Pain guide · Foot pain

Toe walking in children: when it's normal, the signs to get checked, and what helps

Toe walking means walking on the balls of the feet with the heels off the ground. It's common while toddlers learn to walk, and most move to a heel-toe walk by about 2 or 3; in one Swedish group's study, about 8 in 10 children who had ever walked on their toes had stopped by 10 without any treatment. When no cause is found it's called idiopathic toe walking, and it's usually harmless.

This guide is for parents. It covers the signs that mean your health visitor or GP should check, such as toe walking on one side, stiff legs, falls or late milestones; how toe walking links with autism, cerebral palsy and muscular dystrophy; and what helps, from heels-down games, shoes and calf stretches to casts, splints, botulinum toxin and surgery, with what the evidence shows for each and a staged plan with 3D demos.

3-stage exercise plan When to get help 37 sourcesUpdated 22 October 2026

When to get help first

Exercise is for pain that has been checked or is clearly mild and settling.

Get urgent medical help if

Call 999 or go to A&E if your child gets sudden pain in their hip, knee or thigh (hip problems can sometimes be felt in the thigh or knee), can't put any weight on their leg, their leg has changed shape or is pointing at an odd angle, they feel generally unwell and have a high temperature, or feel hot, cold or shivery, they also have severe pain in the lower part of their tummy, or their symptoms get worse.
Very sore, swollen or weak calf muscles with dark pee (red, brown, tea or cola coloured): get medical help the same day. Call NHS 111, or go to A&E if your child seems very unwell. Rarely, muscle breaks down fast enough to harm the kidneys (rhabdomyolysis); our rhabdomyolysis guide has the signs.
Call 999 or go to A&E if your child seems seriously unwell and you think it could be sepsis: they're breathing very fast or having difficulty breathing; have blue, grey, pale or blotchy skin, lips or tongue; have a rash that does not fade when you press it; are confused, not responding like they normally do, difficult to wake or more sleepy than usual; feel very hot or cold to the touch or are shivery; or, if they're under 5, haven't had a pee for 12 hours.
Same day: in casts or splints, pain that is getting worse, toes that are numb or burning, a cast that feels too tight, toes that are swollen, blue or white, or a bad smell from under the cast.

See a doctor or physiotherapist if

See your health visitor or GP if your child is still walking on tiptoe most of the time after about 3, walks on tiptoe on one side only or more on one side, can't stand or walk with their heels down when asked, finds heels-down standing or walking awkward, or started walking on tiptoe suddenly after walking normally.
See your GP if toe walking comes with pain or discomfort in the calves or feet, stiff legs, frequent falls or clumsiness, trouble running, jumping, climbing stairs or getting up from the floor, or difficulty with activities that used to be fine.
See your GP or health visitor if your child wasn't walking by 18 months, is late with other milestones or speech, was born early, is losing skills they had, or there's a family history of toe walking or muscle-wasting disease. The National Institute for Health and Care Excellence (NICE) asks for any child who keeps walking on tiptoe to be referred to a child development service.
A boy who walks on his toes and also falls a lot, waddles, struggles with stairs or pushes up on his thighs to stand up from the floor: ask your GP about a blood test for creatine kinase, a muscle enzyme. These can be early signs of Duchenne muscular dystrophy, and a blood test is the first check.
If you or a professional have wondered about autism, mention the toe walking to your GP: NHS Lothian's guidance for GPs lists suspected autism as a reason to refer a child who walks on tiptoe to a children's orthopaedic clinic.
Sudden pain in both calves and difficulty walking a few days after flu or a cold: ask for an urgent GP appointment the same day, or contact NHS 111. It's usually a short-lived inflammation of the calf muscles (benign acute childhood myositis) that settles within about a week. If your child can't put any weight on their legs, the 999 line above applies.
An older child, about 8 to 12, who starts walking on tiptoe because their heels hurt with sport: see our Sever's disease guide, and a GP if it doesn't settle.
After treatment: if toe walking, tight calves or pain come back, often with a growth spurt, ask to be seen again. Services expect this and can treat it again.

