You noticed it in the kitchen, while they were running towards you, or watching a video filmed months ago. They walk on tiptoe. Not always, perhaps: when they are in a hurry, when they are barefoot, when they are excited. And now you cannot stop looking at it.
It is one of the things parents search for most online, and unfortunately it is also one of the topics with everything on it: people who tell you it passes and that is that, people who send you straight to thinking about autism, people who sell you insoles. It is worth lining up what has really been measured, because it is more reassuring than what you read around, and at the same time there is a precise sign that should not be ignored.
How common it is, and how many stop on their own
Let us start with the numbers, which exist here and are good.
In Sweden, at the routine check-up at five and a half years, 1,436 children were assessed. Thirty of them, 2.1%, were still walking on tiptoe. Another forty, 2.8%, had done it in the past and had already stopped. In total, almost one child in twenty (4.9%) had dealt with this, and at five and a half more than half had already stopped on their own, without anyone doing anything.
Then those same children were followed. Of the 63 who in the cohort had walked on tiptoe, 26 were still doing it at five and a half. By age 8, six of them had stopped. By age 10, 50 of the 63 had stopped: 79%. Spontaneously, without casts, without braces, without interventions.
And there is a second finding from that study that is as important as the first: idiopathic toe walking had not caused shortening of the triceps surae. In other words, the calf of those children, after years of walking on tiptoe, had not shortened. The most common fear, "if I let them do it, their tendon will shorten", did not come true in that cohort.
A more recent figure, on a completely different scale: in 284,925 American children aged 3 to 17, persistent toe walking was found in 1.6%.
Why they do it
In most cases there is no cause to find: it is called idiopathic precisely for this reason. The child walks on tiptoe because it is how they learned to move, often because it is faster, and they keep doing it out of motor habit.
One curious and useful fact: there is often a family link. In a series of 836 children, 64% were boys and 42% had a positive family history of toe walking. Among these, in about six cases out of ten it was the father who had done it as a child. So yes: if while reading this you remembered that you walked like that too, it is not a strange coincidence.
"Idiopathic" means: after ruling out the rest
Here is the point nobody should skip. Idiopathic is not a diagnosis made by looking at the child: it is what remains after ruling out the conditions that can cause exactly the same gait.
A study of 174 children referred from the paediatric orthopaedic surgeon to the neurologist found a neurological cause in 62% of cases. The diagnoses, in order: cerebral palsy never diagnosed before in 37%, peripheral neuropathy in 16.7%, autism spectrum disorder in 15.7%, hereditary spastic paraparesis in 13.9%, ADHD in 8.3%, syndromic pictures in 5.6%, spinal cord abnormalities in 2.8%.
Be careful to read that 62% correctly: it is not the percentage of children who walk on tiptoe. It is the percentage in a group already selected, children whom an orthopaedic surgeon had judged worth a neurological visit. Your child running on tiptoe in the garden does not have a 62% chance of anything. But that group tells us what to look for, and on that it is worth being precise.
The sign that matters most: asymmetry
If you have to remember one thing from this article, remember this.
Idiopathic toe walking is symmetrical: both feet do the same thing. When it is asymmetrical, however, the picture changes considerably. In the same study of 174 children, 71% of those who walked on tiptoe on one side only received a diagnosis of cerebral palsy. And even among those who did it on both sides but clearly asymmetrically, the diagnosis of cerebral palsy came in 32% of cases. The difference compared with symmetrical children was statistically very strong (p<0.001).
It is not only cerebral palsy. A single case has been described of a 17-month-old who walked on tiptoe on one side only and in whom a Chiari I malformation was found: it is one case, not a statistic, but it illustrates well why asymmetry should not be filed away as a quirk.
How to look at it at home, without playing doctor: stand behind them while they walk barefoot on a smooth floor, for a few metres, when they are not thinking about it. Check whether both heels do the same thing. If one puts its heel down and the other does not, if one touches the ground later and later, if one leg seems stiffer than the other: that is material for the paediatrician, not for an exercise found online.
The dorsiflexion test: what it says and what it does not say
It is the examination you will find named everywhere, and it is worth understanding.
