Toe-walking services in pediatric PT: assessment first

This guide is for pediatric physical therapy clinics, and for the OTs and SLPs who see children who toe walk. Idiopathic toe walking is a diagnosis of exclusion, so lead with an evaluation: screen for the conditions toe walking can signal, document the findings, report to the child’s physician, then plan treatment without promising a result.⁠^1,2

What does an assessment-first toe-walking service offer families?

It offers an evaluation first, and a treatment plan only after the findings, the physician’s input where it is needed and the family’s choice. APTA’s consumer guide asks families to have toe walking assessed by a physical therapist when it continues more than six months after a child’s first independent steps or becomes a new walking pattern, and says a PT whose examination suggests the condition cannot be treated only with physical therapy recommends the pediatrician or another specialist.⁠³ The family books an evaluation, not a program.

A package with a set number of sessions or a promised result sells a treatment before anyone knows the cause. APTA’s Code of Ethics requires PTs to give information about their services that is truthful and accurate, with no misleading representations, and to obtain informed consent after giving information that is understandable and honest.⁠¹¹ An evaluation is the one toe-walking service a clinic can describe truthfully before it has met the child.

DrSensory’s family guide to toe walking in children covers when toe walking needs assessment; this guide covers the clinic’s side.

Where do OTs and SLPs fit into toe-walking care?

They screen and refer more often than they run the service. AOTA describes occupational therapy practitioners as playing a central role in identifying and addressing sensory integration and processing challenges, so a child in OT for sensory concerns who also toe walks still needs a PT’s examination of ankle range, tone and gait before anyone calls the toe walking sensory.⁠¹³ An SLP evaluating a late talker who toe walks has a reason to tell the pediatrician: APTA’s guide lists late talking and limited vocabulary among the developmental signs that make a PT evaluation worthwhile.⁠³ In a clinic with all three disciplines, ask about walking on every pediatric intake.

Why is idiopathic toe walking a diagnosis of exclusion?

Because "idiopathic" means no cause was found, and that is true only after the causes have been looked for. The Cochrane review defines it as an exclusionary diagnosis given to healthy children who keep walking on their toes after they should typically have reached a heel-toe gait, and AAOS, the American orthopedic surgeons’ academy, says other possible causes must first be ruled out.⁠^1,2 The causes AAOS names include cerebral palsy, muscular dystrophy, a spinal cord abnormality and nerve conditions such as Charcot-Marie-Tooth disease; APTA’s guide adds clubfoot, leg-length differences, autism, sensory processing differences and ADHD.⁠^1,3

Most toe walking still turns out to be idiopathic. AAOS calls a medical cause very rare in toe walking that continues after age 2, and in a population-based cohort of 1,401 Swedish children, about 5% had ever toe walked, of whom 79% had a typical gait by age 10 without treatment; the authors add that a subgroup with early ankle contracture should not be considered idiopathic.⁠^1,6 Referred caseloads differ: of 174 children sent to a neurology clinic by pediatric orthopedic surgeons, 62% had a neurological cause, most often previously undiagnosed cerebral palsy.⁠⁵

Who decides that a child’s toe walking is idiopathic?

The PT can report that no examination sign points elsewhere; the medical diagnoses toe walking can signal are made by physicians, with tests a PT does not order. APTA’s guide calls toe walking of unknown origin when the child toe walks with both feet most of the time, has not walked with heels down past age 2, has an otherwise typical developmental history, and has been assessed for muscle tone, strength, range of motion, skeletal alignment and sensory components.⁠³ When questions remain, AAOS notes that imaging, nerve and muscle tests or genetic testing may be needed, and the AAP’s motor-delays report describes brain MRI for high muscle tone and a creatine kinase test for low tone.⁠^1,14

A systematic review in Pediatric Physical Therapy recommends specific evidence-based tests and measures to tell idiopathic toe walking from cerebral palsy.⁠¹⁵ Until the physician agrees, write "toe walking, with no finding on today’s examination that suggests a neurological or structural cause," not "idiopathic toe walking."

Which decisions come before a clinic offers toe-walking services?

Settle who the service is for, who evaluates, how red flags are routed, what the evaluation covers, how it is paid for and what the clinic says in public, and keep a record of each.

Readiness has no single credential: APTA’s guide suggests families consider a board-certified pediatric clinical specialist or a PT with a pediatric residency or fellowship, along with experience treating toe walking.⁠³ Claim only what your evaluators hold. The specialty guide covers testing demand for a new service, and the training and equipment guide covers weighing courses and supplies, such as casting materials, against the caseload.

Which red flags should send a toe walker to a physician first?

Any finding that points to a neurological, muscular, spinal or structural cause; send the findings to the child’s physician before writing a treatment plan. A red flag is a reason to involve the physician, not a diagnosis. APTA’s guide notes that tone changes may require a referral to a specialist, and APTA’s code requires PTs to stay within their scope and refer when necessary.⁠^3,11

Two findings need care in the other direction. A tight calf alone is not a red flag: the neurology review found that ankle contracture did not predict a pathologic diagnosis.⁠⁵ New toe walking after a period of heel-toe walking proves nothing alone, but POSNA notes that idiopathic toe walking less commonly appears after years of normal walking, so screen it fully and tell the physician.⁠⁴

Does new toe walking in a teenager or adult need a physician first?

