Toe walking is also called Equinus gait, a condition that is usually seen for the first time in children under the age of two. Equinus gait is described as the inability of the ankle joint to bend in an upward motion or to attain a neutral position. You may see your child go up onto their toes and come back down or they may stay up on their toes as they move their body through space.
In terms of anatomy, the calf comprises two major muscles and a tendon. The gastrocnemius muscle lies on top of the Soleus muscle and merges with the Achilles tendon. The tendon attaches to the heel bone, called the Calcaneus. In cases of toe walking, the child either has a muscle-tendon long enough to walk correctly but suffers from the habit of walking on the ball of their feet or has a short muscle-tendon combination due to prematurity of birth, low birth
weight, developmental delay, musculoskeletal weakness, sporadic/rapid growth, neurologic mapping, or sensory processing dysfunction. A child that continues to toe walk after the age of 3 may have an underlying medical condition, for example, Cerebral Palsy, Muscular Dystrophy, or a Spinal Cord Injury. However, frequently, equinus gait is due to Sensory Processing Dysregulation.
Sensory processing, also referred to as sensory integration, is the registration of sensory input from the environment, including one’s body. The brain receives, organizes, and responds to sensory input from the environment with the intent to behave in a meaningful manner. The three sensory systems, the tactical system, vestibular system, and proprioceptive system allow children to respond to their environment and make sense of their bodies. Sensory integration affects gross and fine motor development, speech and language, social and emotional maturation, and behavior and learning.
When a child has difficulty processing sensory information this is called Sensory Processing Dysregulation/Disorder. The information a child’s brain receives doesn’t allow them to properly respond to the environment around them including their own body. For example, a baby is unable to properly organize sensory input therefore their brain is unable to give meaning to these senses (auditory, visual, olfactory, gustatory, tactile, proprioception, and vestibular). When the sensory systems are unable to work efficiently together, it is referred to as Sensory Processing Disorder. It is described as when a child avoids or has excessive stimulation in response to one or more of the seven senses.
Our Pediatric Physical Therapists frequently see decreased proprioception as the main cause of toe-walking in the children that we work with. Proprioception is defined as the ability of the body to sense movement and know where it is positioned in space. These proprioceptors are located within our joint space. With proprioceptive deficits, joint receptors do not register the information from the environment as quickly as they should. When there is a delay in sensory input, a child’s body seeks input from the external environment to increase registration. To accomplish this, a child will often display one or more of these behaviors including hypersensitivity to sound, touch, or movement, lethargy, distracted easily, poor attention, poor motor skill, poor sleep patterns, constant movement, seeking oral input, and toe walking. A child seeking proprioceptive sensory input, in this case, toe walking, experiences prolonged stimulation of joint receptors which causes the muscles to tighten, thus providing a calming sensation for the child.
The most common causes of a toe-walking gait pattern include:
-Idiopathic Toe-Walking: the initial cause of toe-walking is unknown. In some cases, toe-walking becomes a habit when the child is learning how to walk. Without intervention, this can lead to decreased range of motion, coordination, balance, and motor function.
-Sensory seeking/avoidance behaviors due to Sensory Processing Dysregulation/Disorder: toe-walking begins as avoidance of certain surfaces and textures. Alternatively, toe-walking can begin to increase sensory input.
-Neurological disorder (such as Cerebral Palsy): can affect muscle tone, coordination, and motor skills which can contribute to decreased range of motion, tightness, or shortening of muscles. Children who continue to toe walk will develop tightness in their ankles and calves.
To determine why your child walks on their toes, your child’s Physical Therapist will take a thorough medical history, perform a physical evaluation which will include observation of the way your child walks, assess the range of motion of the hips and knees, check for abnormalities in the right and left foot, check for tightness in the calves, check for abnormalities in the lower extremities and lower back, gross motor skills, neurological development, and ask the child to perform various activities throughout their natural environment.
Once the root cause is determined, your child’s Physical Therapist will be able to come up with an individualized treatment plan for your child and give you recommendations as to what you can do with them on a daily basis to help prevent further toe-walking from occurring.
Depending on the cause of equinus gait your child’s Physical Therapist may make recommendations such as night splinting, heel lifts, arch supports, orthotic devices, and proper shoe wear. There are many exercises a child can perform in the comfort of their home. It may be recommended that on a daily basis, with the caregiver’s assistance, he/she stretches their calves and hamstring to reduce tension, walk barefoot on different textured surfaces, improve balance, coordination, and motor skill development to assist in strengthening their feet, ankles, and lower extremities. Additional recommendations will be made depending
on the cause of their toe-walking gait pattern.