By Dr Jane Williams and Bindy Cummings

Does your toddler or pre-schooler walk on their toes, the tip of their toes, their toe knuckles or even on their knees? You may be wondering if this is OK.  Most of these different walking techniques usually transition into a ‘normal’ walking pattern, however sometimes, these patterns persist and may be cause for concern. When should you be concerned and what can you do to help your child if you are? Here are a few tips.

Lots of babies  who are cruising (holding onto furniture and learning to walk) and toddlers, toe or ‘tiptoe’ walk when they first get up onto two feet. This is caused by a reflex called the Tonic Labyrinthine Reflex (TLR). The TLR in extension occurs when a baby’s head is tilted back, causing the arms and legs to straighten. The TLR in flexion occurs when the head is tilted forward, causing the baby’s arms and legs to bend. The TLR is present when a baby is born and has an important role to play at birth, as it helps the baby straighten out to pass through the birth canal easily.  Its job continues once a baby is born, creating automatic patterns of movement which stimulate the body’s muscles and give the baby practice at stretching and relaxing.

Once its role is complete, the TLR reflex disappears, and voluntary control of movement takes over. Most children have inhibited the TLR in flexion by four months of age. The TLR in extension gradually disappears from approximately six weeks of age, and should be inhibited by voluntary control before a child walks. However, depending on the amount and kind of movement experiences a child has had, it may take another year. The TLR should be fully absent, or ‘integrated’, by three years of age.

Toe walking is a normal part of development. It’s not uncommon to see three-year-olds tip-toeing around the house like a fairy. It’s a normal part of play-acting and a favourite game for many. What’s concerning is when children only toe walk, for example, even when wearing trainers or closed-in shoes. Some children have been known to walk, not only on their toes, but on the very tip of their toes like a ballet dancer, or even on their toe knuckles. Another variation is walking everywhere on the knees – knee walking. In all these instances, a ‘retained’ or not fully integrated TLR is likely to be interfering with the development of muscles in the feet and legs.

Toe walking is sometimes associated with children who have sensory processing and motor skill challenges, however, more often than not, it is likely to be due to a lack of early movement opportunities which integrate primitive reflexes like the TLR.

Children who bottom shuffle and/or don’t crawl on their tummies or creep on their hands and knees are more likely to tiptoe walk for longer. This is because these children have not given their toes and legs the ‘workout’ the brain expects as part of the development of the nervous system in the muscles of the feet and legs. The act of pushing off with the toes when commando crawling on the tummy is important for the inhibition of the TLR reflex. Creeping on all fours, rocking in the hands and knees position and shaking of the head from side to side, are also important actions that promote TLR inhibition. Children with low muscle tone are also more likely to toe walk a little more as the muscles of the legs need to be in extension to function well and enable the child to stay upright.

What can you do to help children who have unusual patterns of walking?

If you are concerned about your child’s mode of walking, don’t hesitate to seek advice from your local health professional, paediatrician, paediatric physiotherapist, or osteopath. Here are a few GymbaROO-KindyROO ideas and activity suggestions  that you can start doing immediately at home.

Massage
Massaging the feet and legs sends messages to the brain so it knows these body parts are there and active! It also helps blood flow to the region and stimulates proprioceptive responses in the joints, muscles and tendons.

Technique: Massage firmly, though not so that it is unpleasant.  Start at the feet and toes, continue around the ankles, along the calf muscles, around the knee joints and up onto the thighs to finish with a squeeze at the hips. Repeat regularly.

Encourage climbing
Climbing up or along ladders in bare feet, exerts pressure on the soles of the feet so that the feet curl and the ankles move. Climbing is also the act of flexing and extending the muscles of the legs, and this action helps inhibit the TLR.

Slides
Encourage children to walk up the slide before sliding down. This really gives the muscles at the back of the legs a great stretch!

Stretching and flexion exercises and games

• Point and flex toes
• With the child lying on their back, the parent holds the ankles, bends the knees up and then extends the legs fully
• With the child lying on their back, do bicycles in the air. Parent can be a ‘bicycle partner’ and place their feet on their child’s, providing resistance while bicycling and making those leg muscles work even harder!
• Bobbing up and down helps the brain learn to move the muscles from flexion to extension
• Squatting and waddling like a duck (for example), will assist the tendons to release and stretch as they tighten over time

Vestibular exercises
Because the TLR reflex is stimulated by the movement of the neck, the vestibular (balance organs) are involved in the activation and inhibition of the reflex. Activities that stimulate the balance mechanisms will therefore help – rolling, spinning and rocking are all beneficial.

Additional activities for knee walkers

Children persistently walking on their knees (instead of on their feet) can do all the above activities as well as:

• Exercise: Hold onto the child’s feet and sing ‘Wheels on the Bus’ as you cycle the legs
• Play stamping games around the room – ‘Everybody stamping just like this!’
• Tap on the bent knee joint. Have fun by tapping out a favourite rhyme
• Encourage standing – get one knee into a bent position and push up to standing. Try tapping the foot on the floor first
• Play ‘Jack in the box’ – squat down and then jump up… surprise!
• Put lots of things safely up high, so the child needs to stand to get them!

Dr Jane Williams (PhD, BMgt, RN(Paeds)) is the Research and Education General Manager for GymbaROO and KindyROO. She is one of Australia’s leading experts on baby and child development.

Bindy Cummings is a teacher, GymbaROO-KindyROO early childhood neurodevelopmental consultant and a long-time member of the GymbaROO-KindyROO Research and Education Team