Yes. NINDS notes that Becker muscular dystrophy usually appears around age 11 but may occur as late as 25 and lists walking on the toes among its early symptoms, and that some people with tethered spinal cord syndrome learn of it only as teenagers or adults.⁠^17,18 An adult clinic receiving such a request should send it to the person’s physician and evaluate afterward; the rest of this guide is about children.

What should a pediatric PT toe-walking evaluation include?

A history, an examination across the five areas APTA’s guide names, walking and running in more than one condition, and developmental and sensory screens, recorded so the physician and the next re-evaluation can compare.⁠³ The checklist combines APTA’s and AAOS’s items, so it also answers the questions a physician asks.⁠^1,3

Which measures help document a child’s toe walking?

Few are standardized, so pick a small set and use it the same way every time. The Toe Walking Tool, a questionnaire built to identify healthy idiopathic toe walkers and screen out medical causes, was tested with 10 clinicians assessing 12 children, and its authors present it as an aid to deciding when to refer.⁠²¹ For outcomes, a Delphi panel of ten health professionals agreed on nine questions and assessments, the iTWO, noting that studies rarely measure more than ankle range and whether the child toe walks.⁠²² A mild, moderate and severe classification exists but rests on instrumented gait analysis.⁠²³ Add the parent’s estimate of time spent on the toes, the rating a Swedish casting trial used.⁠²⁴

How should a PT screen sensory and developmental concerns?

Observe, record and refer. APTA’s guide describes young children who may toe walk to reduce touch on the soles, or to seek or avoid input while walking.⁠³ Treating that is a different step: AOTA’s Practice Smart recommendation is not to provide sensory-based interventions to individual children without documented assessment results of difficulties processing or integrating sensory information, an occupational therapy evaluation.⁠¹³ Communication and social concerns go to the pediatrician, whom the AAP makes responsible for developmental surveillance and screening, and to an SLP when talking is late.⁠²⁵

What should a toe-walking evaluation report to the physician say?

What was examined, what was found, which red flags were looked for, the PT’s impression in movement terms, and one clear question, sent before treatment starts whenever anything points away from idiopathic toe walking. The HIPAA Privacy Rule lets a provider disclose health information for another provider’s treatment, which it defines to include consultation and referral, so the report to the child’s own physician needs no separate authorization under that rule.⁠²⁶ Tell the family at intake that the findings go to their doctor.

The pediatrician referral guide covers introducing a clinic to a pediatric office and reporting back, and the orthopedic referral guide covers orthopedic practices, which see toe walkers too.

Can a PT start treating toe walking before the physician replies?

When the screen is clear and your state and the payer allow it, yes; when a red flag is present, hold the plan until the physician answers. That hold is clinic policy, not statute, following APTA’s referral duty and its guide’s advice to involve the pediatrician when physical therapy alone cannot treat the condition.⁠^3,11 Waiting costs little for many children: POSNA notes that young children who toe walk on both feet with a normal examination, including normal range of motion, typically need no treatment.⁠⁴

What does the evidence show for toe-walking treatments?

Not much, so state each treatment’s evidence at its own strength. A 2019 Cochrane review found four trials with 104 participants; the one it could analyze, comparing casting with casting plus botulinum toxin, was too low in certainty for conclusions, and the others’ data on botulinum toxin, footwear, exercise and orthoses were too limited to assess.⁠² An earlier review of one randomized trial and 18 observational studies found preliminary evidence that casting and surgery improve passive dorsiflexion and walking mechanics, though gait does not seem to normalize and effects on daily activities are unshown.⁠²⁷

There is no guideline yet: APTA Pediatrics lists one on physical therapy management of idiopathic toe walking as in development, estimated for 2024, and it is absent from the academy’s published list, so no clinic’s toe-walking care can be called guideline-based.⁠^7,28 Natural history is the comparison every claim must beat: most children stop on their own by age 10, so one child’s before-and-after change shows nothing about a treatment, and POSNA says physical therapy and shoe inserts have not been scientifically proven to cure toe walking.⁠^4,6

APTA’s consumer guide lists orthoses, serial casting, taping and shoe lifts among interventions shown to be effective, but the Cochrane review found too few usable trials to judge them, so present each as an option matched to a finding, such as limited dorsiflexion for casting, not as a cure.⁠^2,3 AAOS describes botulinum toxin for children whose neurological condition raises muscle tone, and Achilles lengthening for some children over 5 who cannot walk flat-footed; the PT’s part is the casting, bracing or therapy around them.⁠¹

How strong is the evidence on autism, sensory differences and toe walking?