Understand it

What toe walking is, and what's normal

Toe walking is walking on the balls of the feet, without the heels touching the ground, some, most or all of the time. Many toddlers do it while they learn to walk. An NHS trust says that by around 24 months a child should walk with their feet flat on the ground, and by 3 with a heel-toe pattern; the American Academy of Orthopaedic Surgeons (AAOS) says most children stop toe walking after 2; and NHS Lothian's guidance for GPs says it normally settles by itself by 3.

Sources 1, 2, 3, 4

Idiopathic toe walkingStrong evidence

When no cause is found, it's called idiopathic toe walking. A UK consensus of 227 children's orthopaedic surgeons and physiotherapists, from the British Society for Children's Orthopaedic Surgery (BSCOS) and the Association of Paediatric Chartered Physiotherapists (APCP), defines it as toe walking in both feet since a child started walking, with no known neurological condition, carrying on past 2. Autism or attention deficit hyperactivity disorder (ADHD) can sit alongside it and don't rule it out.

Children with idiopathic toe walking can usually walk flat-footed when asked, especially when they're younger. It can run in families and is more common in boys and in babies born early. NHS leaflets list possible reasons: a habit, short or tight calf muscles, weaker trunk muscles, and liking or disliking the feel of the floor under the feet.

Sources 5, 2, 6, 7, 8, 9

How common it is, and how it usually goesEmerging evidence

In a Swedish county, 70 of 1,436 children aged 5½ (4.9%) had walked on their toes at some point: 30 still did and 40 had stopped. In a later report on the 1,401 healthy children in that study, 63 had ever walked on their toes, and by 10, 79% of them had stopped without treatment. Toe walking hadn't caused tight calves, but a separate small group had tight calves from early on (a short Achilles tendon), which the authors say should be treated early. Four of the children still toe walking at 10 had a neurodevelopmental condition. These figures come from one research group's study.

NHS leaflets give figures from around 1 in 20 toddlers to 7 to 24 in 100 children, depending on age and definition. Many children stop by 2, and others carry on to about 6 or 7; a few continue longer, and one leaflet says most walk heel to toe by 10.

Sources 10, 11, 7, 6, 8, 1, 12, 13

When toe walking is a sign of something elseStrong evidence

Cerebral palsy: the National Institute for Health and Care Excellence (NICE) asks for any child with persistent toe walking to be referred to a child development service, and lists not sitting by 8 months and not walking by 18 months as the commonest delayed milestones in cerebral palsy. The NHS lists walking on tiptoes among its possible signs, with late milestones, stiff or floppy muscles, and weak, jerky or clumsy movements.

Duchenne muscular dystrophy, in boys: signs often appear between 1 and 2, NHS inform says. They include difficulty running, jumping, climbing stairs and getting up from the floor, a waddling walk on the toes with an arched lower back, falling more than other children, and learning to speak later. A child may stand up using the Gowers' manoeuvre: facing the floor with the feet wide apart, lifting the bottom first, then walking the hands up from the knees to the thighs. A blood test is usually enough to confirm it. In 20 English boys, parents first noticed problems at about 2.7 years, most often a waddling walk, trouble with steps and falls, and the diagnosis came at about 4.3; the authors ask GPs to test for creatine kinase (CK), a muscle enzyme, sooner. Most of these boys were walking by 18 months, so walking on time doesn't rule it out.

Other causes AAOS names include a problem in the spinal cord and nerve conditions such as Charcot-Marie-Tooth disease. Toe walking on one side only may be more concerning, AAOS says, because it can sometimes be a sign of a neurological problem.

