After the cute and clumsy stage of learning to walk, my daughter quickly developed a new skill: toddling on her toes. People urged me to put her in ballet as she tiptoed around in her soft-soled shoes. I bought her a tutu, signed her up for an intro to dance class and figured she was destined for stardom. But then another mom crushed my dreams, telling me her son also walked en pointe, and he wasn’t a prodigy—he was born with a short Achilles tendon. At my daughter’s two-year checkup, our doctor concluded she had tight calf muscles and recommended a few simple stretches.
Toddlers are a curious bunch and often spring onto their little piggies to catch some of the action that’s happening above. And in the first six months of independent walking, it’s normal for them to spend some time on their toes, says Liesa Persaud, a paediatric physical therapist who gives seminars on toe-walking around the world. However, “if your child is on their toes for longer than six months, it’s problematic, and you should get it looked at,” she says. During that period, their tiptoeing should be decreasing.
There are a number of reasons a child may continue walking on their toes, but often no underlying cause can be found. A study published in the Pediatrics found that five to 12 percent of healthy kids toe-walk for no apparent reason. Sometimes it becomes an unconscious habit and is even encouraged by parents who think it’s cute (oops!). The cause could be as benign as going through a growth spurt.
“As kids grow, the bones in the legs get longer first and the muscles stretch and catch up later,” says Howard Green, a podiatrist in South Surrey, BC. “It’s like pulling an elastic band. Your calf muscle attaches to the back of your knee and the back of your heel, and if you extend those two points, the band gets tighter. Kids are often more comfortable if they lift up their heel, because it reduces the strain.”
But in other cases, toe-walking is associated with sensory problems, like vision impairment and sensory processing disorder, and developmental delays. Often, kids with sensory issues can’t tolerate certain textures underfoot. Some children who were born prematurely do it because they had their heels repeatedly pricked for blood tests and have tissue damage that makes their heels hypersensitive. Toe-walking can even be an early sign of cerebral palsy, muscular dystrophy and autism, so it’s important to get it checked out. A study published in the journal Brain & Development found that 19 percent of children with autism toe-walk, which may be because they’re prone to repetitive behaviours or have sensory issues.
“Toe-walking has become a huge problem in the past 12 years or so,” Persaud says. “We now have increased rates of autism, prematurity and inactivity in children, and those three factors are contributing to the increased rates.” Left untreated, toe-walking can lead to pain in the feet, back, hips and neck, as well as clumsiness.
A Swedish study published in Pediatrics found that by the age of five and a half, more than 50 percent of toe-walkers stop on their own. But the best time to intervene is before age three, says Persaud, so movement patterns don’t become too ingrained or the structure of the foot doesn’t change. “When you’re born, your bones are very soft, and they get firm as you get older. The bones in the foot are firm by about six years of age,” she says. “If you think your kid will outgrow it and they don’t, at that point it could be too late.”
There are a number of treatments available for toe-walking, but finding the right one depends on the underlying cause. For children who don’t like the feeling of their heels on the ground, Persaud suggests exposing their feet to increasingly intense textures, starting with cotton balls and working up to pebbles, for example. Activities that improve balance, control and strength—such as yoga, martial arts and skating—can help those who have become toe walkers out of habit. Children with tight calves can do stretches with the help of a therapist or a parent. If the toe-walking persists, they may be given Botox injections to temporarily paralyze the muscle, followed by serial casting, which involves placing fibreglass casts at progressive angles, to stretch it. In rare cases, the Achilles tendon is surgically lengthened.
Malva Nunez Schmidt’s son, Logan, was two and predominantly walking on his toes when he saw an occupational therapist, who recommended some stretches and exercises. Logan didn’t like loud noises or getting dirty, so Nunez Schmidt, who lives in Duncan, BC, figured his toe-walking was sensory related. At home, Nunez Schmidt’s husband built ramps for Logan to climb up and jump off, because walking on an incline can help. “We made it into a game, so he had no idea he was doing his exercises,” she says.
Nunez Schmidt also bought Logan a pair of rigid thick-soled shoes a size too big so he couldn’t get up on his toes in them. After about six to eight months, she noticed some improvements, but Logan, now four, still tiptoes around the house, and his toddler sister has started copying him. “‘Heels down’ is the catchphrase around our house,” Nunez Schmidt says.
The stretches helped my daughter keep her heels down most of the time, but her old habit recently re-emerged with a vengeance. She’s now seven and in the 97th percentile for height, so our doctor and I agree a growth spurt is the likely culprit. This time, instead of ballet, I signed her up for skating lessons—where she’s taught to stay off her toe picks.