The association is clear; what it means for treatment is not. In a U.S. private-payer database, 8.4% of autistic children had a toe-walking diagnosis against 0.47% of typically developing children, who more often stopped without intervention; in a Swedish study, 4.9% of 1,436 children aged 5.5 had ever toe walked, against 7 of 17 with a neuropsychiatric diagnosis or developmental delay.⁠^33,34 AAOS notes no direct link between toe walking and autism, and POSNA that autism, a sensory disorder or a neuromuscular cause raises the risk that toe walking persists or returns.⁠^1,4 A 2026 review of eight studies in 424 autistic children rated the intervention evidence very low in certainty.⁠³⁵

The sensory evidence points both ways: a 2023 systematic review found little support for the idea that children with idiopathic toe walking have sensory processing challenges, while a 2026 scoping review in the American Journal of Occupational Therapy found differences on parent-report surveys but not in vibration perception, with wide variation between children.⁠^36,37 Neither supports telling a family their child toe walks "because of sensory issues" without an OT evaluation.

Do families need a physician referral for a toe-walking evaluation?

Usually not for access, often for payment. ChoosePT, APTA’s consumer site, states that in every state and the District of Columbia a person can go straight to a physical therapist without a physician’s referral, adding that certain insurance plans may still require one and some states limit the duration or type of treatment without it.⁠⁸ APTA’s state summary, current as of July 2025, describes direct access in all 50 states, DC and the U.S. Virgin Islands, with provisions that differ by jurisdiction.⁠⁹ Read your state’s practice act and each plan’s referral rules.

The rule also differs by discipline. Federal Medicaid rules define physical and occupational therapy as services prescribed by a physician or other licensed practitioner of the healing arts, and speech-language services as those to which such a practitioner refers the patient; before booking a Medicaid-covered evaluation, ask the state program or the child’s plan who may write that prescription.⁠¹⁰ For self-pay families, APTA’s code requires telling patients their financial obligations before charges are incurred.⁠¹¹ The payment guide has wording for referral rules and fees, and the credentialing guide covers enrolling with Medicaid and commercial plans.

How does Medicaid EPSDT cover therapy for a child who toe walks?

Through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, for children under 21 enrolled in Medicaid, when the service is medically necessary. Medicaid.gov states that states must provide any section 1905(a) service that is medically necessary to treat, correct or reduce a condition, whether or not the state plan covers it, with medical necessity decided case by case.⁠³⁸ Physical therapy is among the services the regulations implementing section 1905(a) define.⁠¹⁰ Documentation decides it: the red-flag screen, the measured findings and a plan tied to them. A family told their plan does not cover toe-walking therapy can ask the state or plan how to request it under EPSDT.⁠³⁸

When should a toddler who toe walks be referred to early intervention?

When there are other motor or developmental concerns, refer to early intervention under IDEA Part C alongside the pediatrician. Part C serves children under three and includes physical therapy; parents and "other clinics and health care providers" are primary referral sources, state procedures must provide for referral within seven days of identification, and evaluation is at public expense with no fees to parents.⁠³⁹ The AAP’s motor-delays report stresses pursuing diagnostic tests while referring to early intervention.⁠¹⁴ Toe walking alone in a new walker differs: APTA’s guide describes it as part of early walking under age 2.⁠³ DrSensory’s guide to early intervention and private therapy explains the routes to parents.

How should a clinic explain toe walking to parents?

In plain words, in the order a parent asks: what toe walking can mean, what the evaluation checked, who else is involved, the options and their evidence, and why no one can promise a timeline. Parents surveyed to inform APTA’s guideline reported varying timing of diagnosis and care and of how involved they felt in decisions, and the authors ask clinicians to educate families and share decisions.⁠⁴⁰ The AAP’s autism report calls for the same shared decision making.⁠²⁰

Leave out "we fix toe walking" or a set number of weeks, since POSNA says physical therapy has not been proven to cure it; "it’s just a habit" before the screen; and "it’s sensory" without an OT evaluation.⁠^4,13 Leave out fear too: POSNA notes that persistent toe walking can cause relatively minor problems such as calluses, muscle strain, possible stress fractures or balance difficulty, and that no major long-term complications have been scientifically documented.⁠⁴

How should a clinic market toe-walking services honestly?

Describe the evaluation, the clinicians and the process, and make no outcome or timeline claim the evidence cannot carry. APTA’s code bars misleading representations.⁠¹¹ The FTC’s endorsement guides cover services, state that consumer endorsements are not competent and reliable scientific evidence, and read a testimonial about a key result as a claim that it is typical.⁠¹² A before-and-after walking video is that kind of claim, and the evidence cannot show the change is typical when most children stop on their own.⁠^2,6 The HIPAA Privacy Rule also requires a valid authorization before a provider uses protected health information for marketing, so a child’s video, photo or story needs the parent’s signed authorization for that use.⁠⁴¹

The pediatric service page guide covers the service page, and the pediatric PT growth guide covers outreach. A paid DrSensory listing lets a clinic add a description in its own words and the ages and conditions it treats, so toe-walking evaluation can be named there in the service page’s words; DrSensory does not verify clinical quality, and a listing is not an endorsement (listing options). The directory profile guide covers the description.

Who belongs in a toe-walking referral network?

The professionals who answer what a PT cannot: the pediatrician, pediatric orthopedics, neurology or neurodevelopmental pediatrics, an orthotist, and OT and speech colleagues. APTA’s guide names the neurologist for tone changes, the orthopedist for flexibility therapy does not reach and the orthotist for custom devices, and POSNA adds the neurodevelopmental pediatrician.⁠^3,4 Name one contact for each before the first toe walker is booked.

