Toe walking can occur in all children under the age of 2 as part of early walking exploration and development. However, if toe walking continues longer than six months after a child’s first independent steps or becomes a new walking pattern, it should be assessed by a physical therapist. A thorough examination determines the cause of toe walking and sets a course of treatment. In some cases, toe walking may indicate other underlying conditions beyond a muscle or bone concern. A toe-walking pattern may be classified as “idiopathic,” meaning the cause is unclear; however, other possible causes must be ruled out first.

Toe walking can result in balance and activity limitations, pain, difficulty tolerating shoes, or limited participation in sports and other activities. A physical therapist provides evaluation and treatment to improve walking and help determine if additional medical assessment is needed.

Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.

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On this page

• What Is Toe Walking?
• Signs and Symptoms
• How Is It Diagnosed?
• How Can a Physical Therapist Help?
• Can This Injury or Condition Be Prevented?
• What Kind of Physical Therapist Do I Need?

What Is Toe Walking?

Toe walking occurs when the heel does not or cannot contact the floor during part or all of walking. Some causes include:

• Muscle conditions (like muscle shortening or weakness).
• Skeletal conditions (including clubfoot, leg length differences, or limited joint motion).
• Neurological disorders (including cerebral palsy, muscular dystrophy, or spina bifida).
• Neuropsychiatric conditions (including autism spectrum, sensory processing, or attention-deficit/hyperactivity disorders).
• An unknown (idiopathic) cause. This diagnosis is made after ruling out all other known causes.

Toe walking can appear and is often present, from a child’s first independent steps until walking has matured. It usually lasts no longer than six months after the first steps. Children explore tiptoe standing and walking, reaching over their heads, running, and learning how their bodies feel in different positions. Toe walking typically occurs in short bursts during play or wandering and is not the dominant or only walking pattern used. If it continues more than six months after independent walking begins or is the child’s preferred walking pattern, parents should look for the following signs.

Signs and Symptoms

Seek a physical therapy evaluation if you or other caregivers (teachers or other medical providers) note any of the following about your child:

• Walking or standing up on toes consistently on one or both feet (heels do not touch the ground).
• Walking on toes only when barefoot or only when wearing shoes.
• Unable to put their feet flat on the floor while standing or walking, even when asked.
• Your child is not keeping up with peers or is tripping and falling frequently due to toe walking.
• Balance concerns (difficulty standing still, unable to stand on one foot, or difficulty navigating stairs).
• Developmental delays (including late onset of talking or limited vocabulary for age, difficulty with hand and grasping skills for age, or late movement skills like stair climbing or standing on one foot).
• Other changes to the child’s walking pattern, such as feet or legs turning out or knees hyperextending (bending back the “wrong way”).
• Changes in the shape or structure of the foot (including a wider forefoot — a larger front of the foot as measured by your physical therapist), abnormal calluses, or fat pads on the soles of the feet.

A thorough examination of your child by a physical therapist will include ruling in or ruling out specific common causes of toe walking. The examiner will ask about your child’s birth, medical, and developmental histories. This may include questions about a preterm or breech birth history, the age when your child took their first independent steps, and whether your child is walking up on toes on one or both feet. Your responses will help guide the examination and the treatment recommended.

There are five areas a physical therapist will assess:

Muscle Tone (Tension)

• Not enough muscle tension results in limited control of the lower leg as the body moves over the flat foot to take a step. The child may avoid this challenge by staying up on their toes.
• Too much muscle tension results in limited motion of the lower leg as the body moves over the flat foot to take a step. The child may not be able to relax the muscle enough to lower the heel to the floor, thus staying up on the toes.
• Changes in muscle tone may require a referral to a specialist.

Muscle Strength

• Weakness in the calf muscles or even the thigh and hip muscles can result in fixed postures or avoiding motions weaker muscles cannot control.
• Avoiding the ankle motion needed for flat foot standing and walking reduces the effects of muscle weakness, leading to toe walking.

Range of Motion

• Not enough movement at the ankle joint or in the muscles can occur from a stiff joint in the ankle or foot or from a shortened calf muscle (present at birth or developed over time that can keep the heel from touching or staying on the ground).
• Too much movement at the ankle joint or in the muscles can also occur from instability or lower muscle tone. A child may choose to keep the ankle in a fixed position to avoid the excess motion.

Skeletal and Bone Alignment

• Spine: Scoliosis, an atypical curve in the spine, can result in toe walking due to the connection of the spine to the hips and legs.
• Hips/pelvis: A dislocated or unstable hip or an uneven pelvis can make a leg appear shorter on one side, resulting in a tip-toe position to “lengthen one leg” during standing and walking.
• True leg length difference: Long bones in the leg may be different lengths at birth or grow at different rates after an injury or trauma.
• Foot: Other skeletal issues like a clubfoot may change how the foot contacts the floor during standing and walking.

Sensory Components

• Touch: Standing and walking up on the toes may reduce touch sensation to the soles of the feet, a common tactic of young children trying to avoid that sensation.
• Body awareness: The nerves in the ankle joints and muscles provide a sense of body awareness in space (proprioception). Young children first learning about their body may use toe walking to increase awareness, but this sensation matures after walking is mastered.
• Motion: Children learn through movement. The extra motion and “bounce” from walking up on the toes provides more activity in the brain and more input to the movement detection (vestibular) system than walking on flat feet.
• Registration (sensing): Some children have nervous systems that need more or less information to learn and respond. Toe walking can result when a child is seeking and increasing activity or avoiding and reducing activity to control what is experienced from the environment during walking.

