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Tchildren and toe walkingoe Walking
By: Leticia Hulse PT

Is toe walking part of normal walking development? Toe walking is not normal. However, there is no need for treatment intervention unless the toe walking persists for six months after the initiation of independent walking (not cruising). The majority of toe walking will resolve without modifications within that six months.

Why is it important to treat toe walking that persists? Toe walking can lead to joint pain, degenerative arthritis, knee instability, secondary injuries such as falls, and difficulty with footwear. A person who utilizes a toe walking pattern is using 53% more energy than a person using a normal heel to toe gait (Neptune, R et al 2007). Toe walking decreases heel impact when walking which can lead to secondary impairments. Heel impact when walking stimulates hip and abdominal muscle development necessary for adequate core strength (Yaguramaki & Kimura, 20z02).

What causes toe walking & what are the treatments? There are several different causes of toe walking including: core weakness, muscle tightness, spasticity (usually cerebral palsy), sensory needs (autism or sensory processing disorder), habitual or idiopathic.

Children with developmental delay often demonstrate a weak core and poor balance. Children may compensate with a stepping strategy to shift weight, align joints and stimulate muscle activation. These children benefit from strengthening and balance training to stimulate normalized muscle activation and proprioception strategies. Children with developmental delay may also have muscle tightness which can occur without the weakness. While passive stretching can be beneficial, activities that promote active strengthening tend to be more effective and easier to implement. Other techniques that may be warranted include bracing, taping, and muscle stimulation techniques. When muscle spasticity is assessed a more aggressive treatment approach is required. These techniques include activities for strengthening, stretching, proprioception training, activity modification, and the additional possibilities of casting, Botox injections, and splinting.

For children who need higher levels of sensory input, toe walking provides increased proprioception into the joint and higher impact through the leg with initial contact. Children who avoid sensory input will toe walk (especially when barefoot) to minimize contact with surface area thus decreasing unwanted input. If sensory input is the cause of the toe walking it is important to assess vestibular, proprioception, tactile, visual, auditory and olfactory responses in order to apply the correct treatment modifications. Treating one area of sensory input will not result in lasting effects, so all areas must be addressed to be effective.

Children who present with toe walking benefit from gait training in combination with specific treatments for their specific diagnosis. There is much debate on habitual or idiopathic toe walking, however, most sources agree that a combination of the above techniques is generally effective in normalizing gait when a cause is not clearly identified.

Hannibal Regional Healthcare Systems Pediatric Therapies are well equipped, well trained, well educated, and experienced in the assessment and treatment of children who need treatment for toe walking. If you have a patient that you would like to have further assessed and/or treated for toe walking please call 406-5777 or fax an order to 231-1034.

Yaguramaki n & Kimura T: Acquirement of Stability and Mobility in Infant Gait. Gait Posture. 2002:16(1): 69-77.