What does an assessment-first toe-walking case look like?

Two hypothetical inquiries start the same way, with an evaluation, and end in different first steps; neither is a real patient.

Sources

1. American Academy of Orthopaedic Surgeons, OrthoInfo. Toe Walking (patient information reviewed by members of the Pediatric Orthopaedic Society of North America). Checked October 23, 2026.
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   “In very rare cases, toe walking that continues after age 2 may be a sign of a medical condition. However, in most children, persistent toe walking is idiopathic.”; “Cerebral palsy”; “Muscular dystrophy”; “A spinal cord abnormality”; “Nerve conditions, such as Charcot-Marie-Tooth disease (CMT)”; “Children with autism-related conditions toe walk more often than children who are developing normally. However, there is no direct link between toe walking and autism.”; “Toe walking on only one side may be more concerning since it can sometimes be a sign of a neurological problem.”; “Is there a family history of neurological or muscle disorders?”; “Can your child walk flat-footed when asked?”; “They may then be asked to stand up without using their hands.”; “Look for differences in leg length.”; “Compare the size of the thighs and calves.”; “Look for skin changes or other abnormalities in the legs and back.”; “Idiopathic toe walking is a diagnosis of exclusion. This means that other possible causes must first be ruled out.”; “Sometimes other tests are needed. These may include X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, nerve and muscle tests, or genetic testing.”; “For children who are 2 to 5 years old and can walk flat-footed, treatment always begins without surgery.”; “Some children have a neurological condition that causes increased muscle tone. For these children, an injection of botulinum A toxin (Botox®) may be used to relax the calf muscles for a short time.”; “In children over age 5 who toe walk, the calf muscles and Achilles tendons become very tight. In some children, that tightness makes it impossible to walk flat-footed.”; “For these children, the doctor may recommend surgery to lengthen the Achilles tendons.”; “However, studies show that some children continue to toe walk even after treatment with serial casting or surgery.”.
2. Caserta AJ, Pacey V, Fahey M, Gray K, Engelbert RH, Williams CM. Interventions for idiopathic toe walking Cochrane Database of Systematic Reviews 2019;10:CD012363 (systematic review). doi:10.1002/14651858.CD012363.pub2. Checked October 23, 2026.
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   PMID 31587271.“Idiopathic toe walking (ITW) is an exclusionary diagnosis given to healthy children who persist in walking on their toes after they should typically have achieved a heel-toe gait.”; “Four studies, comprising 104 participants, met the inclusion criteria.”; “The certainty of evidence from one study, which compared serial casting with serial casting with BTX for ITW in children, was too low for conclusions to be drawn. A further three studies reported outcomes relating to BTX, footwear, exercises, and different types of orthoses as interventions, however the outcome data were too limited to assess their effects.”.
3. American Physical Therapy Association, ChoosePT. Physical Therapy Guide to Toe Walking (consumer guide by Jennie Burrowes, PT, DPT, and Anna V. Howard, PT; revised January 9, 2025). Checked October 23, 2026.
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   “Toe walking can occur in all children under the age of 2 as part of early walking exploration and development.”; “if toe walking continues longer than six months after a child’s first independent steps or becomes a new walking pattern, it should be assessed by a physical therapist.”; “other possible causes must be ruled out first.”; “Skeletal conditions (including clubfoot, leg length differences, or limited joint motion).”; “Neuropsychiatric conditions (including autism spectrum, sensory processing, or attention-deficit/hyperactivity disorders).”; “Seek a physical therapy evaluation if you or other caregivers (teachers or other medical providers) note any of the following about your child:”; “There are five areas a physical therapist will assess:”; “Changes in muscle tone may require a referral to a specialist.”; “Standing and walking up on the toes may reduce touch sensation to the soles of the feet, a common tactic of young children trying to avoid that sensation.”; “Toe walking can result when a child is seeking and increasing activity or avoiding and reducing activity to control what is experienced from the environment during walking.”; “For toe walking to be considered of unknown origin, the child must:”; “Toe walk with both feet the majority of the time.”; “Toe walk without heels down past 2 years of age.”; “Have an otherwise typical history of development.”; “Be assessed to rule any issues in the five areas above (muscle tone, muscle strength, range of motion, skeletal/bone alignment, and sensory components).”; “If the results of their exam suggest the condition cannot be treated only with physical therapy, they will recommend you see your child’s pediatrician or other specialist for additional evaluation to rule out a brain-related or other cause.”; “Gross motor skills for their specific age and development.”; “Motor control (planning and using the right muscles at the right time and effort).”; “Developmental delays (including late onset of talking or limited vocabulary for age, difficulty with hand and grasping skills for age, or late movement skills like stair climbing or standing on one foot).”; “Neurologist, to assess changes in muscle tension that could be related to a medical concern or other disease or diagnosis (in the brain, at the spinal cord, or in the nerves of the legs).”; “Orthopedist, to address muscle flexibility not achieved after physical therapy interventions for optimum foot contact when standing and walking.”; “Orthotist, to assist with any custom foot or ankle devices to achieve joint or muscle flexibility or support a new walking pattern.”; “Additional interventions by physical therapists and other specialists shown to be effective include:”; “Orthotics/braces.”; “Serial casting.”; “Therapeutic taping.”; “Shoe lifts.”; “Your physical therapist can work with your health care team to coordinate any need for orthotics, braces, or serial casting.”; “Experienced in treating children’s conditions like toe walking.”; “A board-certified clinical specialist in pediatric physical therapy, or a physical therapist who has completed a residency or fellowship in pediatric physical therapy.”.
