We caught up with Lead Paediatric Physiotherapist and PhD student Jack Donne from Motion Kids Physiotherapy to unpack 'Toe Walking', a topic at the centre of his doctorate research.
What is toe walking? When is toe walking a problem in children?
Toe walking is an abnormality in a child’s walking pattern characterised by walking on their tippy toes and not with a typical heel-toe walking pattern. Toe walking is a normal stage of a child’s development, however if it continues past the age of 2 – it can become problematic.
A toe walking gait pattern will normally appear as a child starts to develop walking skills. Depending on the cause of toe walking, it can occur later in development, however this is less common.
Is toe walking a symptom of autism?
Toe Walking occurs in about 5% of healthy, 5yr old children and it can be present in around 10% of children with ASD.
Children who walk on their toes are more likely to have autism than other forms of developmental delay, according to a study published in January in The Journal of Child Neurology.
Many studies of children with autism report problems with gait, or alignment while walking. Of these, one of the most commonly described is persistent toe walking — for longer than three months after learning to walk — and tight heel cords, which restrict ankles to a 90 degree angle.
How do I know if a child is ‘toe walking’?
Toe walking is normally easy to identify. A child will typically walk or run on the balls of their feet i.e., on their tippy toes. This may happen all or some of the time and may get better or worse when running.
Can toe walking in children become a problem?
Toe walking is associated with the following disabilities:
- Cerebral palsy
- Neuromuscular disorders
Toe walking becomes an issue for a variety of reasons:
- Firstly, toe walking can affect a child’s ability to participate in gross motor activities such as playing sports, climbing play equipment, or balancing activities.
- Children with toe walking are also at a higher risk of falls and sports related injuries.
- Toe walking can often be associated with tight or weak muscles, or changes in their ability to interpret sensory information.
- If left untreated it can cause musculoskeletal issues and injuries by placing increased stress on the child’s feet.
- It can also impact children as they may not be able to keep up with their peers at school, in sports or on the playground.
What causes toe walking in children?
Toe walking can occur for no known reason. Children will toe walk due to either a musculoskeletal cause, neurological cause, sensory processing change or a combination of any of these.
In autistic children (children with an autism diagnosis, it is normally due to tight muscles and sensory processing behaviours.
The biggest misconception when it comes to toe walking is that it is caused by tight calf muscles. Whilst this is true sometimes, children who toe walk have a huge variation in the way that they present.
Sensory processing issues, weakness, neurological changes, motor development and muscle tightness should all be taken into consideration when being assessed for toe walking.
Toe walking can be tricky to treat – so getting a professional with experience in toe walking is essential to get an individualised program to tailor the treatment to the cause of your child’s toe walking.
How do I get a toe walking diagnosis for my child?
Toe walking is often a symptom, not a stand-alone diagnosis. A medical professional is required to diagnose common conditions associated with toe walking such as ASD, cerebral palsy, and musculoskeletal conditions.
Physiotherapists (especially paediatric physiotherapists) can assess the child’s toe walking and determine why a child is toe walking, and what can be done about it.
Do I need to treat my child's toe walking?
Yes. Physiotherapists and paediatricians are often the first point of call for management of toe walking. They will often work together to determine why a child is toe walking and how to best manage it. The cause of toe walking will often dictate the management – and there is no one size fits all approach for treating this condition.
Treatment options range from surgery to lengthen the calf, Botox injections, serial casting, AFO prescription, stretching and strengthening exercises, gross motor skill practise, sensory integration therapy and much more.
How do I get NDIS funding to address toe walking in children? What NDIS funding do I ask for?
Physiotherapy can be used under the NDIS to treat toe walking. Medical appointments with doctors are not covered by the NDIS.
Physiotherapy services fall under the improved daily living category. This category includes therapies such as Physiotherapy, speech pathology, occupational therapy, and early intervention therapists. If a child has no improved daily living funding a report is normally needed.
This report will be different depending on the age of the child but should include:
- How does a child’s toe walking prevent the child from participating in activities?
- Does the child require a higher level of support because of toe walking?
- Does the child require any assistive technology (AFO’s, shoes, insoles, equipment as a result of their toe walking)
- What does the child’s toe walking stop them from doing on a day-to-day basis?
There are a variety of assessments that can be included to help with report writing. These assessments will be carried out by your physiotherapist and normally include the child’s gross motor skills, balance, sensory processing abilities and strength and range assessments.
What NDIS Goals do I need in my child's NDIS plan?
The goals that justify funding for toe walking are normally aligned with a child’s NDIS goals.
The main point to think about when brainstorming goals are ‘what is my child unable to do because of toe walking.’
They might be unable to keep up with their friends at school, or unable to ride a bike or to take part is sporting activities. They might have certain sensory seeking or avoidance behaviours or be in pain due to toe walking.
These limitations might suggest Goals like: "To help improve Johnny's social participation" (keep up with friends) "To participate with the rest of the family" (riding bike" "Increase their access to the community" (avoidance/sensory)
Case study – Eddy's Story
Jack met Eddy when he was 5 years old. Eddy lived with a diagnosis of autism and had toe walked since he could walk. Upon assessment, Eddy had significant tightness in both his calves, tactile sensory seeking behaviours and reduced balance.
Eddy was struggling to make friends at school as he couldn’t run and keep up with his friends, would often fall and injure himself and was often teased for the way he walked.
Through a combination of stretches, footwear and sensory insoles, sensory integration therapy, gait retraining and hard work, Eddy was able to adopt a natural walking pattern and avoid surgery. Eddy is now much more confident at school, top of the class in PE and at reduced risk of significant falls and injuries in the future.
If your child is a toe walker and you would like to get in touch, please don’t hesitate to reach using the details below
ABOUT THE AUTHOR:
Jack Donne is a paediatric physiotherapist and owner of Motion Kids Physiotherapy. He has had many years of treating children who toe walk, both in hospitals and in private practice.