The child lies down, relaxed. The foot is taken and brought towards the leg, measuring how far it can rise, first with the knee straight, then with the knee bent. The difference is the interesting part: the gastrocnemius, the superficial calf muscle, also crosses the knee. If the ankle moves well with the knee bent but gets stuck with the knee straight, the limitation comes from there. If it is stuck in both positions, the deeper layer is involved too.
What it is really for: understanding whether the child can physically put their heel down. A child with good range who walks on tiptoe does it out of motor pattern, and has the simplest path ahead. A child who has lost range has one more problem to solve first.
What it is not for: telling you whether the cause is idiopathic or not. In the study of the 174 children, ankle tightness was present both in idiopathic cases and in those with a neurological cause, and it did not allow them to be told apart. It is valuable information for deciding what to do, useless for deciding what lies underneath.
Autism and development: the data, without alarm
This is the area where the internet does the most damage, so let us take it with the numbers in hand.
In the analysis of 284,925 children, persistent toe walking was present in 6.3% of children with autism against 1.5% of the others: an odds ratio of 4.13 (95% confidence interval from 3.74 to 4.56). The association is real and there is no sense in denying it.
But that comparison has to be read in both directions. 1.5% of children without autism still walk on tiptoe: that is why, faced with a child who does, nothing can be concluded. In the Swedish study of five and a half year olds, among children with a neuropsychiatric diagnosis or a developmental delay the frequency rose a lot, 7 out of 17, 41.2%, but these are very small numbers, and it is an association, not an arrow pointing in one direction only.
There is also a more nuanced finding, on 51 children aged 5 to 13 with idiopathic toe walking, average age 9: as a group, they showed more difficulties than usual in several areas: motor skills in 39%, learning in 25.9%, perception and social skills in 25.5%. The authors conclude that when a child comes in for toe walking it is worth also taking a developmental history, not only looking at the ankles. It is an invitation to look at the whole child, not a reason for alarm.
What the studies say about treatments (and they are honestly few)
Here I have to be frank with you, because this is the part where it is easiest to sell you something.
The 2019 Cochrane review went through the entire world literature on interventions for idiopathic toe walking. It found 4 randomised trials, for a total of 104 children. From only one, with 47 participants, could usable data be extracted. The certainty of the evidence was judged very low, and the authors' conclusion is that no conclusions can be drawn. It is not a polite formula: it is simply the state of the art.
What we know, piece by piece:
- Botulinum toxin. In the randomised trial of 47 children aged 5 to 15, all treated with four weeks of casts below the knee, half had first received an injection of botulinum toxin into the calves. Result: no difference in any parameter, either at 3 or at 12 months. Both groups improved a little on some measures, but many children still walked on tiptoe. Adding the toxin to the casts added nothing.
- Serial casting and exercises. In a more recent trial, 29 children aged 3 to 10 were divided into three groups: casts (10), exercises (9) and waiting list (10). Between casts and exercises no difference emerged at any point in the follow-up; the control group improved less on the severity scale, but all groups, control included, improved in ankle range. These are very small numbers and should be taken for what they are.
- Braces. They work in the most literal and least useful sense: they limit toe walking for as long as the child wears them, and when the brace comes off they tend to return to their previous gait.
- Surgery. Lengthening of the Achilles tendon or of the gastrocnemius exists, and it is documented that it increases ankle range, but it still requires rehabilitation and braces afterwards, and it is a route for older children in whom toe walking persists with a real limitation of movement. In the study of 284,925 children, among those who walked on tiptoe, Achilles tendon lengthening was performed in 2.6% of children without autism and 4.3% of those with autism: a clear minority, and a difference that disappeared once sex, ethnicity and weight were taken into account.
And the most common advice for young children with good joint range, the one that orthopaedic guidelines place first, is the least spectacular: reassure the parents and wait, because it is expected to resolve by itself.
What not to do
- Correcting them constantly. There is no study showing that reminding them a hundred times a day changes anything. What changes, and for the worse, is the atmosphere at home.
- Buying a brace or insoles on your own initiative, because "that way we are doing something in the meantime". Braces act only while they are worn, insoles do not have enough evidence to support them, and neither replaces the real question, which is understanding why that child walks like that.
- Rushing into tests without a clinical reason. Investigations are needed when there is a signal, such as asymmetry, a delay, a regression or a complicated perinatal history, not as blanket reassurance.
