Toe Walking in Toddlers: When to Worry

Toe walking is common and usually harmless when a child is just learning to walk. Many toddlers between about 10 and 18 months walk on their tiptoes while they find their balance, and most settle into a heel-to-toe walk on their own. When no cause is found, doctors call it idiopathic toe walking, which simply means "toe walking with no known reason".

The time to get it checked is if your child still walks mostly on their toes after age 2, walks only on their toes, toe walks on one side only, has pain or tight calves, falls a lot, or has other concerns such as delayed speech or losing skills. Toe walking alone does not mean autism, but it is one of the things a doctor looks at alongside everything else.

Is toe walking normal for a toddler?

Yes, for a while. The American Academy of Pediatrics says toe walking is normal during early walking, but should be evaluated if it continues after age 2. NHS physiotherapy leaflets say much the same: tiptoe walking is common from 10 to 18 months, and some children carry on up to 6 or 7 years before it fades by itself.

A Swedish study of 1,436 children, published in Pediatrics in 2012, found that 4.9% had toe walked at some point by five and a half years, and 2.1% were still doing it at that age. More than half of the toe walkers had stopped on their own. So if your 14-month-old Aarav pops up on his toes on the cold marble floor, that by itself is not a worry.

What causes toe walking?

There are several possible reasons, and some children have more than one. An NHS paediatric physiotherapy leaflet from the Royal Berkshire Hospital and Mayo Clinic describe these:

Habit. Some children simply get used to walking on their toes. Over time, this can tighten the calf muscles, which then makes heels-down walking harder.
Short or tight calf muscles. The child lifts the heels because it is more comfortable.
Weaker trunk muscles. Children whose tummy and back muscles are less strong may toe walk more.
Sensory reasons. Some children like the feeling of being on their toes, or dislike the feeling of their whole foot on the floor. This can be linked to autism when other signs are present.
Neurological causes. Less often, toe walking is a sign of a condition affecting the brain, nerves or muscles, such as cerebral palsy or a muscular dystrophy.

Toe walking is more common in boys, in children born prematurely, and in families where someone else toe walked as a child. Many Indian parents remember an uncle or older cousin who "walked like a dancer".

Toe walking and autism: what the link really is

Toe walking is more common in autistic children. In a US study of 954 children seen at a developmental clinic, persistent toe walking was found in about 20% of the 324 children with autism. An NHS autism leaflet puts it as roughly 1 in 5 autistic children walking on their toes, often for sensory reasons or because of differences in balance and body awareness.

The reverse is not true. Most toddlers who toe walk are not autistic. What matters is the full picture. If your child toe walks but responds to their name, points to show you things, babbles or talks, and enjoys back-and-forth games, toe walking is much less likely to be part of autism. If toe walking comes with fewer words than expected, little pointing or eye contact, strong upset at small changes, or loss of skills, ask for a developmental assessment. Our guide to early signs of autism in Indian toddlers lists what to look for, and you can read more about sensory differences in autistic children.

When to worry: watch and wait or get it checked

Usually fine to watch

Your child is under 2 and has been walking for only a few months.
They can stand and walk with heels flat when you ask, or when they are not rushing.
Both feet do it equally, there is no pain, and the rest of their development is on track.

Book a check with your paediatrician

They still toe walk most of the time after age 2.
They walk only on their toes, or have never developed a heel-to-toe pattern after several months of walking. The AAP flags both of these.
They cannot get their heels down when standing, even when you ask.
They have pain in the feet or legs, seem wobbly, or fall more than other children their age.
Toe walking is on one side only. An NHS autism leaflet lists this, along with pain and heels that stay up despite daily stretching for two months, as reasons to see a physiotherapist.
Their legs feel stiff or very floppy, or they use one side of the body more than the other.
There are other concerns: late talking, limited eye contact, delayed sitting or walking, or loss of skills they had before.

If your child starts toe walking suddenly after walking normally, or walking gets worse, see a doctor promptly rather than waiting.

