• Spitzfuß | © Pohlig GmbH
    Foot deformities
    Foot drop

Toe Walking 

Pes Equinus 

Symptoms and causes

Foot drop (drop foot, pes equinus) is a foot deformity that makes it very difficult for the heel to come into contact with the ground. This causes the patients to walk on the tips of their toes. Many people with pes equinus cannot manage to place their entire foot on the ground and therefore struggle with using their feet properly for walking. In many cases, the Achilles tendon is also shortened, which can affect the functioning of the entire leg. 

Pes equinus appears either by itself or in combination with other foot deformities (club foot, pes cavus (high arch), flat valgus foot etc.).

Distinctions are generally made between neurological or syndromic non-neurological causes.

Spitzknickfuß | © Pohlig GmbH

Neurological or syndromic causes include:

  • Infantile cerebral palsy (the most common here is spastic pes equinus)
  • Hereditary Motor-Sensitive Neuropathy (HMSN), also called Charcot-Marie-Tooth Disease (CMT)
  • Multiple Sclerosis 
  • Chronic Stroke 
  • Trauma

Non-neurological causes include:

  • Idiopathic toe walking (occurs without any predisposing spasticity; often a habit)
  • Compensatory toe walking (ex., to compensate for leg length differences) 

Neurogenic or idiopathic pes equinus?

The most common – especially in childhood – are neurological and idiopathic pes equinus:

Pes Equinus is most commonly observed in patients with underlying neurological disorders. Such disorders are characterized by impaired connections between the central nervous system (CNS), nerves, and muscles and often result in muscle spasticity. Cerebral Palsy is an example of a CNS disorder that causes spastic paralysis.

Children with idiopathic pes equinus walk on the tips of their toes from the very beginning, but, unlike children with neurogenic pes equinus, they can also stand on their entire foot and walk with a normal gait pattern. However, they seem to prefer walking on their toes. 

The cause of idiopathic or habitual toe walking is unknown but underlying neurological diseases are ruled out.  

Children often walk on the tips of their toes when learning to walk. However, they usually develop a normal gait pattern over time. If this is not the case, long-term consequential damage such as Achilles tendon contractures, foot disorders or damage to the spine may occur. In light of all this, it is important to treat idiopathic toe walking. 

Orthotic treatment for pointed feet

Maxim walks 80% on tiptoes

Briefly explained

Your questions about foot drop

Foot drop deformity is either congenital or acquired during life. Pointed toe most frequently occurs in connection with an underlying neurological disease in which the interaction between nerves and muscles is disturbed (neuromuscular disorders). This is the case, for example, with paralysis (cerebral palsy, polio, stroke, etc.).

In the case of acquired foot drop, muscle disorders, bony changes in the ankle joint, tendon injuries, and bedriddenness, among others, can cause the deformity. However, in the majority of idiopathic foot drop, the cause remains unexplained.

Walking permanently on tiptoe is not healthy. The unaccustomed foot position can lead to a shortening of the Achilles tendon and thus to considerable functional disorders of the entire leg. If the tiptoe malposition is not treated in time, long-term consequential damage such as foot deformities or spinal damage and associated knee, hip and back pain can be expected.

In children who frequently walk on tiptoe without an underlying neurological disease, psychological and medical causes can often be ruled out. Rather, tiptoeing has become a habit for them because this gait is more comfortable for the child. The origin of the habitual tiptoe walk is still not clearly understood. In many affected individuals, a shortening of the calf muscles or the Achilles tendon can be identified.

Another cause of tiptoe gait may be a malposition of the foot. The deformity prevents the affected child from stepping on the whole foot or rolling the foot when walking.

In some cases, tiptoe gait may also indicate an intellectual disability or a developmental disorder. It often occurs in autism, for example.

Both conservative and surgical measures (sometimes in combination) are possible for a foot drop. On the conservative side, orthoses are used relatively frequently - in addition to classic physiotherapy and Botox injections - to treat foot drop. With our lower leg orthosis with ring-shaped foot socket, we can offer an orthopedic device that has a high success rate in the treatment of foot drop.

At the beginning of walking development, it is common for children to walk more on tiptoe. This is partly because they still have to train their sense of balance. With a lot of practice and increasing body weight, children become more confident and usually develop a normal gait pattern (heel-toe gait) on their own. This usually happens within the first 3-6 months of walking.

For some children, it may take until they start school for them to step with their whole foot. Even in this case, the heel-toe gait may be completely harmless, but should be checked with a pediatric orthopedist to be sure.

Start as early as possible!

Treatment options with orthoses

Early treatment is of great importance for both idiopathic and neurogenic pes equinus. Both conservative and surgical measures (occasionally in combination) are possible.

In addition to physiotherapy and Botox injections, orthoses are used relatively frequently to treat toe walking.

Unterschenkelorthese mit ringförmiger Fußfassung | © Pohlig GmbH

There are two main orthotic options for pes equinus:

  • Functional orthoses are worn during walking, with the aim of facilitating proper foot mechanics (i.e., rolling from heel to toes).
  • Positioning orthoses are worn at night when the leg is not under load. These devices stretch the muscles and improve joint mobility.

With our lower leg orthosis with a ring-shaped foot shell, we can offer an exclusive orthopedic device that has shown a high success rate in the treatment of pes equinus. What makes this device so special is that it can be worn during the day and at night, thus combining both objectives – improving the gait and stretching the soft tissues.

Special orthopedic shoes, with their differently shaped soles, can reinforce the positive effects of the orthosis. 

If conservative therapy with orthoses does not lead to the desired success, or if further deformities are present, surgical steps may be necessary.


Icon Oberschenkelorthese | © Pohlig GmbH
Orthoses for foot, leg and hip

An orthosis is used to stabilize, relieve, immobilize, guide or correct limbs. This prevents or corrects incorrect postures and strains.

Icon von einem Orthesenschuh | © Pohlig GmbH
Shoes for orthoses wearers

When choosing orthopedic shoes, it is important to make sure that the shoe supports the purpose of the orthosis. There are numerous models with different designs.

New research article

Idiopathic toe walking

Despite the large number of therapeutic approaches for idiopathic toe walking, no gold standard approach exists. The study presented here considered the effects of lower leg orthoses with ring-shaped foot shells on children with idiopathic toe walking. The results are promising.