Toe Walking Update

So you realize that your child is a toe walker?
What do you do next?

It is a movement disorder, with a number of factors to consider.

The first issue is to stretch the heel cords, and hip muscles, while strengthening the opposite muscles. 

The next step is to determine why your child has chosen an inefficient way to walk.  More than likely it is related to one or both of the following:  weak core or sensory processing disorder.

The last steps should involve gait training and considerations of casting and bracing.

If your child is weak, then stiffening their whole body by going up on their toes can help them maintain higher muscle tone, and recruit more muscles to work for them.

The solution is to strengthen the core muscles, then retrain the walking pattern.  Your PT has many ways to do this with fun exercises, use of gym balls, scooter boards, and a home exercise program.



For retraining walking your therapist may use: theraband, treadmills, obstacle courses, hurdles etc.

Here is a fun “tool” to use for a child under the age of 7 or 8 .  I found these duck feet at a toy store.  Swim flippers cut down a bit, or Dad’s big shoes would  work as well.

The duck feet are causing this child to take higher, longer steps.

She can not walk on her toes with these on, so she is getting her heel in contact with the floor. I would want these to be worn for 30-60 minutes a day.

If your PT feels your child has sensory processing issues she will address the areas in a number of ways. Your therapist should evaluate  your child’s tactile, proprioceptive,  visual and vestibular systems- all parts of our sensory systems to determine what senses may be behind in development and causing your child to want to walk on their toes.

If your child has tactile defensiveness; then placing their whole foot on the floor is a challenge.  This needs to be addressed before they can be convinced to change their walking pattern.

Some activities might include: Stomping/marching in bare feet, Placing feet in a bin of sand,  rice or pasta, giving their own foot a massage with oil, then a towel.

Your child have diminished proprioceptive input- which goes hand in hand with low muscle tone and a weak core.  So bouncing along stimulating their inner ear- vestibular system-tells their body where it is in space.  (Because  their muscle and joint receptors aren’t giving them enough information.)  In the picture below, alot is going on.  I have my little friend in a semi squatting position- resting on a stool- reaching forward is giving pressure into her left foot.   The right foot is getting  input from a  mini back massager   I got at the local drug store; her Mom is trying it out.  They will use it at home nightly for 5-10 minutes on each foot. They will  do these two activities separately.

If your child has delays in functional vision, than  they  may be off balance as they walk.  To work on vision you can check out my blog on vision  and bike riding, the activities are appropriate for toe walkers.  Many  children who toe walk  are cautious on stairs ( could be depth perception), and not able to catch a ball ( maybe lack of visual convergence).

The vestibular system may be delayed.  This is a complex system that works closely with vision and assists in maintaining balance.  Your therapist may use slides, swings, trampoline, scooters, balls, and tie these activities into a visual activity at the same time- scanning, holding gaze etc.

And lastly balance should be assessed and addressed if it is a problem.  Your therapist may use a balance beam, rocker board, half foam roller, dyna disc.  They may have your child do activities on one foot, or build an  obstacle courses.
 Home exercises must be done to carry over gains made in therapy.

If your child has very tight muscles,   or has been toe walking for years,  they may need further intervention.

It  is important to have a Pediatric Orthopedist work with you, your child and your PT to determine what next steps are needed.

If your child’s ankles are very tight a cast may be put on for a week or two to stretch out the  muscles.  This is painless, but a significant inconvenience.

Resting casts may be fabricated, to be worn each and every night to help stretch the ankle, and or keep the ankle stretched out  after the casting.

Other types of night splints might be custom made of plastic, or a dynamic system like the   Ultra Flex Bracing System.

Once the ankle muscles have gotten looser, it is important to consider what assistance  might be needed to break the toe walking habit.

Orthotics and Bracing may be needed.  A starting point might be a metal insert usually fabricated by an Orthotist, which inhibits the ability to toe walk. It is a piece of aluminum that is cut to be the size of the sole of the shoe, it goes under the insole of the shoe. This makes it very hard  for many (but not all), children to go up on their toes.