Sources 14, 15, 16, 17, 18, 2

Toe walking and autismEmerging evidence

Toe walking is more common in autistic children: 20.1% of 324 autistic children seen by a US developmental paediatrician; 27.3% of 289 autistic children against 5.5% of matched children in Italy; and persistent toe walking in 6.3% of autistic children against 1.5% of other children in a US health system of 284,925 children.

But AAOS says there is no direct link between toe walking and autism, and toe walking on its own doesn't mean a child is autistic. In the Swedish county study, 7 of the 17 children with a neuropsychiatric diagnosis or developmental delay had walked on their toes. Among 51 children referred to a Swedish orthopaedic unit for idiopathic toe walking, parents' questionnaires showed more difficulties than in other children of the same age with motor skills (39% above the 90th percentile), attention and planning, perception, memory, language, learning and social skills, and the authors suggest asking about these when a toe walker is assessed.

Sources 19, 20, 21, 2, 10, 22

Heel pain, sudden toe walking, and calf pain after a virus

Children of about 8 to 12 with heel pain from growth can walk on tiptoe to ease it, an NHS leaflet says: our Sever's disease guide covers that. The same leaflet says toe walking that begins suddenly needs assessing by a physiotherapist or doctor.

Sudden calf pain and difficulty walking a few days after flu or a cold is different. It's usually benign acute childhood myositis, a short-lived inflammation of the calf muscles: in a review of 22 studies, children averaged 6.8 years old, 92% had pain in both legs, 80% a fever and 56% couldn't walk, and recovery took about 1 to 6 days. Doctors watch the pee, because muscle breakdown can rarely affect the kidneys.

Sources 13, 23

Is it harmful?

NHS Lothian's leaflet says toe walking generally does no harm to children, doesn't usually cause pain or deformities, and is often a habit; frequent toe walking can go with tight calves, which make heels-down walking harder. Untreated, some children carry on into adulthood with a bouncy walk, NHS leaflets say.

Sources 1, 6, 8

How it's assessed

A clinician asks about pregnancy and birth, milestones and family history; watches your child walk, run, hop and get up from the floor; and checks the calf length with the knee straight and bent, strength, reflexes and sensation. Toe walking with a normal examination needs no tests. If something doesn't fit, your child may be referred on, and sometimes has nerve and muscle tests or scans.

Sources 2, 5

What helps, and how strong the evidence is

The UK consensus approachStrong evidence

In 2024, 222 to 227 members of BSCOS and the APCP agreed 31 statements. Toe walking without symptoms, and without a tight ankle (a foot that can't be brought up to a right angle with the leg), doesn't need treatment; the aim is to manage symptoms, not just the toe walking, and lower-leg pain or the effect on a child's daily life can be reasons to treat. Non-surgical treatment should always come first: advice, stretching, strengthening, casting, and day and night splints.

Serial casting can be tried for tight calves, and not reaching flat-footed standing after 6 weeks of casting is given as an example of failure. Surgery is for when that hasn't worked or isn't suitable, with follow-up for at least 12 months. Neurodiverse children should be offered treatment, with advice that toe walking may come back, and families should know how to come back if it returns.

Source 5

Time, heels-down play and shoesEmerging evidence

Giving children time to grow out of toe walking is usually the first option, an NHS leaflet says, and another says treatment is rarely needed under 3. In the Swedish study, 79% of toe walkers stopped by 10 without treatment.

NHS leaflets suggest playing standing with the heels down, heel walking, tightrope walking along a line, marching, moon walking, giant stomping steps, backward walking, squatting, bear and crab walks and leap frog, with prompts to walk slowly with the heels down for older children. Supportive, well-fastened shoes or ankle boots help, and stiff walking boots or wellies make tiptoe walking hard. You can cut the games back as things improve. No trial has tested these on their own.

Ordinary active play counts too: the NHS asks children under 5 to be active for at least 3 hours a day, and 5 to 18 year olds for an average of at least 60 minutes a day, and an NHS leaflet suggests swimming, bikes, balance bikes, scooters, soft play and climbing for strength and balance.