4. Pediatric Orthopaedic Society of North America, OrthoKids. Toe Walking (condition page). Checked October 23, 2026.
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   “Single-sided toe walking at any age requires further evaluation to look for a cause. Causes of one-sided toe walking can include clubfoot, leg length difference, hip dislocation, cerebral palsy, or other neuromuscular condition.”; “Although persistent toe walking can cause relatively minor problems like callouses on the skin, muscle strains/overuse in the legs, and potentially stress fracture of the feet or difficulty with balance, no major long-term complications have been scientifically documented.”; “it less commonly appears after years of normal walking patterns.”; “Young children who toe walk on both feet (under the age of approximately 5) and have a normal physical exam inclusive of normal range of motion, typically do not need treatment or further evaluation, as the condition is most likely to improve without treatment.”; “If there are muscle or nerve differences noted on the physical exam, or toe waking is present in older children, referral to a neurologist or neurodevelopmental pediatrician is recommended to assess for a possible underlying neuromuscular or developmental cause.”; “Physical therapy and shoe inserts have not been scientifically proven to cure toe walking.”; “In older children or children for whom conservative treatment has not worked, surgery may be recommended.”; “Patients with a sensory disorder, autism, or a neuromuscular cause for their toe walking have a greater risk of persistent toe walking, or return of toe walking after treatment.”.
5. Haynes KB, Wimberly RL, VanPelt JM, Jo CH, Riccio AI, Delgado MR. Toe walking: a neurological perspective after referral from pediatric orthopaedic surgeons Journal of Pediatric Orthopaedics 2018;38(3):152–156 (retrospective cohort). doi:10.1097/BPO.0000000000001115. Checked October 23, 2026.
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   PMID 29309384.“We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015.”; “Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW.”; “Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP)”; “Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001).”; “An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients.”.
6. Engström P, Tedroff K. Idiopathic toe-walking: prevalence and natural history from birth to ten years of age Journal of Bone and Joint Surgery (American) 2018;100(8):640–647 (population-based cohort of 1,401 Swedish children). doi:10.2106/JBJS.17.00851. Checked October 23, 2026.
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   PMID 29664850.“In a population-based cohort of 1,401 healthy 5.5-year-old Swedish children, we found the prevalence of idiopathic toe-walking to be approximately 5% (63 of 1,401).”; “By the age of 10 years, 79% of the children who have ever been a toe-walker spontaneously develop a typical gait, without intervention or contractures of the ankle dorsiflexion.”; “One subgroup of children displayed early contracture of the ankle and should thus not be considered idiopathic toe-walkers.”; “Neurodevelopmental comorbidities are common among those who continue to toe-walk.”.
7. APTA Pediatrics (Academy of Pediatric Physical Therapy of the American Physical Therapy Association). Guidelines-in-Development (table of clinical practice guidelines under development). Checked October 23, 2026.
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   “CPGs include graded recommendations for management of a condition based on a systematic review of the literature and are updated every 5 years.”; “The following table indicates the topics that are under development, a targeted publication year”; “Physical Therapy Management of Idiopathic Toe Walking”; “PT examination and intervention with Systematic Review”.
8. American Physical Therapy Association, ChoosePT. Physician Referral Not Needed: You Can See a Physical Therapist First (revised March 23, 2026). Checked October 23, 2026.
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   “In every U.S. state and the District of Columbia, you can go straight to a physical therapist without a physician’s referral.”; “Certain insurance plans may still require a referral. Some states may limit the duration or type of treatment that can be provided without one.”.
9. American Physical Therapy Association. Levels of Patient Access to Physical Therapists Services in the U.S. (Direct Access by State, resource dated September 4, 2024; the full state summary requires an APTA login). Checked October 23, 2026.
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   “While all 50 states, the District of Columbia and the U.S. Virgin Islands, provide some form of direct access to physical therapist services, the specific provisions and limitations differ across jurisdictions.”; “Please note that the data below is current as of July 2025.”.
10. Electronic Code of Federal Regulations. 42 CFR 440.110, Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders, with 42 CFR 440.1 (Medicaid services). Checked October 23, 2026.
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    §440.110(a)(1): “Physical therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified physical therapist.”; “Occupational therapy means services prescribed by a physician or other licensed practitioner of the healing arts”; “for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law.”; “This subpart interprets and implements the following sections of the Act:”; “1905(a) Services included in the term “medical assistance.””.
