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Heel First! Strategies to Prevent and Reduce Toe Walking

Heel First! Strategies To Prevent And Reduce Toe Walking

Toe Walking is defined as the failure of the heel to contact the floor at the onset of stance during the gait cycle, resulting in a bilateral toe to toe gait.

Idiopathic Toe Walking (ITW), as its name implies, refers to the manifestation of this gait pattern without a known underlying pathological cause.

This is a diagnosis of exclusion, in which other conditions causing an equinus gait have been ruled out. When the ankle joint lacks flexibility and upward, toes-to-shin movement of the foot (dorsiflexion) is limited, the condition is called equinus. 

Toe Walking Causes

The definition of toe walking is simple, but what’s not so simple about habitual toe walking is WHY?  There are many possible reasons that children might develop a toe walking pattern and the research does not definitively point to one specific cause.

Some common questions are whether children are exhibiting tactile defensiveness in their feet? 

Is there a sensory or vestibular problem?.

Or could toe walking be a warning sign of a neurological disorder like cerebral palsy or muscular dystrophy? 

Could it be a sign of autism? 

Is the child’s calf musculature so tight that he can’t put his heel down? 

Is this simply a habit that could eventually lead to tight calf musculature and the inability to put the heel down?

Differential Diagnosis

In considering differential diagnosis, at Right Start we know how  important it is to take into account any potential underlying neuromuscular or musculoskeletal conditions.

Toe walking may be caused by Cerebral Palsy, congenital contracture of the Achilles tendon or paralytic muscular disorders such as Duchenne Muscular Dystrophy.

Further Idiopathic Toe Walking may be associated with developmental disorders such as Autism or other myopathic or neuropathic disorders.

The majority of disorders causing toe walking can be ruled out through the history and physical examination, resulting in a diagnosis of Idiopathic Toe Walking.

A child with a diagnosis of ITW will present with a normal neurological exam with respect to muscle tone, reflexes, sensation and strength.

The child may or may not have a passive limitation in ankle dorsiflexion. Idiopathic Toe Walking will always exhibit bilateral and symmetrical presentation, as opposed to other neurologic conditions which may cause unilateral or asymmetric toe walking.

Sensory Connection

Idiopathic toe walking may be linked to hyper or hyposensitivity. Some children may not like the feeling of different surfaces on their bare feet, which causes them to rise up on their toes to avoid having the full surface of their feet contracting floor.

For children who are seeking more input, toe walking increases the force of impact felt during ambulation, as the ground reaction force is distributed through a smaller surface area at the metatarsal heads.

Activities to Reduce Toe Walking

First, speak with your doctor to identify the underlying causes. Then follow up with a physical or occupational therapist to develop appropriate activities  and exercises, which may include a combination of  the following:

Extend Range of Motion:

  • With the child sitting or lying back, grab one foot in your hand (knee straight) and stretch the Achilles heel cord. Hold for 1 minute.
  • Grab a wedge and have the child stand or walk up the wedge/incline.

Do Animal Activities:

  • Walk like a crab or bear with all fours on the ground.
  • Try and walk like a penguin, heels down and toes up.
  • Try a game of leapfrog, jumping, hopping, squatting and then leaping forward.

Strengthen Muscles:

  • Pick up a washcloth or marbles with your toes.
  • Balance a sock or beanbag on the foot.
  • Sit on a scooter board and move the scooter across the floor using bare feet.
  • Walk up a slide.
  • Hold a chair pose against the wall.
  • Run up a hill, stretching the tendon and muscle by keeping the toes pointed up.

Improve Balance:

  • Balance on a wobble board.
  • Walk across a balance beam, balance stones or floor spots.
  • Stand on a round air cushion and balance.

Position the Feet:

  • Wear high top shoes/rain boots/roller-skates and heavier shoes for better foot position.
  • Place a wedge under the heel to encourage heel contact.
  • Use inserts in shoes to promote good foot position.

 Increase Sensory Exposure:

  • Tape squeakers on the bottom of the child’s feet to encourage auditory feedback.
  • If noise doesn’t help, try wheeled shoes. Kids have to pick their toes up to roll.
  • Encourage barefoot walking in the grass and sand. Indoors, try setting up an obstacle course with blankets of different textures.
  • Make art using the feet with paint and paper.
  • Use joint compression to wake up the ankles. Vibration may work as well.
  • Wear scuba flippers to walk heel to toe.
  • March and stomp to make the entire foot have contact with the ground.

The idea behind these movement strategies is to help develop the whole foot, intrinsic foot muscles and lengthen the heel cord. Be creative and playful too — like the parent who taught her child “to drive” by positioning the heel on the pretend-gas pedal

Right Start Inc. is an Early Intervention agency and Autism Spectrum Disorder/ABA services provider that was founded in 2002 to provide therapeutic services to children with developmental concerns. If you found this article interesting, please contact us today to learn more.