Tip-toeing or toe walking is the term used to usually describe a condition where a person, usually a child, is walking using only the balls of the feet whilst the heel is hardly touching the ground. Most toddlers whilst learning to walk display the tip toeing and this usually lasts anything between two to three months after which the walking normalizes. If tip-toeing persists after the 24 months of age it may be an early sign of a neurological problem, one that is common in Cerebral Palsy, as one example. Constant tip-toeing may also in a long run cause damage to child’s ankle, resulting in inability to flex their feet or ankles upwards (dorsiflexion).
As the child growing, their persistent tip-toeing may start to damage the knees and hips, and lead to lower back problems. The child may also start to develop Thoracic Khysosis, in which case the ribs put extra pressure on the diaphragm muscles, while breathing can became shallow and the shoulders may crunch. At the same time calf muscles may stiffen up causing the Achilles tendon to shorten. Tip-toeing can also be a painful experience but unfortunately most of the children are not able to explain it properly. Despite all this, and due to lack of awareness and information, many parents and professionals are not alarmed when a child with autism engages in frequent tip-toeing, as it is often wrongly assumed to be yet another ‘odd autistic behavior’.
During our presentation we ask the parents to have a go and tip-toe for just for a couple of days and see how they would feel and how painful it could be. One can then easily imagine the painful consequences of few months of tip-toeing.
In our experience one in six children on the autism spectrum will continue to tip-toe even after the age of 3. Interestingly parents of those children often report that their child started walking very early and did not crawl long, or at all. Due to the movements required for a child to crawl it engages the left and right side of the brain to work together and helps with development of fine and gross motor skills.
Regular Tui Na acupressure massage can in many cases help reduce toe walking in children who engage in it past their early toddler phase. In some cases, especially when the massage is started early and preformed regularly, the problem can completely eliminated and child’s walking normalized.
In extreme cases, where tip-toeing cannot be reduced or eliminated, a cast intervention may be offered in order to stretch out the Achilles tendon. This involves the child wearing an adjustable plaster or fiber glass cast for a period of 6 to 8 weeks. However, this treatment is not always successful and the child may continue to toe walk. Further forms of treatment may involve surgery, which is usually offered when the child reaches teenage years. Such operative lengthening of the tendon is a very painful experience and requires at least 6 weeks of recovery. During the recovery period a cast, boot or a splint is worn for several weeks, followed by several weeks of slowly increasing and widening the movements of the feet. The operative lengthening is seen as the very last option, due to it not only weakening the muscles but also because it is a very stressful experience, especially for a child with autism. In some cases even such a drastic intervention will not permanently resolve the problem, and the child may revert to toe walking after the surgery.
Western medicine believes there are few reasons why toe walking occurs, to name just few:
1. Tip-toeing may be a learned habit
2. Child may have a dysfunctional vestibular system:
Function of vestibular system is to provide the brain with the information of body motion and position in space. Vestibular system refers to structures in the middle ear. When this system is affected the individual will often be very sensitive to noise and will cover their ears frequently. They will also be very sensitive to touch around ear region.
3. Child may have an acute sensitivity to tactile sensations:
This offers a possible explanation to why some children refuse to wear socks. The sole of the foot, which holds over 200,000 nerve endings, may became very sensitive, and in some cases the heel touching the floor may be a painful experience.
A combination of muscles, joints, and tendons that provides a person with a subconscious awareness of their body’s position in space, and informs the speed of their movement. Proprioception is one of many bodily functions thought to be affected in autism. It is a spatial awareness of your body within its surroundings – one result of its dysfunction may be the feeling of disconnection from own body. Two largest nerves in the bottom of the foot, the medial and lateral plantar nerves, work together to control the small foot and toe muscles. These nerves also relay information to the brain about the positions of joints, muscle tension and speed of movements. With this information, the brain propels the muscles of the legs, ankles and feet and maintains balance.
In Chinese medicine, and in my own clinical experience, tip-toeing is usually a sign of Spleen and Kidney deficiency. Another theory behind it is that Yang Meridians of the Foot (which all start in head region) due to blockages do not reach the foot region as they should, which in turn does not give the child appropriate feeling in lower limbs. It is thought that the energy in meridians also helps the blood circulation and nourishment to the skin and the nerves of the legs.
It is also most interesting to note that many points on Stomach, Spleen, Bladder, Kidney, Liver and Gall Bladder meridians are found on the pathway of sciatica, medial and lateral plantar nerve. This lends support to the theory of Chinese Medicine and to treating these points by acupressure in an attempt to reduce toe walking.
In my own practice I have often observed while performing an examination ,by palpitations on the back of the legs region that hamstrings (muscles in the upper leg) are hypotonic/ underdeveloped, whilst the muscles in the calves (muscles in the lower leg) are hypertonic/ overdeveloped. My conclusion in these cases has been that there is a major blockage at two points: Bladder 39, found on the medial side of the tendon m.biceps femoris, and Bladder 40, which is the midpoint of the transverse crease of the popliteal fossa (behind the knees). Both of those points are usually very ticklish in children on the spectrum which is another sign of energy stagnation.
To conclude, the most important points for treating tip-toeing are:
Bladder: BL-36 Chengfu, BL-37 Yinmen , BL-40 Weizhong, BL-57 Chengshan, BL-60 Kunlun & BL-65 Zutonggu
Kidney: KID-1 Yongquan, KID-3 Taixi & KID-5 Shiuiquan
Stomach: ST-36 Zusanli, ST-40 Fenglong, ST-41 Jiexi & ST-44 Neiting
Spleen: SP-3 Taibai, SP-4 Gongsun, SP-5 Shangqui & SP-6 Sanyiniao
Gall Bladder: GB-31 Fengshi, GB-34 Yanglingquan, GB-43 Xiaxi
Liver : LIV-2 Xingjian & LIV-3 Taichong
I would also suggest that parents include gentle ankle and toes rotation, gentle manipulations to extend the Achilles’ tendon and calves muscles by asking the child to push their foot against your hand holding it, and general foot massage of both legs .
Treatment shown is a short version of the ‘Tui Na for Autism – Treatment for tip-toeing’, and we suggest trying it at home if your child tip-toes. The best results are achieved if the treatment is delivered at least three times per week for a period of minimum six weeks.
Our recommendation is that any treatment with your child is done in a fun atmosphere, in a safe environment, and through constant talking to your child – explaining what you are doing while you doing it. For example, if I rotate their ankle while I am doing the motion I tend to say:”Look, your ankle can rotate in one direction and then in the opposite one”, or if I am working on the toes I name each toe whilst treating. This approach can help make new neuropathways to the brain, which in turn may help with proprioception.
The full version of a video ‘Tui Na for Autism – Treatment for Tip-toeing’ including the manual with anatomical location and further text will be available for purchase via our website from April 2017.
Tui Na centre also offers at home assessment for your child if you are based in UK. Feel free to contact us on firstname.lastname@example.org if you have any queries.