If this does not work, then the next step is to  have  a brace made by an orthotist which will help retrain the correct walking pattern.   Something similar to what is shown in this picture.  It is to be worn most of the day. Consider how long your child spent walking on their toes; they need 6 months to a year to change their walking pattern.  Some children need  more time, some less.

These two  are hinged;- so your child can learn to flex their upper leg over their lower leg and foot.

Image result for image + hinged pediatric afo

 This can all seem overwhelming for what appears to be just a bad habit.  

But long term toe walking can lead to the heel cords being so tight, that children have trouble, walking, running, going up and down stairs,  and squatting. It can lead to ankle, calf, and knee pain.  It can cause tripping, and falling, as well as not keeping up with their peers on the playground, or with sports.

Talk with your pediatrician about your concerns and consider scheduling an appointment with a pediatric physical therapist, and a pediatric orthopedist.  Having the habit broken at age: 2, 3, 4 or 5 years,  is much easier than at 10 or 12 years of age.



The Upsee

The Upsee by Firefly is a product that many parents ask me about.  I decided to post a video of my friend Aaron and his Mom using it.  They enjoy walking together.  She feels stable.  But she would never do this alone.  For one reason; she can not get Aaron into it by herself, and for another, she is tied to him, and if anything were to happen she can not move fast, or undue him from her easily.  So she does it when he has home therapy, or when Dad is home.

As a therapist I have many critiques about this product.  Basically it is not encouraging a typical walking pattern.

Is it doing him any harm?  So far I have to say no.

Is it fun? Yes he and Mom are having a great time.

Is he learning about time and space as he moves about in an upright position? Yes

Is it cognitively appropriate for him to explore his environment on his feet at this age?  Yes.

Is it stimulating his vision?  Yes

As a Mom would I do it?    Yes I  think I would try it.


It is expensive and I would try to find someone to loan me one first if at all possible.

I would try to find one used, children will outgrow this device at a fairly young age.

Firefly does have a fairly decent return policy on their web site.

Here is another Mother’s experience with it.

Why the Upsee was an oopsie for us




Update on Summer fun for All

Image result for family picnic + image

I have been away from the blog page for a few weeks.  My oldest got married, and then we took a family vacation. The years have flown by, even when the days occasionally drag on.  Enjoy your beautiful children.

I want to point out a few blogs that will help get you on the beach, in the woods and enjoying playgrounds in the area.  And we are fortunate to have the Highland Street Foundation bringing us  the annual Free Friday Fun.

Here is my updated post on my favorite play grounds  in the area:

How to stay safe at a playground.

Do you need to motivate yourself and your child to become more active?

This  blog on exercise  may help.

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Here are some thoughts on swimming pool safety,  and   Biking with your child.

This is a great and active blog on outdoor recreation in Massachusetts –everyone outdoors.

Image result for image + floating beach wheel chairs

And last but not least the Highland Street Foundation’s  Free Fridays.


The Hypotonic Child

I am going to do a short series on the child with low muscle tone.

Muscle tone is the amount of stiffness a muscle or group of muscle presents with at a given point in time.  In the early morning most folks have low muscle tone, after a cup of coffee most people have higher muscle tone.  There is a continuum along which most people fall, and it  normally varies during the day, with our level of alertness.   Muscles that are loose, floppy, and do not hold a limb or body part in place are considered low tone or hypotonic.  If your baby has low tone, you may go to pick her up under the shoulders and find that you can lift her shoulders up to her ears- or at least it feels that way.  The muscles are loose and not stabilizing her shoulders. Stomach muscles may seem  “relaxed” allowing the bottom ribs to not mold to the body, but to flare out slightly.  Parents notice that their 2 year old still has a “toddler belly”.  They are not overweight, they just do not have the muscle tone to have a flatter stomach.  Head control is delayed and you feel as though you need to support your babies head even when they are 4 and 5 months old.