- Waiting in silence when a sign is there. It is the mirror-image error, and it costs more.
When you need the doctor, and before a physiotherapist
Take these to the paediatrician, without going through anyone else first:
- walks on tiptoe on one side only, or in a clearly asymmetrical way;
- started walking late, or there was a complicated perinatal history;
- has lost skills they had already acquired, or has got worse instead of stabilising;
- the legs seem stiff, or on the contrary the muscles seem weak and they struggle to get up from the floor;
- started walking on tiptoe after a period in which they put their heel down normally;
- cannot put their heel down even while still or when asked.
One more thing needs saying clearly. If behind toe walking there is cerebral palsy, a neuromuscular disease or a neuropathy, that is not a pathway to tackle by video call: these situations require specialist in-person care, and we say so rather than trying.
What actually makes sense
For a young child, symmetrical, who puts their heel down when asked and has good ankle range, the substance is this: time, movement and no drama. Time is on your side: four children in five stop on their own by the age of ten.
In the meantime, it makes sense to give the foot more chances to land: walking barefoot on different surfaces, going up and down stairs and slopes, games that ask them to balance on their heels, crouching and standing up again. And it makes sense to measure ankle range from time to time, because it is the only thing that, if it changes, changes the options.
If, however, the range is already reduced, or if toe walking takes up almost the whole day after the age of three, then it is worth having it assessed: not to put them on a blanket treatment, but to understand which category they fall into and do the minimum that is needed.
Getting followed
The useful work here is not a machine or a device: it is a well-done assessment, looking at how they walk, whether it is symmetrical, how far the ankle moves with the knee straight and bent, how the rest of their development has gone, and then a few things to do at home, really repeated, with someone checking them from time to time.
It is exactly the kind of pathway that works well by video call, because the hands that are needed every day are yours: a physiotherapist who works with children and teenagers watches the child while they walk and play, measures, shows you how to do it, and tells you whether the right place is not us.
With Ri-Hub Junior you start with a free twenty-minute introductory consultation: you tell us what you have noticed, we watch them walk, and if a doctor is needed first we tell you then. For children up to 10 years old, sessions last 50 minutes and cost 59,90 €.
If the underlying question is broader, "are they behind the others?", the real windows are in Not crawling and not walking: the motor milestones.
On ankle range, which is the measure at the centre of this whole story, there is Ankle dorsiflexion: exercises to improve it.
And if you are wondering whether letting them go barefoot helps or not: Walking barefoot, benefits and precautions.
If instead the problem is not the height of the step but the direction of the feet, the picture is different: Feet turned in or out.
The general picture on movement while growing: movement in young people.
Sources
- The prevalence and course of idiopathic toe-walking in 5-year-old children, Pediatrics, 2012
- Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age, The Journal of Bone and Joint Surgery (Am), 2018
- Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons, Journal of Pediatric Orthopaedics, 2018
- Interventions for idiopathic toe walking, Cochrane Database of Systematic Reviews, 2019
- Botulinum toxin A does not improve the results of cast treatment for idiopathic toe-walking: a randomized controlled trial, The Journal of Bone and Joint Surgery (Am), 2013
- A comparative randomized-controlled trial of serial casting and exercises... in children with idiopathic toe walking, Journal of Pediatric Orthopaedics B, 2025
- The Prevalence of Persistent Toe Walking in Children With and Without Autism Spectrum Disorder and the Odds of Subsequent Surgery, The Journal of Foot and Ankle Surgery, 2025
- Neuropsychiatric symptoms and problems among children with idiopathic toe-walking, Journal of Pediatric Orthopaedics, 2012
- Toe walking: causes, epidemiology, assessment, and treatment, Current Opinion in Pediatrics, 2016
- Idiopathic Toe Walking: An Update on Natural History, Diagnosis, and Treatment, Journal of the American Academy of Orthopaedic Surgeons, 2022
- Idiopathic Toe Walking: Family Predisposition and Gender Distribution, Foot & Ankle Specialist, 2016
- Chiari I malformation presenting as unilateral toe walking in a 17-month-old, Journal of Paediatrics and Child Health, 2022
Last source check: September 2026.
