Should You Be Worried About Toe Walking?

A baby’s first steps are a developmental milestone to celebrate. But learning to walk is an ongoing process, and all children stumble and fall. Many children also develop a habit called toe walking.

Toe walking is very common, with one study showing that 5% of toddlers toe walk. However, most kids stop toe walking after their second birthday. So, if your toddler’s older than 2 years old and still toe walking, here’s what you should know.

Why do kids walk on their toes?

Many toddlers walk on their toes as they learn to balance. But, after 2 years old, most kids have mastered walking  — and running and jumping — so they stop balancing on their toes. 

Some kids continue to walk on their toes after their second birthday. The most common reason is that they are used to it. This is called “habitual” or “idiopathic” toe walking.

However, some kids continue toe walking because of certain medical conditions, like:

• Cerebral palsy: Children with cerebral palsy can have spasticity and tightness in their legs, which can cause them to toe walk. 

• Muscular dystrophy: Children born with muscular dystrophy, especially Duchenne muscular dystrophy, may toe-walk because of muscle weakness.

• Spinal cord damage: Children with medical conditions that affect the spinal cord may toe walk. For example, spina bifida and tethered cord syndrome can lead to nerve damage that causes kids to toe walk.

• Tight or short muscles and tendons: Some children are born with tight or shortened muscles or tendons in their lower legs, which can affect areas like the Achilles tendon and lead to toe walking.

Is toe walking a sign of autism?

Toe walking by itself is not a sign of autism. But children with autism often toe walk. 

One study noted that 41% of children with a neuropsychiatric diagnosis or developmental delays toe walk after age 5, compared to 2% of children in the general population. Researchers believe kids with autism do this in response to sensory stimuli.

When should I talk to a healthcare provider about toe walking?

If your child still toe walks after turning 2 years old, talk to their healthcare provider. They may ask you about:

• Other family members: Habitual toe walking runs in families. Researchers have found that almost 40% of children who walk on their toes have a relative that did as well.

• Birth history: If your child was born prematurely or you had a difficult pregnancy, it raises your child’s risk of developing mild cerebral palsy.

• Walking history: If your child only occasionally toe walks, then it’s likely a habit. But toe walking only with one foot is a sign that your child’s ligament or muscles are shortened or tight. 

• Language and social interaction: Children on the autism spectrum have trouble with communication and social interactions, so this could be a sign that toe walking is related to this condition. (Generally, if you have concerns about how your child talks and interacts, they should be screened for autism.) 

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Your child’s healthcare provider will also perform a physical exam to look for signs of:

• Muscle weakness

• Muscle or tendon shortening

• Increased muscle tone (spasticity)

• Unusual reflexes

• Changes in foot shape

• Limb length discrepancy (when one leg is shorter than the other)

Does toe walking need to be treated?

Not all children who toe walk need treatment. If your child toe walks out of habit and is between 2 and 5 years old, they might just need more time. Most kids stop toe walking on their own by their fifth birthday. You can help your child by reminding them to walk with a flat foot. 

If your child is older than 5, or if they have a medical condition that is causing them to toe walk, they may need treatment. Treatment can prevent issues that occur from long-term toe walking, like tight or shortened tendons and muscles. 

Treatment options for toe walking include: 

• Casting: An orthopedic provider can put casts on the lower legs to lengthen and stretch the calf muscles. Children often need to wear a series of casts over several weeks. One study found that casting worked very well for older children with habitual toe walking.

• Braces: Orthopedic providers sometimes place plastic braces around the foot and ankle. These braces are called ankle foot orthosis (AFO), and they keep the foot in a flat position. Your child may need to wear a brace for several months to help stretch the muscles and tendons.

• Botox: Healthcare providers may also use Botox therapy with casting or braces, or they may try Botox alone. This injectable substance helps relax muscles and aids in the stretching process.

• Physical therapy: A physical therapist can help stretch your child’s muscles. Therapy can speed progression to a typical walking pattern.

• Sensory therapy: If your child is on the autism spectrum, sensory therapy may help, too. This therapy is designed to help your child get used to the feeling of walking on a flat foot.

• Surgery: For a very small number of children, surgery might be needed to lengthen the lower leg muscles or tendons. After surgery, kids need to wear a cast on their lower legs for about a month. They’ll also need to attend physical therapy. 

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Written by:

Brian Clista, MD

Dr. Clista is a board-certified pediatrician who works in private practice in Pittsburgh, Pennsylvania. He previously served as a National Health Service Corporation Scholar in the inner city of Pittsburgh for 11 years.

Edited by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

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