There is ligamentous laxity that goes along with low muscle tone. The ligaments that hold joints together are more elastic when there is low muscle tone, and thus the joints are hypermobile.   This combination of looseness at the joints, and lack of muscle stiffness cause a number of issues for the child with low muscle tone.

It can be hard to bring legs together to get into the crawling position,  and standing  can be delayed because of the hip instability.


Ankle joints tend toward flat footedness, which can cause instability, and delays in learning to walk, or being able to run fast enough to keep up with peers.

Fingers can be very flexible and it is hard for a child to pick things up. Young children may rake to pick up their food:

Image result for image + child taking food instead of pincer grasp

instead of using a pincer grasp:

Muscle Strength:  This is a often affected.  It is no surprise that a muscle that is loose also has difficulty generating force and power.  So throwing and kicking  a ball, jumping, running fast, and mastering  playground structures tend to be a challenge for a child with low muscle tone.  This of course extends to all muscles- so fine motor skills may be delayed as they lack grip strength.  Speech may be delayed and the muscles of the cheeks and mouth are flexible, and may be weak.   When eating, they may show a preference for stuffing their mouth with food; so that they don’t have to work so hard moving food around with their tongue- their is always something to chew if they overfill their mouth.

Your child may lack head control -and as you pull them to sit, their head drops back.

Image result for image head lag

( don’t practice this if they can not do it) look at the next post for ideas to help your child.

Postural Stability:  The child with low muscle tone tends to melt into the supporting surface.  As they get older  they may exhibit   W sitting , lying down on the couch or bed, reclining on any chair, and as a general rule they may avoid sitting up.  This can cause problems in school where they need to sit for hours at a time.

Delays in Motor Milestones:

Babies with low muscle tone tend to be delayed in their motor skills.They are less motivated to move.  They may not try to roll over until they are 6-12 months, they complain when placed on their stomach; and are reluctant to lift their head up.  They sit late, and may try to avoid crawling.  Standing and walking are often late as well.

Endurance:  Most children with low muscle tone have diminished endurance; to sitting upright, walking, running, playing.   Imagine if you have to work harder to do all these motor skills- and you can see why your child may get tired sooner than their peers.

Reflux/Gerd:  Many very young children with low muscle tone have significant reflux during their first few months, or early years.  This may be related to relaxed tone in their muscles, allowing food to come up out of the stomach into their throat.  Talk with your pediatrician about how to  manage this for your child.  In the next blog I will demonstrate how to vary tummy time so that they have less reflux happening when on their stomach.

Diagnosis associated with it:  There are many many conditions/diagnosis which present with low muscle tone.  Down syndrome, Autism, Developmental Coordination Disorder, Ehlers Danlos being  some of the more common.   Here is a fairly good web site if you want to see what other diagnosis can be associated with low muscle tone.

Health of Children

Neurologists will often look at a child and determine if they need further testing.  They may feel further testing is not indicated.  In this case many children come away  away with the diagnosis of ( Benign) Congenital Hypotonia- “born with- low muscle tone.” In general I think this is fine.  Unless you have reason to suspect other areas of concern such as; engagement, language, learning, or an issues with a body system  such as their heart.

But remember it is not benign in the sense that it does not cause problems.  It does, and seeking advise and therapy from professionals is important.

In the Next Blog I will give you ideas for working with your child to help them catch up with their peers.




Miracle League of MA.


Miracle League of  MA holds games for children  each Saturday in the spring and fall.  It is an all volunteer,  nonprofit organization that provides the opportunity for children with special needs to play baseball, with no cost to the family.

To learn more, check out the   Miracle League Web Site.

Finishing the Dream @ Miracle Field

Fun Fest and 5 K run/walk June 12th

“In addition to raising money to operate our league free of charge, we are also raising funds to support the construction of a fully accessible family restroom in the soon to be built NARA Sports Pavilion at Miracle Field. To learn more about the campaign, click here.”


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