The cause of a toe-walking pattern may be classified as unknown (idiopathic) if all other possible causes have first been ruled out.

For toe walking to be considered of unknown origin, the child must:

• Toe walk with both feet the majority of the time.
• Toe walk without heels down past 2 years of age.
• Have an otherwise typical history of development.
• Be assessed to rule any issues in the five areas above (muscle tone, muscle strength, range of motion, skeletal/bone alignment, and sensory components).

How Is It Diagnosed?

Your child’s physical therapist can test for underlying conditions and findings that may contribute to toe walking and provide treatment and management needed. If the results of their exam suggest the condition cannot be treated only with physical therapy, they will recommend you see your child’s pediatrician or other specialist for additional evaluation to rule out a brain-related or other cause.

Your physical therapist will perform a complete evaluation to assess your child. They may ask questions such as:

• What is your child’s birth and developmental history? (This includes any history of breech positioning before birth, prematurity, a complex infancy period, a previous injury to the head or spine, or a broken leg bone from an accident.)
• What age did the child start walking?
• How long has the child been walking on their toes?
• How much of the day (or time of day) do they walk on their toes?
• Do you or any other family members have any history of toe walking or any other nerve, bone, or muscle conditions?
• Does your child have any limitations in activities or participation in play (such as navigating stairs, going on long walks, squatting, or riding a bike)?
• Is your child able to keep up with their peers?
• Does your child experience frequent falls or tripping over their own feet?
• Does your child have any other diagnoses, such as ADHD, anxiety, or speech delays?

Your physical therapist will conduct a physical examination with screening and assessment for the five areas described above, including the following:

• Reflexes.
• Flexibility and range of motion of muscles and joints.
• Strength throughout the body, including the legs and feet.
• Muscle tension (tone).
• Standing, walking, and running patterns.
• Balance and coordination.
• Gross motor skills for their specific age and development.
• Motor control (planning and using the right muscles at the right time and effort).

If concerns are found, referrals to additional specialists might include a:

• Neurologist, to assess changes in muscle tension that could be related to a medical concern or other disease or diagnosis (in the brain, at the spinal cord, or in the nerves of the legs).
• Orthopedist, to address muscle flexibility not achieved after physical therapy interventions for optimum foot contact when standing and walking.
• Orthotist, to assist with any custom foot or ankle devices to achieve joint or muscle flexibility or support a new walking pattern.

How Can a Physical Therapist Help?

Your physical therapist will use the best available evidence to develop a treatment program for your child’s specific needs, challenges, and goals. Your child’s treatment will be based on their age, the underlying cause of the condition, and the severity of the issue(s). They will work with you and your child to:

• Maintain or improve range of motion.
• Improve the gait/walking pattern.
• Build strength.
• Improve balance and coordination.
• Promote development of sensory systems and reflexes.

Interventions can include:

• Stretching.
• Strengthening.
• Manual therapy
(hands-on techniques) to improve movement and flexibility in the joints and ligaments.
• Balance training.
• Sensory-based treatments that focus on enhancing and understanding sensation (feeling) to change the toe walking pattern.
• Special treatments, like functional muscle stimulation, to train nerves and muscles.
• Retraining for walking with the heels on the ground.

Additional interventions by physical therapists and other specialists shown to be effective include:

• Orthotics/braces.
• Serial casting.
• Therapeutic taping.
• Shoe lifts.

When interventions are not working, other medical specialists may recommend more complex treatments, such as:

• Oral medications (like Baclofen) for management of high muscle tension/tone.
• Injected medications like Botulinum Toxin (Botox) delivered to the muscles of the legs.
• Surgery to the muscles of the legs.

Your physical therapy program may also include:

Patient and family education. Your physical therapist will recommend activities to complete at home, like stretching exercises or orthotic use. Parents and caregivers play an important role in the treatment of toe walking. Physical therapists will provide education on the underlying causes found during the examination process. They will provide tips and demonstrations for retraining walking and work with you, your child’s physician, teachers, and others in your child’s life.

Care coordination. Your physical therapist can work with your health care team to coordinate any need for orthotics, braces, or serial casting.

Can This Injury or Condition Be Prevented?

There is no prevention for toe walking. However, once it is identified, it can be effectively managed if addressed early (early intervention). Toe walking is linked to other secondary issues of concern, including long-term bony (skeletal) changes, pain, and balance issues. These secondary issues can be prevented with physical therapy. Early evaluation and intervention are recommended for the best outcome.

What Kind of Physical Therapist Do I Need?

All physical therapists are trained through education and experience to evaluate, manage, and treat various symptoms and conditions, including toe walking. You may want to consider seeing a physical therapist who is:

• Experienced in treating children’s conditions like toe walking.
• A board-certified clinical specialist in pediatric physical therapy, or a physical therapist who has completed a residency or fellowship in pediatric physical therapy. These physical therapists have advanced knowledge, experience, and skills that may apply to this condition.
• Focused on pediatric, sensory-based interventions.

You can find physical therapists in your area with these credentials and clinical expertise through Find a PT, a tool built by the American Physical Therapy Association.

General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family, friends, or other health care providers.
• Ask about the physical therapist’s experience with pediatrics and treating toe walking before you make an appointment.
• Be prepared to describe your symptoms in as much detail as possible. Make a note of what makes symptoms worse or better.