“My newly two-year-old loves to walk on her toes. She’s been doing this for a while, and it doesn’t seem to bother her (although it looks painful to me!) Should I be concerned about this, or is she a budding ballerina?”
This is one of those “dangerous to google” questions. Dr. Google, displaying his usual tact and lack of context and experience, will tell you there are three kinds of toe walking:
- Associated with spastic cerebral palsy
- Associated with diseases like muscular dystrophy
- Or, the one that isn’t caused by anything and is nothing to worry about
So there you go. It’s either something serious, or it’s not. I lurves the internet! Fortunately, we at The Pediatric Insider are here to guide you through this with a minimum of worry.
The kids with cerebral palsy are usually quite easy to spot. They have delayed milestones—they walk late, and often talk late, and do other motor things late. Sometimes they have small heads. They often have an asymmetry to their walk and their use of their body in other ways, strongly preferring one hand over the other. The physical examination of these kids will show that their muscles are tight, and difficult to relax, and that their reflexes are quite strong and overly brisk.
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With muscular dystrophy, toe-walking develops later, as the big muscle of the calf starts to overpower the weaker muscles of the shins. They don’t toe walk when they start walking at age 15-18 months, but develop toe walking later, maybe at age 6 or so. That’s always a “red flag”.
The majority of “toe walkers” seen in a pediatric office fall into the last group, the normal kids who just like to toe walk. These kids start walking at a normal age (by 18 months), and have a symmetrical gait. They don’t always walk on their toes, and if you ask them to they will walk flat-footed, at least for a little while. Their developmental history is normal. On the physical exam, you can gently bend the foot into a nice 90 degree angle with the leg without any pain or undue resistance, and the remainder of the neurologic exam is normal. Almost all of these kids will stop toe walking by age three, and really don’t need a referral or any further tests—though sometimes, if the exam isn’t quite right, I’ll get an orthopedist involved for reassurance.
If a child continues to toe-walk habitually past age three, even with an otherwise normal exam and history, it becomes more likely that the toe-walking will continue. Keeping the foot extended like that will over-strengthen the calf, and it will become physically more difficult for these kids to flat-walk. In some cases, a special orthotic can be made that fits into normal shoes. This “articulated molded ankle-foot orthosis” or “MAFO” extends along the back of the leg and has a hinge that allows the foot to flex up, but not extend downwards past 90 degrees. These seem pretty acceptable to the kids, and do help, but they have to be worn for several months. I wouldn’t really look into one of these until age three or later, and even then only if the child is walking on toes more than 50% of the time.
So: I don’t know if she’s destined to be a ballerina, but as long as your two year old is otherwise doing fine, toe-walking is probably nothing to worry about. I would make sure your pediatrician knows it’s happening at your next appointment, so a careful neurologic and muscular exam can be done. After that, invest in some Tchaikovsky!