Sources 11, 24, 12, 1, 3, 4, 8, 9, 6, 25, 26

Calf stretches and strengthEmerging evidence

Daily stretches can help prevent tight calf muscles, NHS leaflets say. The doses differ: twice a day, holding 30 seconds each time (NHS Lothian); 30 seconds, 4 times on each leg (Plymouth); 15 to 30 seconds with gentle pressure for a parent's stretch (Gateshead); 3 times a day (Lincolnshire). A children's hospital fact sheet says daily calf stretches may help, holding each for 30 seconds. The UK consensus says stretching can be given even when the heels reach the floor.

Activities to strengthen the calf, hamstrings and trunk are part of NHS physiotherapy for toe walking. No trial has tested stretches or strength work on their own.

Sources 1, 24, 3, 12, 9, 5, 6, 8

Exercise or casts: one small trialEmerging evidence

In a trial of 29 children aged 3 to 10, 10 had serial casts, 9 an exercise programme and 10 waited. Both treatment groups improved more on a toe walking severity scale than the waiting group, which was only followed for a month after treatment, and casting and exercise didn't differ at any point up to 6 months, with similar side effects and how well children kept to them. It's one small trial.

Source 27

Serial castingEmerging evidence

Weekly below-knee walking casts, usually on both legs, for about 3 to 6 weeks (Whittington) or 4 to 6 weeks (East Sussex), stretch the calf gradually; only children with very tight calves need them. Children can walk in them with plaster shoes over them, they must be kept dry, and usual sport stops while they're on. The skin can get dry, itchy or rubbed.

In 86 children, changing casts every week gained more ankle movement in the first 2 weeks than changing them every 2 weeks (10.6° against 7.5°). In a Swedish trial, 4 weeks of casts improved ankle movement, strength and walking at 3 and 12 months, but many children still toe walked to some degree. Afterwards, children need help to re-learn walking and to strengthen, and toe walking can come back, often with growth spurts.

Sources 8, 13, 24, 3, 28, 29

Botulinum toxin: no added benefitEmerging evidence

In a trial of 47 children aged 5 to 15, injecting botulinum toxin into the calves 1 to 2 weeks before 4 weeks of casts made no difference to any result at 3 or 12 months, and a systematic review agrees. AAOS describes it mainly for children with a neurological condition and raised muscle tone, to make stretching easier.

Sources 29, 30, 2

Splints and insolesMixed evidence

In a trial of 18 children, an ankle-foot orthosis (a splint up the back of the lower leg) controlled toe walking while it was worn, but children went back to their old pattern when it came off; a foot insole with a stiff plate controlled it less well, but children and parents preferred it, and the effects out of the splint were similar.

Whittington Health's leaflet says splints and insoles have been found to be ineffective on their own and may be used only after serial casting, to hold the gain. Other NHS services use ankle-foot orthoses by day or night to keep the calf's length, and the UK consensus includes day and night splints. The evidence is thin and mixed.

Sources 31, 8, 13, 5

Surgery: the last optionEmerging evidence

Lengthening the Achilles tendon or the calf muscle is the last option, for tight calves that haven't responded to other treatment. Casts follow for about 4 to 6 weeks (AAOS) or 6 weeks (Lincolnshire's leaflet), then physiotherapy.

In 19 children over 10 (average age 12.6), 14 no longer toe walked without meaning to, 5 did occasionally, and all went back to full activity with a heel-toe walk. A systematic review found only surgery reported effects lasting more than a year, though walking didn't fully return to normal after any treatment, and AAOS says some children carry on toe walking even after casts or surgery.

Sources 13, 12, 8, 2, 32, 30

Autistic childrenEmerging evidence

The UK consensus says neurodiverse children should be offered treatment, with advice that toe walking may come back. NHS leaflets say autistic children may need to keep up home stretches and activities for longer, and that treatment is less likely to stop the toe walking for good. A 2026 systematic review of 8 studies (424 autistic children) found the evidence on casts, splints and surgery to be of very low certainty.

