Toe Walking

Have you ever noticed your child walking around on his/her tiptoes and wondered if it’s a real medical condition needing medical treatment or if it’s “just a phase”? Or have you ever noticed as an adult how your walking pattern causes your heel to lift off before your other foot has made contact on the ground? This is commonly known as toe-walking or having an equinus gait.

What Is Toe-Walking?

Despite popular belief, toe-walking is not a condition strictly involving children. It can be found in adults as well, though it is more common in children. Toe-walking is traditionally defined as the way in which the patient walks on their “tiptoes” or “balls of their feet” with their heels lifted off the ground, unlike a normal heel to toe gait. This condition is also known as an equinus gait pattern and it is typically regarded as hereditary trait wherein the Achilles tendon is shorter or tighter than normal. There are several ways to spot and treat this condition. And no, simply telling your child to “stop walking that way” isn't going to work. 

Is This Normal?

A very common question is “is toe-walking normal?”. Yes, it is normal to see your child toe-walking particularly in the early stages when they are 3 years of age or younger. However if the child is above the age of 3 and they do not display a normal heel to toe gait pattern, this can be an early sign of toe-walking. There are a few reasons why this might happen. First and foremost would be that there is a strong correlation with a hereditary component. Underlying neurological conditions such as cerebral palsy, autism, or even pathologies/injuries related to the posterior muscle group can be factors. 

Are There Different Types?

There are 3 main types of this deformity: uncompensated, fully compensated, and partially compensated:

- Uncompensated is the most noticeable and recognizable. The tension force of the tight achilles is not being compensated or counteracted by other joints or tendons in the foot. This is when the person walks on the balls of their feet without the heels ever contacting the floor as they walk. 

- Fully compensated usually demonstrates a greater arch collapse due to the surrounding joints compensating for the tight Achilles. Though this type of compensation does not produce a bouncy gait and the manner in which the person walks appears to be normal, this is in fact the worse type. The ligaments holding the bone structure together are more laxed leading to a lower arch. A collapsed or flattened arch translates to inadequate and inefficient push off of the great toe, producing a slower cadence. This means patients in this category quickly fatigue and are likely to abstain from physical activities such as exercise and sports. 

- Partially compensated is a milder form of the fully compensated foot. It normally is associated with a “bouncy” gait. The contracting force only partially affects neighboring joints and ligaments which means the heel lowers to the ground more than if it were uncompensated but not enough to produce a stable heel to toe gait. 

What Are The Available Treatments?

Physical therapy and stretching exercises can help to gently and serially stretch the tight tendon over time. Certain leg braces such as an AFO or night splints can be utilized as well to lengthen the tendon, though these methods rely heavily on patient compliance. Serial casting with below knee casts can be done if the toe walking gait is diagnosed at an early age. Botox injections can also help stretch the tight muscle complex, though it is rare. When conservative measures fail, surgical tendon lengthening of the posterior muscle compartment of the leg can assist in achieving a more plantigrade foot. It is noteworthy however that if the primary cause for the gait is related to cerebral palsy, autism or other neurological issues, these issues need to be examined and options need to be evaluated in tandem with a neurological consult.