Toe Walking and Tight Achilles in Children
Brief toe walking can be normal when children start walking. If it continues after the age of 2-3, assessment and treatment are needed.
Some children walk on their toes for a short period when they first start walking. This often resolves on its own. But if toe walking continues after the age of 2-3, if the child cannot put the heels down, or if it affects one side only, it should be assessed.
Causes
- Idiopathic toe walking (no known cause): The most common cause. The child can put the heels down if they want to, but toe walks out of habit. Over time the Achilles tendon can tighten.
- Congenital short Achilles tendon
- Cerebral palsy and other neurological conditions
- Muscle diseases (muscular dystrophies)
- Autism spectrum disorder and sensory processing differences
- Leg length difference
Signs
- Constant or frequent toe walking
- Heels not touching the ground when standing
- Difficulty squatting or walking on the heels
- Frequent falls, clumsiness and tiring quickly
- Calf pain
Diagnosis
The upward range of motion of the ankle is measured, a neurological examination is done and walking is observed. If a neurological or muscle disease is suspected, further tests are planned with the relevant specialists. Finding the underlying cause guides treatment.
Treatment
Stretching and physiotherapy
If the Achilles is only mildly tight, regular stretching and gait training can correct it. Doing the exercises at home every day is important.
Night splints and orthoses
Orthoses that hold the ankle at the correct angle keep the tendon on stretch for long periods and help reduce tightness.
Serial casting
For marked tightness, the ankle is cast at a slightly higher angle every 1-2 weeks, gradually lengthening the tendon.
Botulinum toxin
Especially when spasticity is present, injections into the calf muscles can increase the effect of stretching and casting.
Achilles lengthening surgery
For fixed tightness that does not respond to non-surgical methods, the Achilles tendon or the calf muscle covering is lengthened through small incisions. A cast is worn for a few weeks after surgery, followed by an orthosis and physiotherapy.
Stretching exercises at home
Stretching the Achilles tendon and calf muscles is one of the most important parts of treatment. The child leans against a wall with the back heel on the floor and, keeping the knee straight, leans forward until a stretch is felt in the calf. The same movement is repeated with the knee slightly bent. Letting the heels drop over the edge of a step is also effective. Doing the exercises regularly, several times a day with a few repetitions each time, is recommended.
Using play to support treatment
With young children, turning exercises into games improves adherence. Heel-walking races, walking up ramps, playing in a squat and riding a bike all help stretch the Achilles. Gently reminding the child when you notice toe walking during the day helps change the habit.
Serial casting
In serial casting, the ankle is cast at a slightly higher angle at each change. Several changes are usually needed, and the child can walk in the cast. After the cast comes off, a night splint and stretching continue to maintain the movement gained; otherwise the tightness can return.
After surgery
After Achilles lengthening, a walking cast is worn for a few weeks. After it is removed, an orthosis and physiotherapy restore ankle range of motion and calf strength. Children usually return to normal activities within a few months.
Frequently asked questions
Does toe walking go away on its own?
In many children it does. But if it continues after the age of 2-3, the Achilles can tighten, and early assessment makes treatment easier.
Is toe walking a sign of autism?
On its own, no. But if there are other signs related to language and social development, an assessment by the relevant specialists is recommended.
Can it come back after surgery?
Tightness can recur, especially during growth and when there is an underlying neurological cause. Regular stretching and check-ups are important.
Does toe walking harm the muscles?
Toe walking over a long time can shorten the Achilles tendon and tighten the calf muscles, which over time makes it harder to put the heel down.
Which shoes are recommended?
Flat-soled shoes with a supported heel and ankle support may help change the walking habit. Shoes alone are not a treatment.
Will a night splint disturb my child's sleep?
Most children get used to a night splint within a few days. It must be the right size and not squeeze the skin.
How long does treatment take?
Improvement with stretching can take a few months. Serial casting usually lasts a few weeks, and exercises should continue for a while afterwards.
Can my toe-walking child play sport?
Yes. Being active and playing sport is generally beneficial. Sports such as football, swimming and cycling, combined with stretching, support calf flexibility and balance.
The information on this page is general and does not replace an examination. An examination is needed to decide which treatment suits you.