Pediatric PT Guest Blog: Tippy Toes

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By: Dr. Joni Redlich, DPT

Reprinted with the express permission of Joni Redlich, DPT, as originally appeared on her Kid PT Blog, September 11, 2010

Children walk on their toes for various different reasons. Medical causes such as cerebral palsy and muscular dystrophy must be ruled out. This link is a good overview of toe-walking in general. I want to address some of the physical therapy specific aspects of toe-walkers.

When a child who toe walks comes to me, I first rule out any red flags. Did they always toe walk or is this new? Does the child have any stiffness or responses to a rapid stretch?

There is also some research linking toe-walking with language disorders and other neurodevelopmental disorders. Therefore, I always look at the child as a whole and ask parents about speech and school concerns as well. If I don’t see any red flags, the first thing I want to know is the child’s ankle flexibility. Can the child stand flat? If they don’t have enough ankle flexibility to walk heel-toe, that needs to be addressed first. The options for increasing flexibility are stretching, night splints , serial casting , and surgery.

Let’s say the child has adequate ankle flexibility to walk heel-toe. Muscle groups that are commonly weak are the abdominal obliques (rotators), gluteals, shoulder stabilizers and ankles. Weakness in these muscles can put a child in a forward leaning position. Once the child starts walking he would naturally walk on his toes. Strengthening these muscle groups improves postural control and helps to create a more neutral posture. Activities that strengthen these muscle groups include: wheelbarrow walk , bridges (roll a car or ball underneath), climbing on playground equipment, crawling over a mountain of sofa cushions and pillows, and standing on the bed playing catch.

Another big piece of the puzzle with children is sensory processing. Children who toe-walk should have their vestibular (inner ear balance system) system assessed. The vestibular system mediates tone, anti-gravity muscle activity and some reflex activity that affects walking, balance, and ankle control. Some signs that a child has a vestibular disorder is that they dislike swings, never get dizzy, get carsick easily, and have difficulty with ball play. Tactile defensiveness can worsen toe-walking, but isn’t likely to be a sole cause. Toe-walking increases the amount of proprioceptive (feedback from the muscles and joints) input the child is getting as they walk. Children who crave deep pressure may use toe-walking to increase that input that they seek.

Toe-walking can be a persistent habit. I used to be much more aggressive in my treatment of toe-walking, but at the moment I feel that as long as appropriately flexibility is attained/maintained and balance reactions/gross motor skills are developed, then I will let it be. There are often many other priorities to focus on.

Featured Author: Dr. Joni Redlich, DPT

Dr. Redlich is a Mom, Wife and Pediatric Physical Therapist Specializing in Children with Developmental Disabilities. She received a B.A in Psychology from Emory University and her M.S in Physical Therapy and DPT from Arcadia University (formerly Beaver College). Please visit her website at Kid PT

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