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Saturday, May 14, 2016

Toe Walking Treatment by Trisha Roberts

Twinkle Toes The Toe Walker
My Baby Walks on Their Toes—What Can I Do?
 by Trisha Roberts

Do you have a little “Twinkle Toes” that Walks on their Tip Toes? Then this article is for you! 

Tippy Toes
Beautiful If You Are a Ballerina, But.......

It is important to understand normal ambulation to better understand the problems associated with Toe Walking. Children usually begin walking around the celebration of their first Birthday. The beginning walking pattern for a child is typically with their feet flat, legs open (wide base of support) and hands in the air for balance like a mini Tight Rope Walker (Hands at High Guard).  Over the next several months the Beginning Walker should develop a more mature gait pattern that consists of three phases:  Heel Strike or Contact Phase, Foot Flat or Mid-Stance, and Push-Off or Propulsion Phase. The heel of each foot should strike the floor first, followed by a foot-flat stance position as the child moves forward and places their weight on the foot, and then pushing off on the toes as the child propels themselves forward. 
Gait Phases Explained
Phases of Gait

 As this walking pattern develops the child will also start to swing their arms reciprocally with their legs, or in other words, the right arm and left leg move forward and alternate with the left arm and right leg, enabling them to perform a fast walk. By 18 months of age, or after a child has been walking for 6 months, they should consistently be striking the ground with their heels when walking. Children will sometimes rise up on their toes, but this should not be their primary position in standing or when moving.

Children generally develop the ability to walk on tip toes at about 3 years old, but they should always be able to get their feet flat on the floor at any age and should never be using Tip Toe walking as their primary method of locomotion. The philosophy that “they will grow out of it” is not a good philosophy to adopt. 

Standing on Tip Toes Consistently
Walking Consistently on Tip Toes is NOT Typical

In my work as a clinician, I am frequently asked to treat children who have been toe walking for months, and in some cases, years.  It is extremely difficult to undo years of toe walking, especially if the muscles and bony structures of the feet and ankles are tight or contractured. Toe Walking changes the child’s entire body—posture,  balance, bio-mechanics (how a child uses their body to move), and strength.

Walking consistently on tip toes can be an indication of a more serious problem and should be discussed with your Pediatrician. Toe walking can be caused by Cerebral Palsy, high muscle tone, or weakness.  It is frequently associated with Autism or sensory issues (children who have increased or decreased tolerance to sensation). Sometimes there is not a specific cause for the toe walking and it is referred to as Idiopathic Toe Walking or ITW.  Most physicians will refer your young child to an Early Intervention Specialist—A Physical Therapist that specializes in working with children birth to three years old.  Your Physical Therapist will have lots of ideas, activities, massage, and exercises for you to work on with your child.  It is vitally important that you follow your therapist’s treatment plan. Exercise and braces (night time and/or day time use) are typically the “First Line of Attack” when addressing issues surrounding Toe Walking. In severe cases or in cases of Toe Walking that have not responded to exercise and bracing, other, more aggressive treatment options might be considered that may consist of Serial Casting, Botox Treatment, or surgical procedures to lengthen tight/shortened muscles and tendons.

The following are activities that I use in my Physical Therapy practice that I find fun and effective:

  • Have your child stand on a Wedge or Incline while playing at the refrigerator, mirror, or wall. 

Standing on an Incline
Standing on an Incline Promotes Heels Down

With their feet in an “uphill” position, their heels are in a better position to weight bear.  You might try using a re-positionable marker board or other toy to encourage play in this position.

  • Have your child sit on a Scooterboard and propel themselves forward using their heels. 

Scooter Board Encourages use of Dorsiflexors
Scooter Board Encourages Heels Down and Feet Up Position

This activates and strengthens the Dorsiflexors of the foot (muscles responsible for lifting the foot).  Using the feet in this position counters the Plantarflexors (muscles responsible for pointing the foot down) and are the muscles that get tightened in Toe Walkers.