Who to see and what happens at the appointment

Start with your paediatrician. They will watch your child stand, walk and run, check how far the ankle bends, feel the muscle tone in the legs, test reflexes and ask about birth, milestones and family history. Most toe walkers need nothing more than this.

Depending on what they find, your child may be referred to:

A paediatric physiotherapist for calf tightness, strength and walking pattern. Our post on OT or physiotherapy explains the difference.
An occupational therapist if sensory reasons seem to be driving it, such as dislike of certain textures under the feet.
A paediatric neurologist or orthopaedic surgeon if the doctor suspects a nerve or muscle condition, or if the calves are very tight. Tests such as a walking analysis may be suggested.
A developmental paediatrician if there are concerns about speech, social skills or overall development.

What treatment for toe walking looks like

Treatment depends on the cause and on how tight the calf muscles are. NHS physiotherapy leaflets describe a stepped approach:

Observation. Sometimes no active treatment is needed, especially in younger children.
Stretching and strengthening. Daily calf stretches, plus play that builds calf, hamstring and trunk strength.
Heels-down practice. Games and reminders to walk slowly with feet flat.
Supportive footwear. Well-fastened shoes or boots that come up over the ankle can help hold the heel down outdoors.
Serial casting. For children with very tight muscles, below-knee plaster casts are changed regularly over a few weeks to gradually stretch the calf.
Splints, insoles, injections or surgery. These are used in a small number of children when other steps have not worked. A Cochrane review found the evidence too uncertain to say whether adding botulinum toxin injections to casting helps more than casting alone.

Simple things you can do at home

Check with your physiotherapist first, but these are typical of what NHS leaflets suggest:

Play games that involve squatting with heels flat, such as picking up blocks from the floor or helping you sort vegetables into baskets.
"Penguin walks" on the heels with toes in the air.
Walking up a gentle slope or ramp with knees straight and heels down.
Sitting on the floor with legs straight out and back against a wall during a story or a song.
Standing on a step with heels over the edge and slowly lowering them, holding the basin while brushing teeth.

Skip the baby walker. An NHS Grampian physiotherapy booklet notes that walkers do not teach walking and can encourage toe walking that continues after a child walks on their own. Do not worry if your child goes back on tiptoe when barefoot on smooth tiles. Many do.

Keeping track of progress

Take a short video of your child walking barefoot and in shoes every few weeks, on the same floor. It is much easier for a doctor or therapist to judge change from a video than from memory, and it saves you trying to make your child "perform" in a busy clinic. Note any falls, pain, or new milestones. Our free developmental milestone tracker helps you see the bigger picture at a glance, and our post on gross motor delay in toddlers covers other movement concerns.

If you are in Bangalore and want a second pair of eyes, Carely's physiotherapists and occupational therapists can assess your child at home, on your own floors and in their own shoes, and set up a simple daily plan. You can also look at our services or message us on WhatsApp.

Frequently asked questions

At what age should a child stop toe walking?

Most children settle into heel-to-toe walking within a few months of starting to walk. The AAP advises getting toe walking checked if it continues after age 2. Some healthy children toe walk occasionally until 6 or 7 years before it fades.

Is toe walking a sign of autism?

It can be one sign, but on its own it is not enough to suggest autism. Around 1 in 5 autistic children toe walk, but most toddlers who toe walk are not autistic. Doctors look at speech, social engagement and play alongside walking.

What is idiopathic toe walking?

It is toe walking in a healthy child with no medical cause found after examination. It often runs in families. Many children grow out of it, and others improve with stretches, footwear and sometimes casting.

Can toe walking fix itself?

Often, yes. In the Swedish study, more than half of the children who had toe walked had stopped by five and a half years without treatment. If calves are getting tighter or there is pain, treatment helps prevent the muscles from shortening further.

Should my toddler wear shoes at home to stop toe walking?

Barefoot time at home is good for balance and foot strength. If a physiotherapist recommends it, well-fastened high-ankle shoes can help outdoors. Ask before buying special shoes or insoles.

Sources

By The Carely Team