Sources 5, 1, 8, 33

How strong the evidence is overallMixed evidence

A 2019 Cochrane review found 4 trials with 104 children; only one, of 47 children, gave usable results, and its evidence was of very low certainty. There was too little evidence to judge botulinum toxin, footwear, exercises or splints. A 2014 systematic review (1 trial and 18 observational studies) found early evidence that casts and surgery improve ankle movement and walking, though walking doesn't fully return to normal, and no evidence yet on everyday activities and joining in.

Sources 34, 30

How much pain is OK while you exercise?

Stretches should never hurt, and pain means a check (borrowed from NHS leaflets, our wording)

Toe walking itself usually doesn't hurt. Pain or discomfort in the calves is one of NHS Lothian's reasons to get help, and pain is a reason to see a GP in other NHS leaflets.

Stretches: use a gentle pressure. Your child should feel a pull in the back of the leg, never pain. If your child cries out, pulls away or the stretch hurts, ease off. For young children, watch for wincing, pulling the leg away or refusing the next stretch; a stretch that's fine is one they'll let you repeat (our wording, following the approach in our Köhler's guide).

Play and strength work: comfort leads. Calf muscles may ache for a day after new heel-walking or squatting games, like any new exercise; aching that lasts longer, or pain in one spot, means drop back, and see a GP if it carries on (editorial).

In or just out of casts: do only what the team allows. Walking can feel strange when casts come off, and the team gives a walking and strength plan. Pain that's getting worse in a cast is a warning sign.

Sources 1, 7, 6, 3, 24, 13

The exercise plan: 3 stages

Start at the first stage. Each move opens a full guide with a 3D demo.

Stage 1

Heels-down play (toddlers and young children, most days)

Games that bring the heels down, supportive fastened shoes or boots, and time. The UK consensus says toe walking without symptoms and without tight calves doesn't need treatment, so these are optional and should stay fun. Stop while it's still a game; the written steps below have more ideas.

3D demoHeel walkBeginner · No equipment

Penguin walks on the heels: 3 walks of 5 to 10 steps · Editorial dose; NHS leaflets suggest heel walking

Easier: Tibialis raise · Harder: Single-leg tibialis raise

Standing march demonstrated on the 3D figure

3D demoStanding marchBeginner · No equipment

1 min, marching like soldiers · The animal moves workout's amount; an NHS leaflet suggests marching

Easier: Seated march · Harder: Standing band hip flexion

Tandem stance and heel-to-toe walk demonstrated on the 3D figure

3D demoTandem stance and heel-to-toe walkBeginner · A wall

Tightrope walking heel to toe along a line: 3 walks of 10 steps · Editorial dose; NHS leaflets suggest it

Easier: Semi-tandem stance · Harder: Single-leg stand

Backward walking demonstrated on the 3D figure

3D demoBackward walkingBeginner · No equipment

Walking backwards, touching toe to heel: 1 to 2 minutes · Editorial dose for young children, shorter than the move page's 5 to 10 minutes; an NHS leaflet suggests it

Harder: Backward sled drag

Bear crawl demonstrated on the 3D figure

3D demoBear crawlIntermediate · No equipment

Across the room and back · The animal moves workout's amount; NHS leaflets suggest bear walks

Easier: Knee hover (Pilates tabletop hover) · Harder: Spider crawl (low push-up knee drive)

Deep squat hold demonstrated on the 3D figure

3D demoDeep squat holdIntermediate · No equipment

Playing in a squat with the heels flat: 30 s to 1 min at a time, a few times a day · Editorial dose; NHS leaflets suggest playing in a squat

Easier: Goddess pose (Utkata Konasana) · Harder: Cossack squat

Move on when: The heels come down more of the time. If the calves feel tight, the heels won't come down when asked, or toe walking is still most of the time after about 3, add stage 2, ideally with a physiotherapist's advice.

