Toe Walking in Children Under 8 (Pediatric Equinus)

Causes, Symptoms, and Treatment

Understanding Causes & Conservative Care

If you’ve noticed your child walking on their toes, you’re not alone. Toe walking is a common concern parents bring to us. In many cases it’s simply a habit that resolves with a little guidance. In others, it’s a sign of something underlying that benefits from a specific treatment approach. This page will help you understand why toe walking happens and what conservative (non-surgical) treatment looks like for children under age 8.

If your child is 8 or older, treatment options may look different, including surgical intervention.

What About Toddlers Under Age 3?

Toe walking in children younger than 3 is often completely normal and, in many cases, doesn’t require any formal evaluation or workup. Many toddlers toe walk simply as part of learning to walk, and it resolves on its own.

That said, this doesn’t mean a young toddler’s toe walking should be ignored entirely. It’s still worthwhile to have the severity of the toe walking and the rigidity of the foot and ankle looked at, even under age 3 — this gives us a sense of whether we’re watching a normal developmental pattern or something that’s likely to persist and benefit from earlier attention.

This matters because the sooner toe walking is addressed, the easier it generally is to treat. As children get older, the calf muscles and other soft tissues can undergo adaptive changes that become progressively more difficult — and eventually irreversible — to correct with conservative treatment alone.

Early evaluation doesn’t necessarily mean early treatment, but it does mean we can catch and monitor anything that needs attention before it becomes harder to reverse.

The Two Categories of Toe Walking

Understanding which category applies to your child is the first step toward the right treatment plan.

1. Neurological

2. Structural

How We Tell the Difference: The Silfverskiöld Test

To determine whether toe walking is structural, we perform a quick, painless test called the Silfverskiöld test. It checks how far your child’s ankle can flex upward (dorsiflexion) in two positions: with the knee straight, and with the knee bent.

Why does knee position matter?

One of the calf muscles (the gastrocnemius) crosses both the knee and the ankle, while the other (the soleus) only crosses the ankle. Testing both positions helps us determine which muscle is tight.

What we're looking for :

If your child’s ankle can’t reach at least 15 degrees of upward bend past neutral in either position, this suggests a structural cause.This test is done during a routine exam and takes just a few minutes.

Structural Toe Walking: Gastrocnemius vs. Soleus

Once we’ve confirmed a structural cause, we look more closely at which muscle is involved:

● Gastrocnemius tightness — restriction improves when the knee is bent, since bending the knee relaxes this muscle

● Soleus tightness — restriction persists even when the knee is bent, since this muscle isn’t affected by knee position

This distinction matters because it can influence stretching technique, bracing, and for children who go on to need surgical care after age 8 which procedure is most appropriate.

Anatomical Anomalies Worth Knowing About

In some children, structural toe walking is related to a variation in calf muscle anatomy rather than simple tightness:

● Low-lying soleus muscle — the soleus muscle extends lower into the leg than typical, which can affect ankle flexibility and the exam findings

● Accessory soleus muscle — an extra, less common muscle that can also contribute to reduced ankle motion and toe walking

These anomalies aren’t something you’d notice at home, but they’re worth understanding because they can shape both conservative treatment and, later, surgical planning. Dr. Mikkel Jarman, a pediatric podiatrist, has written and spoken extensively on these anatomical variations.

Conservative Treatment for Toe Walking in Children

For structural toe walking, treatment focuses on gradually and consistently stretching the tight calf muscle(s) and Achilles tendon. Options Include:

Night Bracing	(Our Preferred First-Line Treatment) A night brace holds the ankle in a stretched position while your child sleeps, providing hours of consistent, low-effort stretch; far more than a few minutes of daytime exercises can achieve. This is why night bracing is our preferred treatment for structural toe walking. Night bracing is especially effective for two reasons. First, each leg is stretched independently, so both sides receive the correction they individually need. Second, it takes advantage of sleep, when the body is fully relaxed and free of the guarding that limits stretch tolerance during the day. Sustained over six to ten hours nightly, a pediatric night brace applies a prolonged, low-effort stretch to the Achilles tendon and gastrocnemius-soleus complex, gradually lengthening the tissue and resolving the underlying equinus (calf tightness). We use pediatric night braces designed specifically for toe walking, fitted through Pediatric Orthotics.
Physical Therapy & Stretching	A home stretching routine and/or physical therapy reinforces the work done by the night brace and helps build lasting flexibility.
SHOE GEAR	Certain shoe features can support a more neutral foot position during the day and complement other treatments.
DAYTIME ORTHOTICS	In some cases, daytime orthotic inserts are used alongside night bracing and stretching to support foot positioning during walking.

A Note on Timeline

Conservative treatment works gradually and requires consistency. In the office, we re-evaluate every three months, since structural toe walking in younger children typically shows an appreciable, measurable change on that timeline. On average, equinus significantly improves and possibly resolves after around six months of consistent nighttime bracing, though this varies from child to child, and we'll adjust the plan based on how your child is progressing at each check-in.

Conservative Treatment for Neurological Toe walking

When toe walking is related to a neurological or sensory condition, treatment looks different, and is tailored to the underlying diagnosis.