11. American Physical Therapy Association. Code of Ethics for the Physical Therapy Profession (Standards of Conduct; the policy page is dated January 1, 2026). Checked October 23, 2026.
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    “Physical therapists and physical therapist assistants shall obtain ongoing informed consent after providing information that is understandable, honest, and necessary to allow the patient or client or their surrogate to make informed decisions about participation in physical therapist services or research.”; “Physical therapists and physical therapist assistants shall not exceed their professional, jurisdictional, and personal scopes of practice and shall communicate with, collaborate with, or refer to a peer or other health care professionals when necessary.”; “Physical therapists and physical therapist assistants shall provide information about their services that is truthful and accurate and shall not make misleading representations in any forms of communication, including billing.”; “Physical therapists shall ensure that patients and clients are informed of their financial obligations prior to incurring charges so that shared decision-making can be incorporated into the treatment plan.”.
12. Federal Trade Commission. 16 CFR Part 255, Guides Concerning the Use of Endorsements and Testimonials in Advertising (§255.0(d) and §255.2(a)–(b), as published in the eCFR). Checked October 23, 2026.
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    “the term “product” includes any product, service, brand, company, or industry.”; “Consumer endorsements themselves are not competent and reliable scientific evidence.”; “An advertisement containing an endorsement relating the experience of one or more consumers on a central or key attribute of the product will likely be interpreted as representing that the endorser’s experience is representative of what consumers will generally achieve with the advertised product in actual, albeit variable, conditions of use.”.
13. American Occupational Therapy Association. Sensory Integration & Processing (clinical topic page, with AOTA’s Practice Smart recommendation). Checked October 23, 2026.
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    “Occupational therapy practitioners play a central role in identifying and addressing sensory integration and processing challenges with clients across the lifespan.”; “Don’t provide sensory-based interventions to individual children or youth without documented assessment results of difficulties processing or integrating sensory information”.
14. Noritz GH, Murphy NA; Neuromotor Screening Expert Panel. American Academy of Pediatrics clinical report. Motor delays: early identification and evaluation Pediatrics 2013;131(6):e2016–e2027. doi:10.1542/peds.2013-1056. Checked October 23, 2026.
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    PMID 23713113.“A multidisciplinary expert panel developed an algorithm for the surveillance and screening of children for motor delays within the medical home, offering guidance for the initial workup and referral of the child with possible delays in motor development.”; “Use of diagnostic tests to evaluate children with motor delays are described, including brain MRI for children with high muscle tone, and measuring serum creatine kinase concentration of those with decreased muscle tone.”; “The importance of pursuing diagnostic tests while concurrently referring patients to early intervention programs is emphasized.”.
15. Schlough K, Andre K, Owen M, Adelstein L, Hartford MC, Javier B, Kern R. Differentiating between idiopathic toe walking and cerebral palsy: a systematic review Pediatric Physical Therapy 2020;32(1):2–10. doi:10.1097/PEP.0000000000000659. Checked October 23, 2026.
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    PMID 31842091.“Five articles were used that compared key clinical findings, walking characteristics, and muscle firing patterns of participants with CP and ITW.”; “The authors recommend that clinicians perform specific evidence-based tests and measures in accordance with the International Classification of Functioning, Disability and Health model.”.
16. National Institute of Neurological Disorders and Stroke. Cerebral Palsy (health information page). “Stiff or tight muscles and exaggerated reflexes (spasticity)”; “Unusual walking style (gait)—including walking on the toes, a crouched gait, or a “scissored” gait”; “Children generally walk later and on tiptoe.”. Checked October 23, 2026.
17. National Institute of Neurological Disorders and Stroke. Muscular Dystrophy (health information page). Checked October 23, 2026.
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    “DMD usually becomes apparent during the toddler years, sometimes soon after an affected child begins to walk.”; “Frequent falls and clumsiness (especially when running)”; “Difficulty when getting up from a sitting position or when climbing stairs”; “The calf muscles, and less commonly, muscles in the buttocks, shoulders, and arms, may be enlarged by an accumulation of fat and connective tissue, causing them to look larger and healthier than they actually are (called pseudohypertrophy).”; “The disorder usually appears around age 11 but may occur as late as age 25”; “Early symptoms of Becker MD include:”; “Walking on one’s toes”; “Difficulty rising from the floor”.
18. National Institute of Neurological Disorders and Stroke. Tethered Spinal Cord Syndrome (health information page). Checked October 23, 2026.
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    “TSCS is often diagnosed in children. Symptoms in children can include:”; “Sores, hairy patches, dimples, or tumors on the lower back”; “Changes in the shape of feet and the spine”; “Weakness and numbness in the legs”; “Trouble controlling when to go to the bathroom”; “Some people don’t know that they have TSCS until they become teenagers or adults.”; “Doctors usually diagnose TSCS with imaging scans.”.
