Children who walk on tiptoe

In brief

Walking on tiptoe is fairly common when children first start to walk. If it continues beyond the age of 2–3, an assessment is advisable to identify the cause and check for tightness of the calf or Achilles tendon. In many children it is idiopathic, with no underlying condition to explain it. Treatment may include observation, physiotherapy, orthoses, serial casting or, in selected cases, surgery.

Typical age

Common when first walking; worth assessing if it persists after age 2–3

Also known as

Idiopathic toe walking · Idiopathic equinus gait · Equinus gait · Equinus foot

What is it?

Walking on tiptoe means the child lands on the front of the foot, without the heel usually touching the ground while walking. In the first steps this can be part of learning to walk normally, as the walking pattern is still maturing.

When this way of walking persists, it is important to distinguish idiopathic toe walking from other causes. Toe walking is called idiopathic when the child walks this way without any neurological, muscular, structural or other cause being found. It may affect both feet and continue as a habit, although some children gradually develop a limitation in bringing the ankle upwards.

Persistent toe walking can be related to tightness of the gastrocnemius-soleus complex and the Achilles tendon, which limits the ability to put the heel down. It can also occur in certain neurological or neuromuscular conditions and in children with developmental differences. It should therefore not be put down to habit without a proper assessment.

The course varies. Some children stop walking on tiptoe on their own, while others keep the pattern or develop ankle stiffness. Early assessment identifies the cases that need follow-up or treatment and helps choose the most suitable option.

Signs parents may notice

The most common signs are:

• The child walks mainly on the front of the feet.
• The heels barely touch the ground when walking or running.
• They walk on tiptoe both barefoot and in shoes.
• They may be able to put their heels down when asked, even if it feels uncomfortable, or may be unable to do so.
• The calf muscles look or feel tight.
• They trip often, get tired when walking or have difficulty joining in some activities.
• Toe walking affects both feet or is sometimes clearly more marked on one side.

It is important to notice whether the child can walk with the whole sole of the foot on the ground when asked. It also helps to remember whether they ever walked normally with their heels down and then started walking on tiptoe.

When to see a specialist

It is advisable to see a specialist if toe walking continues beyond the age of 2–3, especially if it is frequent, does not improve or limits the child’s activities.

An assessment is advisable if:

• The child cannot get their heels down to the ground.
• Toe walking is more marked on one foot than the other.
• The ankle is gradually losing movement.
• There is pain, excessive tiredness, frequent falls or difficulty walking.
• The child used to walk normally with their heels down and has started walking on tiptoe persistently.
• There are motor delays, weakness, loss of previously acquired skills or other signs suggesting a neurological or neuromuscular cause.

When is it urgent?

An urgent medical assessment is needed if the child’s walking changes suddenly and is accompanied by new weakness, loss of skills, severe pain or inability to walk.

How is it diagnosed?

The diagnosis is based on the clinical history and physical examination. The specialist asks when the toe walking started, whether it has been present since the first steps, whether it affects one or both feet and whether the child can put their heels down voluntarily.

The examination assesses:

• Ankle movement: whether the child can bring the foot upwards with the knee both straight and bent. This helps identify whether the tightness is mainly in the gastrocnemius or whether there is more general tightness of the gastrocnemius-soleus complex and Achilles tendon.
• Foot flexibility: whether the foot can be placed in a neutral position and whether there is any associated deformity.
• Walking: how the child walks barefoot and in shoes, whether they can put their heels down and whether there is any asymmetry.
• Neurological and muscle examination: strength, tone, reflexes, balance and motor development are assessed when indicated.

In idiopathic toe walking, the neurological examination is usually normal and no other cause is found to explain the pattern.

Not every child needs further tests. If there are warning signs or doubts about the diagnosis, specific tests such as blood tests, X-rays, MRI or neurological studies may be requested, depending on the clinical suspicion.

Treatment

Treatment depends on age, how long the toe walking has lasted, the ability to put the heels down, the degree of muscle tightness and the cause identified. Not every child needs treatment, but it is important to detect whether toe walking is causing a progressive loss of movement.

Conservative treatment

1. Observation and follow-up

In young children with good ankle movement and no warning signs, clinical follow-up and monitoring may be enough. The decision depends on age, how often the child walks on tiptoe and the examination findings.

2. Physiotherapy and stretching

Physiotherapy can help maintain or improve ankle movement, work on walking control and provide exercises tailored to each child. Stretching should be individualised according to whether there is muscle tightness. On its own, it does not always correct persistent toe walking.

3. Orthoses, especially at night

In selected children, orthoses can help keep the ankle in a good position and prevent further loss of movement. Night orthoses may be an option when there is a tendency to tightness or as an add-on to other treatments.

Whether they are suitable depends on ankle flexibility and how well the child tolerates them. They are not needed in every case and do not replace an assessment of the cause.

4. Serial casting

When tightness prevents the heel from reaching the ground, serial casts can be used to gradually increase ankle dorsiflexion. The casts are changed regularly, usually every one or two weeks, according to the specialist’s plan.

The total duration depends on the degree of stiffness and the response to treatment. After casting, an orthosis and exercises may be needed to maintain the movement gained.

Surgical treatment

Surgery is reserved for selected cases with significant tightness of the gastrocnemius-soleus complex or Achilles tendon, with limited movement and persistent toe walking despite appropriate conservative treatment.

The operation may involve lengthening the gastrocnemius-soleus complex or the Achilles tendon, depending on where the tightness is and the examination findings. The aim is to allow the ankle to reach a good position and make it easier to put the heel down when walking.

The technique is tailored to age, cause and degree of stiffness. It is usually performed under general anaesthesia and may require a short hospital stay. After the operation, some children need temporary immobilisation in a cast, followed by orthoses and physiotherapy.

If there is a neurological or neuromuscular cause, treatment must be adapted to the underlying diagnosis. Surgery is not recommended simply because a child walks on tiptoe: a functional indication must be demonstrated and the benefits and risks carefully weighed.

Outlook and recovery

The outlook depends on the cause, age and ankle flexibility. Some children improve on their own, while others need treatment to regain or maintain good movement.

Timescales are approximate and must be adapted to each case:

• With observation or physiotherapy: follow-up continues over the following months to check how walking and ankle movement are progressing.
• With serial casting: each cast is usually kept on for about one or two weeks, and the full course may last several weeks. Movement is then reassessed and a decision made on whether an orthosis is needed.
• After surgery: immobilisation may be needed for several weeks, depending on the technique. Weight-bearing is allowed according to the procedure performed and the medical team’s instructions.
• School: a return is usually possible when the pain is under control and the child can get around safely, taking into account whether they have a cast, orthosis or walking aids.
• Return to sport: should be gradual, once movement, strength and functional walking have been regained, and always following the specialist’s advice.

Follow-up is important to make sure the movement gained is maintained and that the child can put their heels down when walking. In some cases the tendency to walk on tiptoe may persist, so treatment should be adapted as things progress.

This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.