A mother recently brought her young son to Dubai Podiatry Centre because the family had noticed something unusual about the way he was walking.

His mother had noticed that he frequently walked with his feet pointing outwards, while his grandfather had spotted something different: the child’s fourth and fifth toes appeared to be curling and gripping.

When we watched him walking in the clinic, we could see why.

The child alternated between two very distinctive walking patterns. At times he walked with his feet turned considerably outwards. At other times, he went up onto his tiptoes and toe walked.

When he tried to put his whole foot onto the ground and walk in a conventional heel-to-toe pattern, it was surprisingly difficult for him.

The “Slapping” Sound When He Walked

When the child attempted to walk with his feet facing forwards, his feet tended to come down quite flat onto the floor, producing a noticeable slapping sound.

Instead of smoothly contacting the ground with the heel and progressing through the foot towards the toes, he lifted his knees higher and almost marched.

His mother encouraged him to try walking normally from heel to toe, but he found this difficult.

Interestingly, his walking became much easier when he either:

• turned his feet outwards, or
• lifted his heels and walked on his toes.

These were not simply habits. His body was finding alternative ways to move around a mechanical difficulty at his feet and ankles.

 

 

Why Were His Little Toes Curling?

His grandfather had been particularly concerned about the fourth and fifth toes curling.

This provided us with another clue.

When the child stood, his ankles and subtalar joints rolled significantly inwards. As this happened, the outside of the foot became less stable against the ground.

The smaller toes then tried to compensate by curling and gripping.

What the family could see at the toes was therefore only part of the picture.

The toes themselves were not necessarily the primary problem. They were reacting to what was happening underneath the foot and at the ankle.

His Arches Looked Normal When He Was Sitting

This is something that can surprise parents.

When the child sat on the examination chair with his legs extended in front of him, his feet looked quite different.

His ankles appeared straight and his arches were nicely formed.

But when we asked him to stand and put his body weight through his feet, the picture changed dramatically.

His ankles rolled inwards, his feet flattened and his little toes began to curl.

This distinction between a child’s non-weight-bearing foot and their weight-bearing foot can be extremely important.

A child can have a perfectly good arch while sitting and yet demonstrate significant hyperpronation when standing and walking.

What Is Hyperpronation of the Subtalar Joint?

The subtalar joint sits underneath the ankle and plays an important role in allowing the foot to adapt to the ground.

Some children have softer, more flexible ligaments, allowing considerably more movement through this area.

When excessive inward movement occurs under body weight, we describe this as hyperpronation.

In this child’s case, the inward movement was significant enough to affect the way he was choosing to walk.

Walking on his toes gave him another way of generating momentum and moving forwards.

Turning his feet outwards and adopting a wider stance also gave him another way to negotiate the excessive movement occurring around his feet and ankles.

Rather than repeatedly telling him to “put your heels down” or “keep your feet straight”, we needed to address why he found those positions difficult in the first place.

Correcting the Foundation

We recommended corrective orthotics designed specifically for his feet.

The purpose was to support the foot and ankle in a more neutral position and reduce the excessive inward movement occurring when he stood and walked.

His orthotics were manufactured and fitted into both his school shoes and sports shoes.

Then we asked him to walk again.

The difference was immediate.

With his feet and ankles better supported, he began walking much more easily and naturally. Most noticeably, he no longer felt the same need to rise onto his tiptoes to move forwards.

Don’t Look Only at the Arch

Parents often associate flat feet with simply looking at whether their child has an arch.

But children’s foot mechanics are more complicated than that.

We also look at:

• the position of the heel and ankle
• movement through the subtalar joint
• whether the arch changes significantly under body weight
• the position of the toes
• whether the toes grip the ground
• whether the feet turn inwards or outwards
• whether the child toe walks
• how the heel contacts the ground
• whether the child can comfortably achieve a smooth heel-to-toe walking pattern

Sometimes the smallest observations can be extremely useful.

In this child’s case, his grandfather noticing those curling little toes was an important clue to what was happening throughout the foot.

 

When Should Parents Have Their Child’s Walking Checked?

Children naturally have considerable variation in the way they learn to stand, walk and run, and not every flat-looking foot or unusual movement requires treatment.

However, if a child consistently walks on their toes, turns their feet markedly outwards, has difficulty walking heel-to-toe, produces a noticeable foot slap, curls or grips their toes, frequently trips, complains of discomfort, or simply appears to be working unusually hard to walk, it can be worthwhile having their gait and lower-limb mechanics assessed.

Sometimes what appears to be a habit is actually the child’s clever way of finding the easiest way to move with the mechanics they currently have.

At Dubai Podiatry Centre, we assess not simply how a child’s feet look while they are sitting, but what happens to those feet when the child stands, walks and moves.

Because ultimately, feet are designed for movement — and that is where their true function can be seen.

This article is for general educational information. Toe walking and altered gait can have a number of causes, including musculoskeletal and neurological causes. Persistent, new, asymmetric or otherwise concerning gait changes should be appropriately assessed rather than assumed to result from flat feet or hyperpronation alone.

 

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