19. National Institute of Neurological Disorders and Stroke. Charcot-Marie-Tooth Disease (health information page). “CMT causes a range of sensory and motor symptoms, including numbness, tingling, pain, muscle weakness and atrophy, and foot deformities that get worse over time.”; “Foot deformities, like high arches and curled toes (hammertoes)”. Checked October 23, 2026.
20. Hyman SL, Levy SE, Myers SM; Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics. American Academy of Pediatrics clinical report. Identification, evaluation, and management of children with autism spectrum disorder Pediatrics 2020;145(1):e20193447. doi:10.1542/peds.2019-3447. Checked October 23, 2026.
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    PMID 31843864.“Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior.”; “Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings)”; “Shared decision making calls for collaboration with families in evaluation and choice of interventions.”.
21. Williams CM, Tinley P, Curtin M. The Toe Walking Tool: a novel method for assessing idiopathic toe walking children Gait & Posture 2010;32(4):508–511. doi:10.1016/j.gaitpost.2010.07.011. Checked October 23, 2026.
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    PMID 20692159.“an online Toe Walking Tool questionnaire was developed that utilized questions to identify healthy idiopathic toe walkers and excluded those who toe walk as a result of a medical condition.”; “A group of 10 allied health professionals assessed 12 children utilizing the Toe Walking Tool.”; “This tool can assist with the decision of when to refer a child for further specialist investigation of their toe walking.”.
22. Gray K, Pacey V, Caserta A, Polt D, Williams C. Development of the Idiopathic Toe Walking Outcome (iTWO) proforma: a modified Delphi study and online parent survey for measurement consensus Gait & Posture 2023;99:111–118. doi:10.1016/j.gaitpost.2022.11.005. Checked October 23, 2026.
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    PMID 36399873.“Treatment effectiveness studies rarely collect data other than ankle range of motion or presence of toe walking.”; “Ten health professionals developed nine questions and assessments through consensus and agreement over the three rounds.”; “Parents expressed a willingness to self-complete questions or be taught assessments to monitor their child’s progress.”.
23. Alvarez C, De Vera M, Beauchamp R, Ward V, Black A. Classification of idiopathic toe walking based on gait analysis: development and application of the ITW severity classification Gait & Posture 2007;26(3):428–435. doi:10.1016/j.gaitpost.2006.10.011. Checked October 23, 2026.
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    PMID 17161602.“Three primary criteria, presence of a first ankle rocker, presence of an early third ankle rocker, and predominant early ankle moment, were used to classify idiopathic toe walking into three severity groups: Type 1 mild; Type 2 moderate; and Type 3 severe.”; “Prospectively collected gait analysis data of 133 children (266 feet) with idiopathic toe walking were analyzed.”.
24. Engström P, Bartonek Å, Tedroff K, Orefelt C, Haglund-Åkerlind Y, Gutierrez-Farewik EM. Botulinum toxin A does not improve the results of cast treatment for idiopathic toe-walking: a randomized controlled trial Journal of Bone and Joint Surgery (American) 2013;95(5):400–407. doi:10.2106/JBJS.L.00889. Checked October 23, 2026.
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    PMID 23467862.“Forty-seven children constituted the study population.”; “the parents rated the time that their child spent on his/her toes during barefoot walking.”; “Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking.”; “Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.”.
25. Lipkin PH, Macias MM; Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics. American Academy of Pediatrics clinical report. Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening Pediatrics 2020;145(1):e20193449. doi:10.1542/peds.2019-3449. Checked October 23, 2026.
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    PMID 31843861.“Early identification and intervention for developmental disorders are critical to the well-being of children and are the responsibility of pediatric professionals as an integral function of the medical home.”; “Developmental concerns elicited on surveillance at any visit should be followed by standardized developmental screening testing or direct referral to intervention and specialty medical care.”.
26. U.S. Department of Health and Human Services, HIPAA Privacy Rule. 45 CFR 164.506(c), Uses and disclosures to carry out treatment, payment, or health care operations, with the definition of treatment at 45 CFR 164.501. Checked October 23, 2026.
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    “A covered entity may disclose protected health information for treatment activities of a health care provider.”; “Treatment means the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another.”.
27. van Kuijk AA, Kosters R, Vugts M, Geurts AC. Treatment for idiopathic toe walking: a systematic review of the literature Journal of Rehabilitation Medicine 2014;46(10):945–957. doi:10.2340/16501977-1881. Checked October 23, 2026.
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    PMID 25223807.“One randomized controlled trial and 18 observational studies were identified.”; “There is preliminary evidence for beneficial effects of serial casting and surgery on passive ankle dorsiflexion as well as on walking kinetics and kinematics, although normalization does not seem to occur. Botulinum toxin type A does not improve the results of casting. Only after surgery are sustainable effects lasting > 1 year reported. Effectiveness on functional activities and social participation has yet to be demonstrated.”.
