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Toe Walking in Children (Pediatric Equinus)

Toe Walking (Pediatric Equinus) Causes, Symptoms, and Treatment

Is Your Child Walking On Their Toes?

Toe walking is a gait pattern where a child walks on their toes or the balls of their feet without their heels touching the ground. This can be normal in toddlers but may indicate an underlying condition if it persists beyond age three.

In children 3 years and older walking on tiptoes may not be normal and could be associated with a neurological immaturity or medical condition.

Fortunately, over 90% of these cases can be treated with conservative treatment options and surgery is not required. 


In the following video, Dr. Mikkel Jarman discusses toe walking and some conservative treatment options and when or if surgery may be necessary.

What Every Parent Should Know About Toe Walking

Common Causes of Toe Walking

Idiopathic Toe Walking (ITW)

Idiopathic Toe Walking is a condition where a child over the age of three continues to walk on their toes without any identifiable neurological, orthopedic, or mental illness. This affects 7-24% of children and may be due to a habit or an undiagnosed physical anomaly. Over time, ITW can lead to muscle tightness, improper bone growth, and joint discomfort if not addressed.

Neurological Disorders

Conditions such as cerebral palsy or muscular dystrophy can cause toe walking due to muscle spasticity or weakness. Cerebral palsy often results in increased muscle tone, leading to a shortened Achilles tendon and toe walking. Muscular dystrophy, a group of genetic diseases, weakens muscles over time, contributing to gait abnormalities.

Developmental Disorders

Autism spectrum disorders (ASD) can be associated with toe walking. Children with ASD might exhibit this gait pattern due to sensory processing issues or motor development delays.

However, due to their developmental condition it is often mistakenly ignored in these children, as more often they actually have a physical abnormality that needs surgery.

Learn more »

Physical Conditions

  • Shortened Achilles Tendon: A congenitally short Achilles tendon restricts the heel from touching the ground, necessitating surgical intervention in severe cases.
  • Heel Pain: Conditions like Sever’s disease cause heel pain, leading children to walk on their toes to avoid discomfort.
  • Musculoskeletal Issues: Other structural abnormalities, such as flat feet or tight calf muscles, can contribute to a toe-walking gait.

Symptoms and Diagnosis


Toe walking in children is characterized by walking on the toes or balls of the feet without the heels touching the ground.

  • Walking on toes or balls of feet
  • Lack of heel contact with the ground
  • Discomfort or pain in knees, hips, or lower back
  • Unnatural gait and posture
  • Tightness in the calf muscles


Diagnosis often requires a physical examination to assess muscle and joint function, followed by gait analysis to observe walking patterns.

 Alternatively, Dr. Jarman can also pre-diagnose toe walking through a virtual consultation, providing convenience for families.

Learn More About Virtual Consultations with Dr. Jarman » 

Toe Walking Treatment Options

Conservative Treatments

Physical Therapy

Physical therapy focuses on exercises designed to stretch and strengthen the Achilles tendon and calf muscles. This helps improve flexibility and promote a normal gait pattern. Therapists may use techniques such as manual stretching, functional exercises, and gait training to address muscle imbalances and enhance motor skills.

Bracing and Orthotics

Orthotics and braces like the Toe Walking Brace are used to support proper foot alignment and encourage heel-to-toe walking. These devices are often custom-fitted to ensure comfort and effectiveness. They work by gently correcting the foot’s position, reducing muscle strain, and promoting a normal gait during walking.


Serial casting involves applying a series of casts to the child’s lower leg and foot. This method gradually stretches the Achilles tendon and calf muscles, helping to correct foot positioning over time. Each cast is typically worn for a few weeks before being replaced with a new one that further improves alignment.

Dr. Jim Sears discusses toe walking with Sarah, a concerned mother of a 3-year old daughter, who had called into the show because her daughter is walking on her toes. Dr. Sears briefly goes over some stretches, but makes the primary point that it is always a good idea to contact a pediatric podiatrist. A pediatric foot and ankle specialist can run additional tests, and if deemed necessary, prescribe a custom orthotic.

Achilles Tendon Lengthening (ATL) Surgery

Achilles Tendon Lengthening is a surgical procedure performed when conservative treatments for toe walking fail. Dr. Jarman, with over a decade of experience, routinely performs this surgery every Wednesday. This procedure involves lengthening the Achilles tendon to allow for normal foot positioning and gait.

Dr Jarman's Toe Walking Surgery Process

Pre-Surgery Consultation:

The process starts with a telehealth appointment to discuss the child’s condition and eligibility for surgery. An in-person office visit the day before surgery confirms their candidacy.

Day of Surgery:

On the surgery day, arrive an hour before the procedure. Post-surgery, a cast is applied, and patients typically leave an hour after. A follow-up at two weeks involves removing the initial cast and applying a new one.

Post-Surgery Care:

At week four, the child transitions to a walking boot for two weeks. Around week seven, they move to regular shoes. Physical therapy begins six weeks post-surgery, with a final follow-up six months later.

Dr Jarman's Explains ATL Surgery

Dr. Jarman's Toe Walking Treatment Success Stories

Dr. Jarman Treats Sawyer's Chronic Toe Walking

Sawyer began walking on her toes at a young age and never outgrew it. Children would comment on it and it was affecting her dancing which she loved to do. Her and her mom found Pediatric Foot & Ankle researching online and scheduled an appointment with Dr. Mikkel Jarman.

Dr. Jarman Treats Cameron's Chronic Toe Walking

Cameron began toe walking at around the age of two. After following the foot physical therapies and exercises recommended by their pediatrician with little to no improvement, she decided something needed to be done.

Types of Toe Walking & Terminology


Toe walking, or Pediatric Equinus, refers to a walking pattern where the child walks on the balls of their feet without their heels touching the ground. It can be classified based on its cause or persistence.

Types of Toe Walking:

  1. Idiopathic Toe Walking (ITW): Persistent toe walking without an identifiable medical cause, affecting 7-24% of children. Common in children over three years old.
  2. Neurological Toe Walking: Caused by conditions like cerebral palsy, which result in increased muscle tone and spasticity.
  3. Developmental Toe Walking: Associated with developmental disorders such as autism spectrum disorders.
  4. Physical Toe Walking: Due to physical conditions like a shortened Achilles tendon, heel pain, or other musculoskeletal abnormalities.

The Toe Walking Brace By Pediatric Orthotics

The Toe Walking Brace (aka Toe Walking Boot) by Pediatric Orthotics is an orthotic device designed specifically to address and resolve toe walking in children. The brace is worn at nighttime while the child sleeps. It provides gentle yet effective support to the foot and ankle to promote proper alignment and natural gait development.

The brace helps target underlying causes of toe walking like muscle tightness and imbalances.
Consistent and proper use of the Toe Walking Brace at night can help retrain the muscles and tendons over time. This leads to improved balance, stability, and functional mobility as the child develops a more natural heel-to-toe walking pattern during the day. The brace is engineered for comfort, comes in 3 different sizes and can be adjusted further to ensure a proper fit. 

Toe Walking FAQ's

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.

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