At the beginning of independent walking, toddlers may walk on their toes. Within three to six months the heel should be touching the ground during normal walking. Intermittent toe walking may be present in normal children until seven years of age.

Most children who present as persistent toe walkers are able to lower their heels to the ground when standing. A heel-toe gait is possible, but usually awkward. Toe walkers are more common in boys. In some cases they are a cause of concern.

History and physical examination is extremely important. Physical examination usually reveals limited movement with the foot trying to go from a down to up position at the ankle joint. This is usually due to a tight calf muscle. Neurologic examination is necessary and is usually normal. Neuromuscular diseases must always be ruled out.

Treatment of habitual toe walkers may be necessary to avoid problems that may occur secondary to compensating for the abnormal gait. Compensation may occur by hyperextending the knee, rotating the entire leg towards the outside or having the foot turn out causing a flatfoot. It is important to assess the degree of muscle tightness in the legs. Spontaneous resolution may take place in some cases. If the calf muscles are not severely tight stretching by the parents at home may be of benefit. Usually casting the foot and leg is necessary to stretch the tight muscle group. Cast may be applied every two weeks for a six to eight week period. Casting is almost always successful in the younger child.

Failure to stretch the muscle group with casting the extremity may necessitate surgically lengthening the Achilles tendon. This is done by making three small incisions in the back of the leg each about one-twelfth of an inch. Casts are applied postoperatively for six weeks and night splinting for six to twelve months to maintain the correction.