All children learn to walk on their toes. But persistent toe walking, particularly with language delays, may signal autism spectrum disorder.
Does your child walk on their toes? Tiptoe walking is very common among young children — especially when they’re learning to walk. In most cases, this early toe-walking naturally progresses into the typical heel-to-toe pattern within a few months of learning to walk.
When children continue to walk on their toes well after the age of two, it’s called persistent toe-walking. Sometimes it’s just a habit they’ll eventually outgrow. In other cases, it may be an indicator of a neuromuscular condition, such as cerebral palsy (CP) or muscular dystrophy.
When combined with language delays, persistent toe-walking may be a sign of autism spectrum disorder (ASD), a neurodevelopmental condition marked by repetitive behaviors and difficulties with communication and social skills.
Research suggests that toe walking can be a sign of autism, particularly when it’s combined with language delays. In general, toe walking is more common in children with ASD and other neuropsychiatric conditions than in the general population.
Other signs and symptoms of autism
Children with autism may show a variety of signs in early childhood, including:
- avoidance of eye contact
- lack of babbling (baby talk)
- lack of response to their name
- delayed language skills
- delayed movement skills
- flaps hands, rocks body, or spins in circles
- gets upset by minor changes
- doesn’t use simple gestures (like waving goodbye) by 12 months
- lack of emotional expressions (happy, sad, surprise, anger)
- doesn’t point to express interest in something
- doesn’t play simple interactive games like pat-a-cake by 12 months
- doesn’t respond to others’ pain by 24 months
- doesn’t seem to notice other children or want to play with them by 3 years
- lack of imaginative play (like pretending to be a cowboy, princess, or superhero) by age 4
- doesn’t sing, dance, or act by age 5
It’s believed that toe walking may be directly or indirectly due to a dysfunctional vestibular system — a condition commonly seen in autism.
The vestibular system, which involves the inner ear and central nervous system (CNS), is what gives your body a sense of:
- spatial orientation
If the system isn’t working correctly, you can have difficulties with coordination and balance.
Research from 2021 suggests that the majority of people with ASD have some degree of auditory and vestibular dysfunction. In ASD, vestibular dysfunction may include:
- postural instability (problems with balance)
- impaired gaze
- gait dysfunction, such as toe-walking
It’s important to seek evaluation if your child has persistent toe walking, as the condition can cause the calf muscles and Achilles tendons to tighten, giving less range of motion in the feet and ankles.
Treatments for persistent toe-walking may include:
- Physical therapy: The child engages in physical exercises to stretch the muscles and encourage a typical heel-to-toe gait.
- Casting: The child wears a cast day and night to help the calf muscles and tendons loosen and stretch. The cast is changed every 2 weeks for a total of 6-8 weeks.
- Tendon-lengthening surgery: This surgery loosens and lengthens the calf muscles and Achilles tendons, which attach the heel and calf muscles.
- Ankle-foot orthotics (leg braces): A plastic leg brace holds the foot at a 90-degree angle to stretch the muscles and tendons.
Based on the large database study of more than 2 million children mentioned above, those with ASD and toe-walking received surgical correction at nearly triple the rate of non-ASD children with toe-walking.
According to the study, children with toe-walking took part in the following interventions:
- Physical therapy: 59.3% of ASD children; 38.1% of non-ASD children
- Casting: 7.4% of ASD children; 3.6% of non-ASD children
- Surgery: 3.3% of ASD children; 1.2% of non-ASD children
Typically developing children with toe-walking were more likely to overcome the issue without intervention.
Among children who didn’t receive intervention, 63.6% of those with ASD continued to toe-walk within 10 years of their diagnosis, compared with 19.3% of children without ASD.
Toe walking is more commonly seen in children with:
- language delays
- intellectual disability
Persistent toe walking can lead to a stiffening of the calf muscles and Achilles tendons, making it more difficult over time to walk with a typical gait.
If toe walking continues, it’s important to seek evaluation. Treatment may involve:
- physical therapy
- tendon-lengthening surgery
If your child is still walking on their toes after age two, be sure to talk with your pediatrician about potential options.