-to-toe walking, clear asymmetry, or abnormal neurologic findings. Prioritize pediatric medical evaluation. Ask about changes in strength, endurance, or previously acquired motor skills.

British consensus on assessment and treatment · Neurology referral study · Spinal MRI referral study

If there’s no pain, why change it?

One reason to consider treatment is concern that a child will lose ankle motion over time. In a Swedish population-based cohort, 50 of 63 children with a history of toe walking stopped spontaneously by age 10. The researchers identified a separate subgroup with early contracture. That distinction matters. A child who already lacks the motion to get their heels down has a different exam from a child who can do it easily and keeps up with friends. The British consensus says children with asymptomatic idiopathic toe walking and no ankle contracture don’t require treatment. Swedish natural history study · British consensus

What does “do no harm” look like here?

“Who defines what constitutes illness, diagnosis, treatment?”

Thomas S. Szasz, The Myth of Mental Illness, preface to the second edition (1974), p. viii

Szasz was writing about medicine and psychiatry. In a PT exam, his question makes me pause before I call a gait pattern a problem. Whose concern brought the child in, and what would the child want to be easier?

I think about what I’m asking the child and family to take on. Repeated reminders can make a child self-conscious about how they walk. Appointments take time, and braces or casts can be uncomfortable. A trial included in a Cochrane review reported calf pain and minor skin problems in both casting groups. If the only benefit I can name is that the gait might look more typical, that’s a thin case for putting the child through treatment. Cochrane review of idiopathic toe walking interventions

For the child who’s comfortable, has the ankle motion they need, and keeps up with friends, I’d explain what I found and what would bring us back to the question, such as new pain, loss of ankle motion, or trouble keeping up. For the child with a new, one-sided change, doing no harm means getting that change evaluated. In either case, I’d ask the child what they notice and whether anything about walking bothers them. British consensus on assessment and treatment

Before I write “improve heel strike” as a goal, I want to finish the sentence “Improve heel strike so the child can ___.” For the first child in the clinic, I might have a good gait observation and no reason to turn it into a goal. For the second, the priority is finding out why his gait changed.

-the pissed-off PT-comment, like, share-

References

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Kent McCuistion
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