Follow along: a timer, a cue and the next move, one step at a time.

Stage 2

Calf stretches and strength (tight calves, or older children)

Daily calf stretches, and strength for the calves, hamstrings and trunk, as NHS physiotherapy leaflets suggest. For young children, a parent does the stretch (written steps below); older children can do the standing stretches themselves. Keep the stage 1 games going.

Wall calf stretch (gastrocnemius) demonstrated on the 3D figure

3D demoWall calf stretch (gastrocnemius)Beginner · A wall

Hold 30 s, 4 times on each leg, daily, back knee straight and heel down · Plymouth's NHS leaflet's dose

Easier: Seated calf stretch with a towel · Harder: Heel-on-step calf and hamstring stretch

Soleus wall stretch demonstrated on the 3D figure

3D demoSoleus wall stretchBeginner · A wall

Hold 30 s, 2 to 4 times on each leg, daily · A children's hospital fact sheet shows this bent-knee stretch held for 30 s; the count is editorial

Easier: Seated calf stretch with a towel · Harder: Toes-tucked kneeling (toe squat)

Seated calf stretch with a towel demonstrated on the 3D figure

3D demoSeated calf stretch with a towelBeginner · Other / check instructions

A towel stretch: hold 30 s, twice a day · NHS Lothian's dose for calf stretches; useful before a child can do the standing ones

Harder: Wall calf stretch (gastrocnemius)

Tibialis raise demonstrated on the 3D figure

3D demoTibialis raiseBeginner · No equipment

2 sets of 10, lifting the front of both feet with the heels down · Editorial dose

Harder: Single-leg tibialis raise

Glute bridge demonstrated on the 3D figure

3D demoGlute bridgeBeginner · No equipment

10 bridges, high enough for a toy car to drive under · The animal moves workout's amount; NHS leaflets include trunk and hamstring strength

Easier: Pelvic tilt into bridge · Harder: Single-leg glute bridge

3D demoDead bugBeginner · No equipment

A beetle on its back: 5 slow reaches on each side · Editorial dose, as in our Köhler's guide

Easier: Dead bug heel taps · Harder: Forearm plank

Move on when: The heels reach the floor easily when standing and walking. If they don't after a few months of daily stretches, a physiotherapist may suggest casts or splints (written steps below), then stage 3.

Follow along: a timer, a cue and the next move, one step at a time.

Stage 3

Walking, strength and balance again (after casts, splints or surgery, as your team allows, or once the heels are down)

After casts or surgery, children need help to re-learn walking and to strengthen, and splints at night may hold the stretch if your team prescribes them. Bikes, scooters, swimming, soft play and climbing build strength and balance.

3D demoHeel walkBeginner · No equipment

3 walks of 10 steps · Editorial dose

Easier: Tibialis raise · Harder: Single-leg tibialis raise

Slow calf raise demonstrated on the 3D figure

3D demoSlow calf raiseBeginner · A wall

2 sets of 10, lowering the heels all the way to the floor each time · Editorial dose

Easier: Seated bent-knee calf raise (soleus raise) · Harder: Standing dumbbell calf raise

Single-leg stand demonstrated on the 3D figure

3D demoSingle-leg standBeginner · A wall

The flamingo: 20 s on each leg · The animal moves workout's amount

Easier: Tandem stance and heel-to-toe walk · Harder: Single-leg reach matrix

3D demoTandem stance and heel-to-toe walkBeginner · A wall

3 walks of 10 steps forwards and 3 backwards · Editorial dose; a children's hospital fact sheet suggests walking forwards and backwards along a line

Easier: Semi-tandem stance · Harder: Single-leg stand

Standing broad jump with stuck landing demonstrated on the 3D figure

3D demoStanding broad jump with stuck landingIntermediate · No equipment

4 frog leaps, landing and freezing like a statue · The animal moves workout's amount