Sensory-Related Toe Walking	Some children, often those with sensory processing differences, toe walk as a response to sensory input rather than muscle tightness. For these children: Sure Step SMO (supramalleolar orthosis) braces are often used. Unlike a night brace, these are typically worn during the day and provide gentle support and sensory feedback to encourage a more typical walking pattern. orthotic management is coordinated with your child’s occupational therapist, particularly when sensory integration therapy is already part of their care. It’s worth noting that not every child with sensory-related toe walking needs orthotics. Whether orthotic management is appropriate depends on a proper workup and exam to determine if your child actually meets the criteria for it. Orthotics aren’t a default or automatic part of treatment, and we’ll only recommend them if the evaluation supports their use.
Cerebral Palsy & Spastic Equinus	Children with cerebral palsy may toe walk due to spastic equinus; increased muscle tone in the calf that limits ankle motion in a way that’s different from simple tightness. Treatment often includes: Orthotic management (bracing, including AFO’s as appropriate) Physical therapy and stretching as an ongoing part of care Botox (botulinum toxin) injections – Botox works by temporarily relaxing an overactive, spastic muscle. It’s typically considered when spasticity is limiting the effectiveness of stretching or bracing on their own. Botox is commonly used in children with cerebral palsy who have spastic equinus, and is usually delivered as part of a coordinated treatment plan with your child’s neurology or physiatry team, alongside, not instead of bracing and physical therapy. It’s important for parents to understand that spastic equinus is a constant, progressive contracture. This means that even with consistent bracing, physical therapy, and Botox, some children with cerebral palsy will still go on to develop tightness that these conservative measures can’t fully control. In these cases, surgical lengthening of the Achilles tendon may eventually become necessary. This isn’t a sign that conservative care failed or wasn’t done correctly – it reflects the progressive nature of spastic equinus itself, and surgery may simply be part of the long-term picture for some children with cerebral palsy.
Other Neurological Conditions	For toe walking associated with other neurological or developmental conditions, treatment is individualized, but generally follows the same principles: Address the underlying condition with the appropriate specialists while managing toe walking itself with orthotics, bracing, and stretching as appropriate.

When to reassess

We recommend a follow-up evaluation if:
Conservative treatment hasn't led to improvement after an adequate trial
Your child had improved or corrected but is now relapsing; Meaning they're losing the correction they'd gained
You're noticing worsening rigidity or new changes in how your child walks
Your child is approaching or has reached age 8

Out of state? Schedule A Virtual Consultation with Dr. Jarman to assess your child's toe walking

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How Toe Walking Is Evaluated

Your Child's Visit - What to expect

Our Toe Walking evaluations are:

Gentle and child-friendly
Based on age, activity level, and symptoms
Focused on function—not just appearance

The visit may include:

Gait and posture analysis
Foot alignment evaluation
Muscle flexibility and strength testing
Digital X-ray Imaging, when necessary

Parents are fully involved in the discussion and decision-making. Our goal is to ensure at the end of appointment you have the following:

An accurate diagnosis of your child’s foot condition, or at least a list of possible differentials
Understanding of this diagnosis
Understanding of ALL available treatment options

It is often encouraged to record this initial encounter as the amount of information can feel overwhelming.

X-rays available on site - Schedule An Appointment to Learn More

Success stories

Click The Card Below To See The Full Story & Video

Cameron's Story

Cameron began walking on his tippy toes starting at about two years old. Cameron's mom took him to different pediatricians trying to figure out if Cameron's toe walking was a symptom of something more serious, and if so, what can they do about it?

Watch Video

JOIN OUR FACEBOOK COMMUNITY FOR TOE WALKING SUPPORT!

You’re not alone—many parents have questions and concerns about toe walking, and we’re here to help! Our Facebook group is a welcoming space where parents, caregivers, and medical professionals from around the world come together to share experiences, ask questions, and find solutions for children who walk on their toes.

Toe Walking FAQ's

Parents often have similar questions when their child is dealing with toe walking. Here are answers to some of the most common concerns about the toe walking condition.

What causes toe walking in kids?

Toe walking can be caused by idiopathic reasons (habitual), neurological disorders (e.g., cerebral palsy), developmental disorders (e.g., autism), or physical conditions like a shortened Achilles tendon.

At what age is toe walking a concern?

Toe walking is common in toddlers under 2 but typically resolves by age 3-4. Persistent toe walking beyond 4-5 years old often requires medical evaluation.

Is toe walking always a cause for concern?

Not always. It can be a normal part of early walking development but should be assessed if persistent to rule out underlying conditions.

How is toe walking diagnosed?

Diagnosis involves a medical history, physical examination, gait analysis, and possibly neurological and orthopedic evaluations. Dr. Jarman can often diagnose toe walking through a virtual consultation.

What is Idiopathic Toe Walking (ITW)?

ITW is toe walking without an identifiable cause, affecting 7-24% of children. It is diagnosed when no neurological, orthopedic, or mental illness is present.

What are the conservative treatments for toe walking?

Conservative treatments include physical therapy, bracing and orthotics, and casting to gradually correct foot positioning.

What does Achilles Tendon Lengthening (ATL) involve?

ATL is a surgical procedure to lengthen the Achilles tendon, allowing the foot to achieve a normal position and gait.

How long is the recovery from Achilles Tendon Lengthening?

Recovery involves an initial cast for two weeks, transitioning to a walking boot for two weeks, and physical therapy starting six weeks post-surgery.

What is the success rate of treating toe walking?

Toe walking is 100% treatable, with many children responding well to conservative treatments or surgery if necessary.

Your Child’s Feet Are Built for Life. We Help Keep Them That Way.

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