ITW is a persistent pattern of walking on the balls of the feet without the heel touching the ground, occurring without an identifiable medical cause. While common in toddlers, it typically resolves by age two or three. When toe walking continues beyond early childhood, it is considered persistent, and a significantly higher incidence is observed in individuals with Autism Spectrum Disorder (ASD). Roughly 9% of children with ASD exhibit persistent toe walking, a rate nearly twenty times greater than in typically developing children. This article explores the relationship between ASD and this gait pattern, outlining practical strategies and professional pathways to address it.
The Connection Between Autism and Toe Walking
The increased occurrence of toe walking in the autistic population is attributed to differences in sensory processing and motor control. Toe walking provides heightened proprioceptive input—the body’s awareness of its position in space—by increasing pressure through the forefoot. Alternatively, this pattern may minimize uncomfortable tactile input from the ground or certain textures on the soles of the feet.
Motor planning difficulties, frequently observed in ASD, also contribute to this gait persistence. Coordinating the complex sequence of muscle movements required for a typical heel-to-toe pattern can be challenging. Toe walking may be an unconscious strategy to simplify the walking motion, requiring less balance and coordination. Repeated use of this pattern can lead to secondary physical changes, such as the tightening and shortening of the calf muscles (the gastrocnemius and soleus complex).
Actionable Home-Based Management
Parents and caregivers can implement activities at home to encourage a heel-down gait and improve sensory regulation. Structured stretching routines address potential muscle tightness in the calves. Simple exercises like heel-to-toe walking (often called a “penguin walk”) actively stretch the posterior muscles and strengthen the muscles in the front of the shin.
Wall pushes are an effective stretching method: the child stands facing a wall, places their hands on it, and leans forward with one leg back, keeping the heel on the floor to stretch the calf. Engaging in heavy work activities provides the intense proprioceptive feedback a child might be seeking. Examples include pushing a weighted box or toy car across the floor or carrying a slightly heavier backpack during walks.
Adjusting the environment can promote a more typical gait by challenging the child’s sensory system. Encouraging walking barefoot on varied surfaces, such as sand, thick carpet, or grass, provides different tactile inputs to the soles of the feet. For children who are sensory-seeking, wearing ankle weights or high-top shoes provides increased deep pressure input, which helps ground their awareness of their feet. These strategies focus on breaking the walking habit while addressing sensory and motor differences.
Professional Treatment Pathways
When home-based strategies are insufficient, or if a child exhibits pronounced muscle tightness, professional intervention is necessary. Both Physical Therapy (PT) and Occupational Therapy (OT) assess the sensory and biomechanical factors contributing to the gait pattern. A physical therapist develops a program focused on improving ankle flexibility, increasing muscle strength, and retraining the gait to achieve a heel strike.
For significant calf muscle tightness, a physical therapist may recommend specialized interventions such as serial casting. This non-invasive technique involves applying a series of lightweight, short-leg casts changed every week over four to eight weeks. Each new cast progressively holds the ankle in a slightly more dorsiflexed position, gradually stretching the tight tendons and muscles. Once the desired range of motion is achieved, custom Ankle Foot Orthoses (AFOs) are often prescribed.
AFOs are specialized braces worn inside the shoe that hold the foot and ankle at a right angle, preventing the child from pointing their toes while walking. The orthoses help maintain the flexibility gained through stretching or casting and provide consistent sensory input to the foot. Surgical intervention, such as Achilles tendon lengthening, is considered only in rare instances when persistent toe walking has caused severe, fixed contractures that have not responded to conservative treatments.