Easier: Snapdown to athletic landing · Harder: Single-leg hop and stick

Stationary cycling demonstrated on the 3D figure

3D demoStationary cyclingBeginner · Cardio machine

A bike or scooter ride, 10 to 20 min · Editorial, as in our Köhler's guide

Easier: Recumbent exercise bike · Harder: Air bike intervals

Move on when: Back to all activities. Keep the stretches and heels-down games going a few times a week through growth spurts, and if toe walking comes back, ask to be seen again.

Follow along: a timer, a cue and the next move, one step at a time.

What to change for now

A parent's calf stretch for a young child (written steps)

From the Gateshead, Plymouth and NHS Lothian leaflets, with our suggestion marked.

1. Your child lies on their back with the leg straight.
2. Cup one hand around their heel, with your forearm along the sole of the foot. Steady the leg with your other hand.
3. Using your forearm, gently draw the foot up towards a right angle, with a gentle pressure. Your child should feel a stretch in the back of the leg.
4. Hold for 15 to 30 seconds (Gateshead's leaflet), or 30 seconds, 4 times on each leg (Plymouth's). NHS Lothian suggests stretching twice a day.
5. Stop if it hurts or your child pulls away. A song, a story or a screen can help them relax (our suggestion).

Sources 3, 24, 1

Heels-down games (written steps)

From the NHS Lothian, Lincolnshire, Gateshead and Worcestershire leaflets and a children's hospital fact sheet.

1. Play standing at a table or sofa with the heels down.
2. Penguin walks on the heels, marching like a soldier, giant stomping steps, stomping on a pillow and moon walking.
3. Tightrope walking heel to toe along a line, forwards and backwards.
4. Playing in a squat, bear and crab walks, and leap frog.
5. Swimming, bikes, balance bikes, scooters, soft play and climbing, for strength and balance.
6. Cut back gradually as things improve, and bring the games back if toe walking returns.

Sources 1, 12, 3, 7, 9

Shoes and prompting (written steps)

From NHS leaflets, with our suggestions marked.

1. Supportive, well-fastened shoes, or boots that come up over the ankle.
2. Stiff walking boots or wellies for longer walks: they make walking on tiptoe hard.
3. Toe walking can be more obvious barefoot, or on carpet, cold tiles or grass; shoes help on those days (our suggestion).
4. For older children, a calm reminder to walk slowly with the heels down. Praise heels-down walking rather than telling a child off for toe walking (our suggestion).

Sources 1, 6, 8, 13, 3

Living with serial casts (written steps)

From the East Sussex, Whittington, Plymouth and Gateshead leaflets.

1. Below-knee walking casts, usually on both legs, changed every week for about 3 to 6 weeks to stretch the calf gradually.
2. Your child can walk in them, with plaster shoes over them. Keep them dry. Usual sport and activities stop while they're on.
3. Check the toes and the skin at the cast edges every day: dry, itchy or rubbed skin can happen. Numb, tingling, swollen, blue or white toes, a cast that feels too tight, pain that's getting worse or a bad smell: contact the team the same day (the cast warning sign at the top of this page).
4. After the casts come off: help to re-learn walking and to strengthen, and sometimes splints at night to hold the stretch. Toe walking can come back, often with a growth spurt, so keep the stretches going.

