Toe Walking – When should I get help?

Parents can’t wait for the moment their child starts walking on their own.  It is a sign of achievement and is usually met with great excitement. Sometimes, however, that excitement turns to worry when a child does not walk as the parents expect. One common walking problem is toe-walking or walking on the balls of the feet. Toe walking could be relatively benign (termed “idiopathic toe walking”) or it could be a sign of something more serious.

There are a number of reasons why a child might toe walk. Some of the reasons for toe walking include musculoskeletal or neurological conditions. If your child is walking on his toes and does not have any specific condition that would cause the toe-walking then he has what is known as idiopathic toe walking.  Fortunately, most cases of toe-walking are idiopathic in nature and might not need any specialized treatment.

Idiopathic toe walking is the most common diagnosis for toe walking. It is defined as a gait pattern with no contact between the heels and floor after the age of three. Studies have shown that the majority of idiopathic toe walkers will begin to walk normally between 5 and 6 years of age without the need for treatment.  There are a number of theories given for idiopathic toe walking although none are proven. We do know it is more common among children with neurodevelopmental disorders (such as autism, sensory processing disorder, and ADHD).

If your child is unable to walk with a heel-to-toe pattern when prompted before three years old or is toe walking after three years old you should seek medical attention. If toe-walking is from a musculoskeletal or a neurological condition it is better to start treatment as soon as possible. Treatment might consist of physical therapy, bracing, surgery or a combination of each. If the toe walking is idiopathic the treatment can be as simple as observation.

If physical therapy is recommended, treatment might consist of stretching the tight Achilles tendon, strengthening of the muscles in front of the ankle, “core” strengthening, proprioceptive, and balance exercises.  Other strategies used might include taping and footwear assessment and recommendations.

Dr. Jay Semel PT, DPT is a pediatric physical therapist, who along with Dr. Joshua Mazalian, run LA Orthopedic and Pediatric Physical Therapy in Encino. You can reach them at info@laoppt.com or check out www.laoppt.com

W-Sitting – Should you change your child’s sitting position?

If you search up w-sitting on Google you will undoubtedly come across multiple opinions about correcting your child’s sitting position. So who is right? Should you correct your child’s sitting position?

Throughout the course of a day your child may transition in and out of a sitting position many times. Most normally developing children have a repertoire of sitting postures that may include w-sitting. As long as this sitting posture is not the primary means of sitting, it is not a concern. If however, you find your child mainly sitting in this position then you may want to take action.

Why do kids w-sit?

W-sitting may be a natural way to sit because of the amount of rotation, or anteversion, in their thigh bones. Children that have increased anteversion may find it more comfortable to sit in a w-sit position than in a tailor-sit position (with legs crossed).

W-sitting also provides a very stable base of support. Kids that are low tone or have difficulty with balance or stability may favor this position as it allows them to explore their world in an upright position and free their hands for play.

So if w-sitting can help kids sit up better, why should I change it?

  1. First, it limits the ability to cross midline. Developing the ability to cross midline in sitting is an important developmental skill. It helps build core strength and control. It also helps with bimanual development and coordination of arms and hands.
  2. Sitting in a w-sit position for long periods of time limits the amount of balance, strength, control and coordination of the trunk that children would otherwise get if sitting in a different position.
    1. Normally when sitting your abdominal and back muscles or constantly correcting and adjusting your position to keep your balance in sitting. This is especially important for children that have not yet mastered sitting balance. Because of the wide base of support in the w-sit position there is a limited amount of “correction” that the muscles need to make and the child misses out on the balance and muscle activation that alternate sitting positions provide.
    2. Furthermore, since the w-sit position “locks” the pelvis posteriorly, the abdominal and spinal muscles don’t need to work to correct the constant back and forth shifting of the pelvis.
  3. Experimental models show that being placed in a w-sitting position places increased rotational forces against the thigh and shin bones. Although controversial, some think w-sitting may affect the rotational development of these bones as the child grows.
  4. W sitting places the ligaments in the hip and the inside of the knees into a stretched position. Kids with hip pathology (such as developmental hip dysplasia) are especially discouraged from sitting in this position.

How can you help your child learn alternative sitting positions?

First show your child alternate sitting positions to build his repertoire of sitting postures. Some alternative positions include ring sitting, half-ring sitting, long sitting, side-sitting, or tailor sitting. Once they are accustomed to alternative sitting positions, gentle reminders to “fix your legs” may help cue them into changing into a different position.

Help them work on their trunk strength and balance. Some ideas you can use to help build strength and balance include:

  1. Practice some of the other sitting positions with your child as you play with them. Have them sit in a long-sit position and have them catch and throw a ball.  Or place them in a tailor-sit position and reach for toys just outside their comfort zone. Having your child practice an actual sitting position while performing a task will reinforce the position for them.
  2. Play with a puzzle while sitting on balance disk. As the child reaches for the puzzle pieces he will be using his “core” muscles to help build strength, coordination, and balance of his trunk. As it gets easier you can have him reach further for the puzzle pieces to increase the challenge. You can also have them practice reaching across midline to add an additional challenge.

So should I change my child’s sitting position?

Like most things, it depends on each individual child. Kids may w-sit because it is comfortable or because it affords increased balance. Whether you should change their sitting position comes down to why they are w-sitting. If it’s simply a comfortable sitting position that your child can easily transition in and out of then it’s likely just a normal part of their development. If it’s because of a lack of muscle strength, balance, or control then having your child change sitting positions can help them further develop their fine and gross motor skills.


Dr. Jay Semel, PT, DPT is the co-owner of LA Orthopedic and Pediatric Physical Therapy in Encino and specializes in pediatric and orthopedic physical therapy. You can reach him at 323-680-5616 or by email at jay@laoppt.com.