  • Pedaling a Tricycle can also be useful in getting a child to use the foot with their heel down and in a flattened position. Most children by 2 or 2 1/2 years old can ride a small tricycle. Younger children can benefit from a Ride On Toy that they propel "Flintstone-Style".

Folding Tricycle for Decreasing Toe Walking
Feet Flat on a Tricycle

Make sure that your Toe Walker has their feet flat on the pedals.  If they are trying to cycle using just their toes, you can try using an Ace Wrap to secure their feet to the pedals in a flattened position or even using a large sock placed over the pedal and the front of their shoe.

  • Play games that encourage your child to Walk Backward
    “Simon Says” take 10 steps backward. 

  • Do a dance that requires lots of heel stompin’! 

  • Take a walk at a park and look for Climbing Hills.  It is difficult to walk uphill using just your toes!

  • Kicking a ball is an action that requires standing on one leg and swinging through with the other leg.  

Practice Kicking Balls to improve Toe Walking
Balance on One Foot While Kicking a Ball
Foot Flat when Kicking a Ball
Kicking a Ball

It is very difficult to kick while standing on tip toe!

  • While your child is standing, lift one of their feet or tilt your child in standing so that they have to weight bear on a flat foot on the supporting leg.

Standing on 1 foot decreases toe walking
Lift One of Baby's Feet so that She has to Stand on a Flat Foot

Treatment for Toe Walking by Standing on 1 Foot
Standing on One Foot with Heel Down

  • Have your child sit on a small step stool with their feet flat on the floor during a play activity. 

 Place a puzzle or other game on the floor and have them lean forward to play with the game while making sure that their heels stay in contact with the floor. Have your child sit on the step stool and then ask them to stand up while you hold their feet flat on the floor.

  • The heels of our feet should make contact with the floor when we are in a Squat position.  

Decrease Toe Walking by Playing in Squat Position
Squatting in Play Gets Heels Down 

Toe Walking Decreased by Playing in Squat Position
Squat Position for Play

Reduce Toe Walking by Playing in Squat Position
Making Playing in Squat Position Fun

Scatter Blocks or Legos on the floor.  Have your child squat to pick up a block and walk (heels down!) over to the ‘Construction Zone’ and add to their architecture. Repeat until their tower is complete or they run out of blocks!

  • Get a pair of child-sized Swim Flippers

Use Swim Flippers to Improve Toe Walking
Walking in Swim Flippers

 Have your child walk with the flippers on their feet—impossible to walk on your toes!

  • Animal Walks

Everyone squat down and “Walk like a Duck”!  Make it a fun game—put out food for the ducks (crackers or other small snacks) in different places and have your child Duck Walk to each ‘feeding station’. 

Duck Walk to Decrease Toe Walking
Duck Walk

"Walk like a Crab"--feet flat, tummy toward the ceiling, and hands behind the back and on the floor.

Walk like a Crab to Improve Gait Pattern
Crab Walking

"Walk like a Bear"--feet flat on floor, hands on floor, bottom in the air. 

Walk Like a Bear
Bear Walk
Improve gait by Bear Walking
Feet and Hands Down--Bear Walk

Walking Like a Bear Exercise to Decrease Toe Walking
Improve Gait-- Bear Walk

"Walk like a Penguin"--toes up and waddle forward! 

Walk Like a Penguin
Toes Up and Walk Like a Penguin!

"Jump Like a Frog"--Squat down with feet flat and hands next to your body and then 'spring' forward like a frog, landing on flat feet again.

Frog Jumping Reduces Toe Walking
Jump Like a Frog!

Your therapist will have other suggestions, but this should get you started walking along the road with heels down!

Author:  Trisha Roberts

As always, we welcome any suggestions, questions, comments or concerns!

Copyright © 2016 TNT Inspired Enterprise, LLC, All rights reserved.
Unauthorized duplication is a violation of applicable laws.

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