Toe-Walking: Why is it bad?
Toe-walking involves walking on the toes and ball of your foot, without bearing much weight or pressure through the heels and sole. Usually children and toddlers just learning to walk will demonstrate some toe-walking. However, it usually disappears with development and once typical walking patterns are established.
If it pervades beyond the early years, it may be due to poor positioning of the muscles of the lower leg and ankle, a neurological issue resulting in effective control and movement of muscles, or internal/structural problems with the muscles and tendons of the foot. Another cause is actually weakness in the muscles of the stomach, as it puts less demand on the abdominals and thigh muscles if a child is walking on their toes. Processing issues among other sensory systems is another possible explanation for some children who toe walk. Read on!
Why Is It an Area of Concern?
Toe-walking puts abnormal wear and tension on the muscles, tendons and ligaments of not only the lower leg and feet, but also the knees, hips and spine, affecting alignment overtime. Improper alignment may lead to pain at joints and increased risk for injuries.
Toe-walking may also be a sign of an underlying condition. It is associated with certain conditions such as Autism Spectrum Disorder, Cerebral Palsy, Muscular Dystophy, and a shortened Achilles tendon.
Sensory Processing Issues?
More recently, there has been discussion of toe-walking as a result of underdeveloped areas of vision. Particularly, the vestibulo-visual system is affected (i.e., problems in vision which affect the body system that is responsible for balance and coordination—the vestibular system--necessary for activities like walking). Why is this? Researchers believe a deficit in ambient (peripheral) vision, may play a large role because this type of vision is closely tied with balance, coordination and motions (Eiff, 2008). In other words, they both influence the other. An issue in one can lead to issues in the performance of its close counterpart.
Ambient vision is what allows us to see in 3-D. As one can imagine, a disruption in how we see and perceive the planes in which we move can cause a disruption in our actual movements through them!
How Can Occupational Therapy Help?
Gentle stretching is often effective and necessary in order to counter the tightness of the affected muscles of the legs and ankles (e.g., hamstrings, gastrocnemius, plantaris). An OT may design treatments for a child so that they are keeping their feet flat on the floor or in dorsiflexion (the opposite of the undesired toe-walking position) while participating in a game or obstacle course. Reminders of "feet flat, no toes" should continue outside of the game and at home, and should be encouraged to be used by the child's parents and teachers.
A child may be toe-walking because they lack awareness of the position of their body in space, thus needing help in areas of proprioception. Specific activities to help build awareness of their ankles and feet can help.
Picking Up Marbles Activity
Place 10 marbles on the floor next to a bucket and have a child pick up each marble, one at a time, using his or her toes, and then dropping them into the bucket. Encourage the use of all spaces between toes, not just between the big toe and second toe. Repeat on other foot.
Extra challenge: Instead of a bucket, have them place the marble into a smaller or narrower target, such one hole in an empty egg carton, or empty cardboard toilet paper roll, will encourage even greater control and stability of the muscles through the foot.
Other proprioceptive activities:
- have child dance, roll or play in a body sock, specifically doing activities with the feet and legs
- walking on texturized stepping stones or seat cushions (particularly fun in a game of Alligator, where they must only jump onto a stone/cushion and avoid the "water" a.k.a. floor)
- various animal and yoga poses, such as downward dog (shown below), which stretches the achilles tendon and plantaris in dorsiflexion position
- have child stomp, march, or tap feet to a rhythm, while feet are on a texturized mat, in sand or dirt, against resistance like rubber bands or Theraband, or while they have ankle weights on
If it’s suspected that the problem is related to the visual-vestibular system, an occupational therapist may evaluate and treat in areas of visual perception, and make a referral to a developmental optometrist alongside OT services if needed. In this case, a pair of ambient prism lens, along with vision therapy, may make a significant difference.
Casting may be appropriate for more severe or long-time toe walkers. Other services beyond OT can be explored if more invasive (i.e., surgical) correction is necessary.
M. Patrice Eiff. "What is the appropriate evaluation and treatment of children who are "toe walkers"?". Journal of Family Practice. . FindArticles.com. 17 Sep. 2008. http://findarticles.com/p/articles/mi_m0689/is_5_55/ai_n26877929
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