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Pediatric Foot Management: Q&A

Pediatric foot management is therapy to address any foot or ankle concerns that a family or medical practitioner may have for a child. It can encompass many different intervention options and can address a wide array of concerns that are centered around what matters most to the child, family, and medical team.

Our physical therapists are trained in evidence-based interventions to address foot management-related concerns. They are an excellent resource to families and medical teams and provide information on appropriate intervention strategies.

Julie Burkhardt PT, DPT with Milestone Pediatric Therapy Services, a HealthPRO Pediatrics Company, is sitting down to answer some of the most commonly asked questions when it comes to foot management in order to help guide families.


A: There are many reasons a child can walk on his/her/their toes. We think of toe walking as a symptom of another system of the body that is functioning differently than expected. Toe walking can stem from so many different systems. Many children will grow out of the toe walking by the age of 7, but currently, there aren’t great tools to predict who will grow out of toe walking and who will not.

Toe walking can be caused by a lot of factors including but not limited to:

  • Decreased ankle flexibility
  • Decreased balance when walking on flat feet
  • Vestibular hypofunction
  • Oculomotor impairment
  • Sensory seeking or avoidant behaviors
  • Impaired foot position when standing (pronated, flat feet, etc.)
  • Decreased strength in certain leg/hip/trunk muscles
  • Leg length difference
  • Neurologic involvement


A: Toe walking is not necessarily “bad” for your child. Toe walking can, however, lead to a cascade of other challenges and concerns as your child gets older. Toe walking is a symptom of something else happening in the body. Our concern for toe walking can sometimes depend on the “why” of your child’s toe walking. If there is a concern for neurologic involvement of impaired ankle flexibility, that may be more concerning than a sensory-based reason. Ongoing toe walking can cause abnormal forces to go through the feet and ankle over a long period of time, which can cause foot/ankle/knee/back pain as your child gets older. It also can cause challenges with your child being able to keep up with his/her/their friends while playing or during sporting activities. Toe walking can also lead to safety concerns with increased tripping and falling.

It’s always best to get a physical therapy evaluation for toe walking to ensure a happy and healthy body as your child gets older.


A: There is a wide range of “normal” when it comes to flat feet. Children are continuing to build the arch on the middle of their feet, the medial longitudinal arch, through the age of 7 years old. That being said, some bodies are more challenged to develop robust arches. This arch of our foot assists with shock absorption and is a big reason that we can run fast, jump, and walk without pain or limitation.

If your child has flat feet and has any of the following concerns, we would recommend getting a physical therapy assessment to determine if any intervention is necessary:

  • Your child has pain in his/her/their feet or ankles with walking, running, jumping, or any play activity
  • Your child is tripping and falling more than their peers
  • Your child gets tired quickly and prefers activities that are sedentary or don’t require standing up


A: There are a few reasons that may be leading to increased tripping and falling. The following may be leading to increased tripping and falling:

  • Unstable ankles or feet that could be due to pronation. Pronation refers to the way your foot rolls inward for impact distribution upon landing.
  • Decreased proprioception: information sent to the brain from the body related to where it is in space when still or with movement
  • Impaired sensory components
  • An impaired oculomotor system that leads to challenges with depth perception and provides poor visual information to the brain
  • Vestibular dysfunction

If this is a concern of yours, it would be best to consult with your local pediatric physical therapist to assess and intervene.


A: If your child is having foot, ankle, or heel pain with walking, activity, play, running or jumping, it is best to get a physical therapy foot management evaluation to assess what intervention option will be most effective. Two of the leading causes of foot/ankle pain are overly pronated feet or decreased ankle flexibility. If the foot and ankle complex pronates or drops towards the middle too much, this can cause significant pain and limitation when walking or running. Depending on the severity, your physical therapist may recommend semi-custom or custom orthoses to decrease pain and increase the ability to participate in age-expected activities. The other leading factor of decreased ankle flexibility may be trickier to diagnosis at home. If the muscles of your child’s calves are too short, this can add too much tension to the foot and ankle and result in significant pain.

Check with your physical therapist to determine if this is a factor in their pain and how to best intervene. Some options that may be considered are dynamic serial casting, night splints, or static stretching.


A: Not every child with flat feet or that trips and falls more than peers will need orthotics. There is a wide range of “normal” when it comes to flat feet. Your physical therapist will be able to assess if orthotics versus a different intervention will be the best plan of care depending on their findings and your family’s goals.


A: There are a few driving factors of both in-toeing and out-toeing. The main boney reasons for abnormal foot positioning while walking are:

  • Metatarsus adductus (in-toeing)
  • External (out-toeing) or internal tibial torsion (in-toeing)
  • Femoral anteversion (in-toeing) or retroversion (out-toeing)

Some other aspects that may be driving the in-toeing or out-toeing are poor balance, frequent W-sitting, or muscle imbalances in strength or range of motion. Many children will grow out of the in-toeing or out-toeing as they continue to develop, but if you are concerned then consult your local pediatric physical therapist.

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Author: Julie Burkhardt PT, DPT

Julie graduated with her Doctorate of Physical Therapy from the University of Colorado Physical Therapy program. While at CU, her clinical work with Aurora Public Schools, Denver Health, and Children’s Hospital of Colorado provided the opportunity to work with pediatric patients in a variety of environments. She found her passion in working with the neurodevelopmental population and the subspecialty of Foot Management. Julie has worked with a diverse group of children including the autistic population, as well as children with spina bifida, Cerebral Palsy, Down’s Syndrome, Charcot Marie Tooth, solid organ transplants, muscular dystrophy, idiopathic toe walkers, genetic syndromes, and developmental delays. Julie worked for a pediatric hospital for two years and was so excited to transition to join the Milestone Physical Therapy team!

When Julie is not in clinic, she enjoys trail running, mountain biking, and skiing. She applies her passion for movement to the children she works with, collaborating with families to find fun ways for each child to move their body for lifelong health. She has also used this passion for power-training based therapy with the neurodevelopmental population to meet some incredible goals!

Julie has sought additional training and expertise in the following:

  • Foot management: serial casting, night splints, custom and semi-custom orthotics, tuning and refining orthotics
  • Resistance training intensives: power training to achieve functional goals with the neurodevelopmental populations
  • Solid organ transplantation rehabilitation
  • Bike riding for the neurodevelopmental population

Tags: Pediatrics, Physical Therapist, foot management