Blog Post January 26, 2023 Idiopathic Toe Walking

This can be quite a challenge for children and families, and for pediatric physical therapists- will children just grow out of this? Is it an indication of other diagnoses? What are evidence based tests and measures that can guide clinical decision making and measure the impact of interventions? What are the best evidence based interventions? When are orthotics a good option? The Academy of Pediatric Physical Therapy is developing a Clinical Practice Guideline to guide clinical decision making, and an important step in that process is to get input from key stakeholders. This article by Barkocy et al is part of that effort.

Barkocy et al. Parent Perspectives regarding care delivery for children with idiopathic toe walking to inform an American Physical Therapy Association Clinical Practice Guideline. 2021. Pediatric Physical Therapy. 33: 26–266

Purpose: to explore and characterize PT Idiopathic Toe Walking (ITW) care experiences from the parent perspective to inform development of a Clinical Practice Guideline and identify strengths and gaps in care perceived by parents to optimize care

Key Takeaways


  • Children ages 2-21 with onset of toe walking since independent ambulation- bilateral, habitual, idiopathic; excludes CP, Autism/ PDD, myopathy, DMD, CMT, SMA, tethered cord, clubfoot, unilateral, or sudden onset
  • A diagnosis of exclusion
  • Correlations with language delays, learning disabilities; anecdotal with sensory processing issues; increased forefoot, midfoot, and/or hindfoot pain in adulthood

Common Interventions: HEP, stretching, strengthening, gait re training, serial casting, botox, AFO, surgery (usually reserved for older children)


  • Substantial variability in ITW diagnosis and referral processes, PT eval and RX, and parent experiences
  • Parents often first identified ITW and asked HCP about this (median 3 years), but referral to PT was often delayed (median 4 years)- many parents commented that they would have preferred an earlier referral to PT
  • Lots of inconsistent and confusing messaging- fewer than half of parents reported being satisfied and only 30% felt that PT was very effective
  • Ideal outcomes to strive for: PROM > 10 degrees with knee extended; heel strike > 75% by parent report & clinician observation; gross motor and balance skills at age appropriate level

Additional Reference: Cincinnati Children’s Hospital Evidence-Based Care Guideline: Management of Idiopathic Toe Walking in children and young adults ages 2 through 21 years; 15-February-2011

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