Toe walking is probably one of the most common reasons for a child visiting an orthopaedic surgeon. While many children toe walk up to the age of 15 to 18 months, it is something that needs to be checked if your child continues to toe walk over the age of 2 years. In the majority of children, this toe walking is idiopathic. This means that there is no medical reason for your child walking on the ball of his or her feet rather than walking flat footed with a heel-to- toe strike.
Understanding a normal heal to-toe strike
Believe it or not there are a lot of different muscles involved in making sure your child walks with a good heel-to-toe strike. It is interesting to understand what takes place in the body to create a stride. This way we can appreciate how intricate proper walking is.
Heel strike– when the foot touches the floor at the start of a step your child will be making use of the dorsi flexor muscle (these pull the toes up), the hip flexor, the gluteus muscle (bottom) and the Hamstring muscle at the back of his or her thigh. Your child will be most stable in this stage of the step.
Foot flat– your child’s foot is now flat on the floor and all his or her weight is on that foot. In this position the hip extensors are working really hard.
Heel off- Now the muscles push the heel off the floor, followed by the toes being used to push the entire foot off the floor. The muscles involved here are the hip extensors and plantar flexors (they pull the toes down), the calf muscles and Achilles tendon.
The foot is lifted into the air and the other foot begins the intricate process all over again. Not so simple is it?
What happens when a child toe walks?
When a child toe walks it may just be due to habit or a reason that can’t be medically explained. In other words it is idiopathic. The muscles of the calf and Achilles tendon are long enough for your child to walk properly and there are no knee or hip problems. He or she may just have to be reminded to walk flat footed.
On the other hand some babies may be born with shortened tendons in the calf or these tendons may shorten over time. Shortened tendons would prevent your child from being able to put his or her heel onto the floor, making the heel-to-toe strike difficult.
Children with cerebral palsy, muscular dystrophy or a spinal cord abnormality may find the normal heel-to-toe strike difficult and they will need medical attention.
What should I do if my child continues to toe walk after the age of 2 years old?
If you, as the parent, are concerned about your child toe-walking then speak to your healthcare provider. There is nothing worse than worrying about possible problems later in life. A simple check-up and reassurance may be all that is required.
You do need to be concerned if your child is still toe walking at 5 years of age. A child that has difficulty wearing shoes or finds sports activities problematic because of the toe walking needs to be assessed.
What will the doctor’s assessment involve?
- Taking a full history which may include questions around prematurity, achieving of milestones, ability to walk flat footed and so on.
- A physical examination which would include observing how your child walks, tightness of the calf muscles, foot abnormalities as well as the range of motion of the knees and hips.
- A neurological examination where the doctor will check reflexes in the legs, test feeling in different parts of the body like fingertips, arms and legs as well as the strength of the muscles in the arms and legs.
- Further investigations may be indicated and if this is the case your doctor may order an x-ray, CT scan or MRI.
What can I as a parent do to help my child develop normal heel- to-toe- walking?
- Allow your child to go barefoot– This is particularly important in the early years of walking. A child that is barefoot has better control of his or her foot when it strikes the ground encouraging heel- to- toe walking. Being barefoot improves a child’s balance and body awareness making movement easier and strengthening muscles and ligaments. One must obviously be aware of protecting your child’s feet when in public space but having the opportunity to walk and run on grass or beach sand does wonders for development.
- Avoid walking rings – If you have ever watched a baby racing around in a walking ring you probably would have noticed him or her propelling themselves at high speed, using their toes. In a walker the baby is not able to learn about balance because the wheels and ring perform this function. Children who have been allowed to spend long periods of time in a walking ring have been found to be more prone to toe walking than those who have not used a walking ring.
- Provide opportunities for good sensory integration – Babies have 8 sensory systems that allow them to interact with the environment. These include the tactile system (touch), vestibular system (balance and movement), proprioception (body awareness from the muscles and joints), visual system (sight), olfactory (smell), auditory (hearing), gustatory (taste) and interoception (sense of pain, hunger and temperature. The tactile, vestibular and proprioception senses are really important for walking. A child needs loads of opportunities to develop these senses. These opportunities would include creating a little obstacle course for your child to manoeuvre around, be it while they are still gliding or beginning to walk, gentle rough and tumble, dancing, push and pull toys. Allowing your child to do activities on different surfaces like grass or sand. All of these activities will feed into the child and encourage good sensory development required for activities related to walking and running.
What are the treatment options for a child who toe walks?
Treatment will depend on the age of the child and whether your child is actually able to walk flat footed or not.
- If your child is very young and the are no medical reasons for this problem then your doctor is most likely to suggest encouraging your child to walk properly or getting the assistance of a paediatric physiotherapist that is able to provide exercises to get your child walking normally.
- Non-surgical treatments include:
- Serial casting – these are short leg casts which slowly stretch and lengthen the muscles and tendons to allow for normal heel-toe walking. A series of casts are used over a period of a few weeks.
- Bracing- this involves your child wearing an ankle-foot orthosis (AFO) which holds the foot at a 90 degree angle for a couple of months. In this time the muscles and tendons are stretched to allow for normal walking.
- Botox-this treatment is usually used for children with neurological problems. The Botox weakens the calf muscle for a short period of time making the muscles and tendons stretch more easily during casting or bracing.
- Surgical treatments are really a last resort. Unfortunately, there are children who have toe walked for so long that walking flat footed is just not possible. Under these circumstances an orthopaedic surgeon may need to surgically lengthen the Achilles tendon to allow the foot and ankle to function properly.
Conclusion
It goes without saying that if you as the parent are concerned about the toe-walking or any other developmental issue, rather seek help early. Above all else allow your child to play. Give your child loads of opportunities to chase after the dog, barefoot and carefree. Get your children off the couch and away from screens. Untold delays in development are being caused because children are not being allowed to be children. Allow your child to explore, climb, run and jump. These little bodies need to be used so that normal development can take place.
