There are various causes of toe-walking, including a congenital short Achilles tendon, muscle spasticity and even ‘habitual’ or ‘idiopathic’ toe-walking, which has no known cause.
The condition is often misunderstood, says Johannesburg occupational therapist Tamryn Paulsen of Innova OT. In some cases, it may actually be linked to our most primitive evolutionary reflexes.
A retained primitive reflex is a likely cause of toe-walking, which may present in the following ways:
- Struggling to put her feet flat on the ground.
- Difficulty balancing when standing upright.
- Walking in an uncoordinated way.
“Remember, though, that some children walk at nine months and others at 15 months or later, so we need to look at the quality of a child’s movement first, which can be more important than her ability to stand flat on two feet.”
“All babies are born with primitive reflexes,” explains Tamryn. “Many intertwine with each other, such as the plantar and Babinski reflexes.
“Both of these reflexes are required to develop and initiate the movement and coordination of the small muscles of the foot. They initiate many of the foundation movements that build gross motor movements later.”
Babies and toddlers perform Olympian feats as they develop. They master a series of skills in a relatively short time: transitioning from the floor to their feet, crawling, pulling up to a stand, walking and, finally, playing, running, skipping, jumping and climbing.
The plantar and Babinski reflexes are important as they help babies reach developmental milestones, like gripping the floor with their feet, rolling, sitting, crawling, standing and walking. They are no longer needed when your baby can perform these movements consciously and independently.
“At certain ages, we expect specific reflexes to become integrated (disappear); this is an indication of normal neurological development.”
You may notice your baby spontaneously opening and closing her toes and feet – these are healthy reflexes at work. “The purpose of these reflexes is to encourage movement of the toes and feet and prepare them for walking and weight-bearing later in life,” says Tamryn.
The plantar reflex emerges between three and four months in-utero and usually disappears between 10 and 12 months of age, or as late as 18 months.
The Babinski reflex typically emerges at birth and will integrate between 12 and 24 months of age.
Reflexes are integral to your baby’s overall development as they stimulate the central nervous system (brain and spinal cord), muscles and neurological pathways, and strengthen nerves, says Tamryn.
As with all reflexes, medical experts expect the plantar and Babinski reflexes to disappear once your baby no longer requires the support they provide.
“A reflex gives us a glimpse into a baby’s neurological maturity and indicates how multiple systems in the body are working together.
“Unintegrated reflexes can affect higher centres of the brain, such as emotional and cognitive centres. Reflexes have a shelf life – once they’ve done their job developing the central nervous system, we want them to disappear.”
Spotting the signs
How do you know when a primitive reflex problem is the reason for toe-walking?
“If your child is toe-walking and is between 24 and 36 months, the first step is to take her to a paediatrician,” advises Tamryn. “Children develop at different rates – some take longer to integrate their reflexes. A paediatric healthcare professional, like your paediatrician, an occupational therapist or physiotherapist with an understanding of child development and reflexes, can help.”
Together with the inability to walk flat, your toddler may exhibit the following:
- Reduced balance.
- Often falling or tripping.
- Difficulty mastering walking.
- Uncoordinated or awkward running.
- During dressing, the child’s toes may curl up when putting on socks and shoes, which can make dressing difficult.
- Older toddlers may show reduced performance in sports that require coordination and balance.
When to see your doctor
“There is no reason to panic – many children toe-walk and it doesn’t necessarily mean something is wrong,” says Tamryn. “Much of the time, children have what is called idiopathic toe-walking, and ‘tippy-toe’ out of habit – they are perfectly healthy and developing well.”
If your little one is older than 24 months and seems to have any of the following problems, Tamryn advises visiting your paediatrician to rule out underlying issues:
- Walks on her toes most of the time.
- Stiffness in her muscles or joints.
- Uncoordinated movements.
- Walks awkwardly or waddles when walking.
- Frequently stumbles.
- Has difficulty weight-bearing on a flat surface.
- Can use her hands well, but seems to have difficulty with her feet.
MORE reasons for toe-walking:
- Sensory sensitivity or tactile defensiveness.
- Cerebral palsy or muscular dystrophy can cause tight calf muscles and tendons, which affects the ability to stand flat or walk.
- Some orthopaedic conditions, such as ‘club foot’ (congenital talipes equinovarus), or even inflammation of the growth plate within the leg bones, may disrupt flat walking or standing.
- Some developmental delays and autism spectrum disorders have been associated with toe-walking.
Always consult your paediatrician if you are concerned, advises Tamryn.
“Reflexes were designed to be integrated naturally through active movement and engagement with the environment,” says Tamryn. “Encourage your baby to move with these simple activities.”
- Kicking and bouncing when your little one is on your lap.
- Holding your baby upright and allowing her feet to bear her weight on a variety of different surfaces and textures.
- Doing baby massage regularly. “This is a great way to bond with your baby while providing gentle pressure to the soles of her feet,” explains Tamryn.
- Gently bouncing your baby in a standing position – this gives a firm, but gentle, pressure to the balls and heels of the feet.
While your paediatrician, occupational therapist or a child specialist should do a proper reflex check, says Tamryn, there are a few simple ways to test your baby’s reflexes at home.
- The plantar reflex: When you stroke the sole of your baby’s foot, the automatic response is for your baby’s foot to flex and her toes to curl up. Alternatively, apply gentle pressure just below the ball of the foot – the toes will respond with a curling or gripping action.
- The Babinski reflex: This can be assessed by applying pressure down the outer sole of the foot, from heel to the metatarsal pads, and towards the big toe. A normal response is the downwards extension of the big toe (and often other toes, too). An abnormal, or ‘positive’ response is for the big toe to fan upwards, which may include upward flexing of the ankle, knee and hip.
In most cases, it is unlikely that your child’s toe-walking is anything to worry about, says Tamryn. A correct diagnosis will offer you peace of mind.