Walking on the toes or the ball of the foot is a variation of normal gait for many children between 10 to 18 months of age as they begin to walk. This variation usually progresses to a toe-heel gait and eventually to the normal heel-toe gait pattern within 3 to 6 months.[9]

Some children, when asked to walk normally, can simply put their heel down on the ground before their toes. However, as soon as no one is observing them, they revert to toe-walking because it is habitual (idiopathic toe-walking). Cerebral palsy is commonly associated with toe-walking that persists beyond 2 years of age. A congenitally short tendocalcaneus causes persistent toe-walking even though the child can toe-heel and heel-toe walk. These latter gaits are awkward and are less comfortable for children until 6 to 8 years of age, when their toe-walking disappears.

Children with idiopathic or habitual toe-walking have a history of normal development. A family history of persistent toe-walking may be found. As with pes cavus, certain rare muscular, peripheral, spinal, and central neurologic diseases should be ruled out when toe-walking persists beyond 2 years of age.

Children with idiopathic or habitual toe-walking have a normal examination. A thorough neurologic examination is required to rule out cerebral palsy or other associated neuromusculature system disorders.

Radiographic examination is not indicated in most cases of toe-walking. Neuroimaging is necessary if the toe-walking is acquired (develops after a period of normal gait) to rule out intracranial lesions.

The only treatment required for either idiopathic or habitual toe-walking is reassurance.

However, in the child who continues to toe-walk beyond 2 years of age, a dorsiflexion-assist ankle-foot orthosis may be of benefit.[9] [10] [11]