Sources 13, 8, 24, 3

Positions to swap, and why

Habit or position	Why it matters	Instead
Telling a child off for toe walking	Toe walking is usually harmless and often a habit, and pressure can make walking stressful (our reasoning).	Heels-down games, and praise for heels-down walking.Try: Heel walk
Pushing a stretch through crying or pulling away	NHS leaflets use a gentle pressure; a stretch should be felt, never hurt.	Short, gentle holds while your child is relaxed.
Relying on special insoles or shoes alone	One NHS service found splints and insoles ineffective on their own, and no trial supports them.	Supportive boots or fastened shoes, alongside play and stretches.
Waiting it out with toe walking on one side, stiffness, falls, lost skills or late walking	These need checking, and NICE asks for persistent toe walking to be referred.	A health visitor or GP check.
Expecting botulinum toxin to fix it	It added nothing to casts in a trial of 47 children.	Stretches and play, and casts if the calves are tight.
Stopping everything once the casts come off	Toe walking can come back, often with growth spurts.	Keep the stretches and heels-down games going a few times a week.Try: Soleus wall stretch

Routines to follow

Animal moves for kids: a 15-minute active play workout

Fifteen minutes of animal moves, jumps and balance games for children, building the muscle- and bone-strengthening activity they need, with nothing to buy.

15 minBeginner16 movesA wall

Balance exercises routine

Balance practice in 10 minutes: tandem stance, single-leg stands, marches, heel walks, tree pose and floor transfers.

10 minBeginner7 movesA wall, A bench or box

More moves for this area

Questions people ask

Is toe walking normal?

In toddlers learning to walk, yes: most walk heel to toe by about 2 to 3. In a Swedish study, about 5% of children had walked on their toes at some point by 5½.

Will my child grow out of toe walking?

Most do. In one Swedish group's study, 79% of children who had ever walked on their toes had stopped by 10 without treatment. NHS leaflets say some carry on to about 6 or 7, and a few longer.

When should I worry about toe walking?

See your health visitor or GP if your child is still toe walking most of the time after about 3, does it on one side only, can't put their heels down when asked, or has stiff legs, pain, frequent falls or other worries about their development. Toe walking that starts suddenly in a child who walked normally needs checking too.

Is toe walking a sign of autism?

It's more common in autistic children, but there's no direct link, and toe walking on its own doesn't mean a child is autistic. If you or a professional have wondered about autism, mention the toe walking to your GP.

Could it be cerebral palsy or muscular dystrophy?

Rarely. Walking on tiptoes can be a sign of cerebral palsy, especially with late milestones or stiff muscles, and NICE asks for persistent toe walking to be referred to a child development service. In boys, falls, a waddling walk and pushing up on the thighs to stand can be signs of Duchenne muscular dystrophy, and a blood test is the first check.

Is toe walking harmful?

Usually not: it's often a habit and doesn't usually cause pain or deformity. Some children develop tight calves, which is why the calves are checked.

What can I do at home to help?

Heels-down games such as penguin walks, marching, tightrope walking, squatting and bear crawls; supportive, well-fastened shoes or ankle boots; and daily calf stretches if the calves are tight. Keep it playful.

How do I stretch my child's calves?

With your child lying down, cup the heel with your forearm along the sole and gently draw the foot up, holding for about 15 to 30 seconds. NHS Lothian suggests stretching twice a day. It should feel like a gentle stretch, never pain.

Will my child need casts?

Only if the calves are tight and don't respond to stretches: a few weeks of weekly below-knee casts stretch the calf. A small trial found casts and exercise both helped more than waiting, and neither beat the other.

Does Botox help toe walking?

Not on top of casts: in a trial of 47 children, botulinum toxin before casting made no difference. It's mainly used for children with a neurological condition and stiff muscles.

What if my child suddenly starts walking on tiptoe or won't walk?

Toe walking that begins suddenly in a child who walked normally needs checking by a GP or physiotherapist. Sudden pain in both calves and difficulty walking a few days after flu or a cold is usually a short-lived calf muscle inflammation, but needs a GP the same day or NHS 111. A child who can't put any weight on their legs needs 999 or A&E, and dark pee with calf pain needs medical help the same day.

Can toe walking come back after treatment?

Yes, sometimes with a growth spurt, so keep up the stretches and games. Services expect children to be referred back if it returns.

Related exercise guides

Other pain guides

Sources

Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.