The Next Step for Toe Walking

By: Elizabeth Zeppernick, M.Ed., BCBA, LBA

Toe walking, defined as stepping with no heel contact on the ground, is relatively common in individuals with Autism Spectrum Disorder (ASD).  It has been estimated that about 20% of young children with ASD have this ambulation disorder (Ming et al., 2007).  Aside from the possible social impact of an abnormal gait, toe walking can negatively impact the physical health of the individual as it can result in a tightening of the calf and ankle muscles, and poor posture which is persistent later in life (Pendharkar et al., 2008).  It can lead to bunions, increase the risk of falling, cause fatigue and pain (Sobel et al., 1997).  For these reasons, an effective intervention is necessary. 

Medical interventions exist to address toe walking including surgery, casting, orthoses, and Botulinum toxins injections.  These interventions can be both intrusive, expensive and don’t necessarily lead to a permanent fix.  Researchers have shown some improvement with a variety of behavioral interventions as well.  When looking to expand upon current use of behavioral interventions to address toe walking, researchers Wilder et al., (2021) studied the effect of various walking surfaces and the use of textured shoe inserts, publishing their findings in an article titled “Evaluation of Shoe Inserts to Reduce Toe Walking in Young Children with Autism.” 

In this published study, researchers worked with two male participants ages four and five in Early Intensive Behavioral Intervention (EIBI) centers.  In order to assess which conditions led to the most and the least amount of toe walking, they collected data on the percentage of steps with toe walking on a variety of surfaces including linoleum, grip tape (similar to the top surface of a skateboard), smooth tile and artificial grass.  For Participant 1, a tile-like smooth surface produced the least amount of toe walking while Participant 2’s lowest percentage of toe walking occurred on the artificial grass surface.  These surfaces were then used during the treatment phase of the study.

Treatment consisted of five minute sessions, with 2-3 sessions per day in which the participants walked continuously, each with their respective surface shoe inserts.  For Participant 1 wearing the tile inserts, toe walking went from 99.4% during the initial baseline screening, down to as low as 2.5% of intervals.  For Participant 2, toe walking went from 53% of intervals, down to 5.3% as a result of the intervention.  An additional intervention was added for Participant 2, in which, contingent on toe walking, therapists placed their hand on his shoulder, adding gentle pressure so that the participant's heels touched the floor.  This further reduced Participant 2’s toe walking to 3% of the intervals.  During follow up probes a week after treatment, participants toe walking remained below pre-intervention levels (17.5% for Participant 1 and 4.5% for Participant 2). 

There are several possible advantages to this treatment procedure.  This intervention is discreet and less socially stigmatizing than full ankle and calf braces.  In-soles are decidedly low tech and affordable.  This behavioral intervention is not as invasive as surgery, injections, or casting.  While this study’s participant pool was small, the data suggests that assessing and implementing the use of specific insoles may reduce toe walking and should be explored further as a possible behavioral intervention. 

Sources: 

Ming,X., Brimacombe, M., & Wagner, G. C. (2007). Prevalence of motor impairment in autism spectrum disorders. Brain & Development, 29(3), 565-570. https://doi.org/10.1016/j.braindev.2007.03.002

Pendharkar, G., Lai, D. T., & Begg, R. K. (2008). Detecting idiopathic toe-walking gait pattern from normal gait pattern using heel accelerometry data and Support Vector Machines. In Abstract from the 30th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (pp. 4920-4923). https://doi.org/10.1109/IEMBS.2008.4650317

Sobel, E., Casseli, M. A., & Velez, Z. (1997). Effect of persistent toe walking on ankle equinus. Journal of the American Podiatric Medical Association, 87, 17-22. https://doi.org/10.7547/87507315-87-1-17

Wilder, D. A., Ingram, G., & Hodges, A. C. (2021). Evaluation of shoe inserts to reduce toe walking in young children with autism. Behavioral Interventions, 1-12. https://doi.org/10.1002/bin.1860

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