28. APTA Pediatrics. Clinical Practice Guidelines and Resources (list of the academy’s published guidelines). “produced by the APTA Academy of Pediatric Physical Therapy, provide graded recommendations based on systematic reviews of literature using internationally acceptable methods.”; “Concussion/Mild Traumatic Brain Injury”; “Congenital Muscular Torticollis”; “Developmental Coordination Disorder”; “Three-Dimensional Instrumented Gait Analysis for Children with Cerebral Palsy”. Checked October 23, 2026.
29. Giray E, Akpinar P, Illeez OG, et al. A comparative randomized-controlled trial of serial casting and exercises on ankle range of motion, toe walking severity, walking balance, and functional health-related quality of life in children with idiopathic toe walking Journal of Pediatric Orthopaedics B 2025;34(5):465–476. doi:10.1097/BPB.0000000000001250. PMID 40167594. Checked October 23, 2026.
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    Children aged 3 to 10 were randomized to serial casting (10), exercise (9) or a wait-list (10).“Randomized-controlled trials (RCTs) investigating nonoperative interventions for idiopathic toe walking (ITW) are limited.”; “The control group was followed up until the 1 MPT assessment.”; “No differences were found between the treatment groups in ankle ROM and TWSS at any follow-up points. The control group showed less improvement in the TWSS compared with the intervention groups.”.
30. Clark E, Sweeney JK, Yocum A, McCoy SW. Effects of motor control intervention for children with idiopathic toe walking: a 5-case series Pediatric Physical Therapy 2010;22(4):417–426. doi:10.1097/PEP.0b013e3181f9d5b8. Checked October 23, 2026.
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    PMID 21068642.“Five children received motor control intervention in a multiple-case series design using a nonconcurrent, variable baseline.”; “Parents indicated minimal gait change within the children’s regular environments.”; “Intervention improved ankle mobility, but additional components appear necessary to attain spontaneous heel-toe gait.”.
31. Herrin K, Geil M. A comparison of orthoses in the treatment of idiopathic toe walking: a randomized controlled trial Prosthetics and Orthotics International 2016;40(2):262–269. doi:10.1177/0309364614564023. Checked October 23, 2026.
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    PMID 25628380.“A total of 18 children with idiopathic toe walking were randomized to either the ankle-foot orthosis or foot orthosis treatment group in a Parallel Randomized Controlled Trial with no blinding.”; “The ankle-foot orthosis controls idiopathic toe walking, but subjects may revert to earlier patterns following treatment. The foot orthosis does not control idiopathic toe walking as well but is less restrictive and more accepted by children and their parents, with similar out-of-brace effects.”.
32. Sätilä H, Beilmann A, Olsén P, Helander H, Eskelinen M, Huhtala H. Does botulinum toxin A treatment enhance the walking pattern in idiopathic toe-walking? Neuropediatrics 2016;47(3):162–168 (randomized controlled trial). doi:10.1055/s-0036-1582138. Checked October 23, 2026.
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    PMID 27089542.“A total of 30 toe-walkers participated”; “Adding BTX injections did not significantly enhance the goal to walk either flat foot or with heel strike at 24 months posttreatment.”.
33. Leyden J, Fung L, Frick S. Autism and toe-walking: are they related? Trends and treatment patterns between 2005 and 2016 Journal of Children’s Orthopaedics 2019;13(4):340–345 (retrospective review of a national private-payer database). doi:10.1302/1863-2548.13.180160. Checked October 23, 2026.
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    PMID 31489038.“8.4% of patients with ASD also had a diagnosis of toe-walking (n = 484). For typically developing children in the database, 0.47% of patients had a diagnosis of persistent toe-walking.”; “Typically developing children have higher rates of toe-walking resolution without intervention than children with ASD.”.
34. Engström P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5-year-old children Pediatrics 2012;130(2):279–284 (cross-sectional study of 1,436 children in Blekinge County, Sweden). doi:10.1542/peds.2012-0225. Checked October 23, 2026.
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    PMID 22826572.“At age 5.5 years, the total prevalence of toe-walking was 70 (4.9%) of 1436.”; “For children with a neuropsychiatric diagnosis or developmental delay, the total prevalence for active or inactive toe-walking was 7 (41.2%) of 17.”; “At this age, more than half of the children have spontaneously ceased to walk on their toes.”.
35. Perricone E, Caldaci A, Cacciaguerra G, di Nora A, Parano C, Pavone V. Comparative effectiveness of conservative and surgical interventions for toe walking in children with autism spectrum disorder: a systematic review Frontiers in Medicine 2026;13:1832930. doi:10.3389/fmed.2026.1832930. Checked October 23, 2026.
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    PMID 42549164.“Eight studies including 424 ASD patients, aged 2-16 years, were included.”; “Current evidence is of very low certainty and does not allow conclusions regarding comparative effectiveness or treatment superiority.”.
36. Donne JH, Powell JA, Fahey MC, Beare R, Kolic J, Williams CM. Some children with idiopathic toe walking display sensory processing difficulties but not all: a systematic review Acta Paediatrica 2023;112(8):1620–1632. doi:10.1111/apa.16821. Checked October 23, 2026.
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    PMID 37161850.“Twelve articles met the inclusion criteria; however, only two papers included data permitting meta-analysis.”; “This study highlights that despite children with ITW often conceptualised as possessing sensory processing challenges, there is little evidence supporting this theory.”.
37. Chu VWT, Rolin OY, Girolami GL, Grant-Beuttler M. Sensory processing differences in children with idiopathic toe walking: a scoping review and exploratory meta-analysis American Journal of Occupational Therapy 2026;80(5):908–929. doi:10.1177/19437676261464097. Checked October 23, 2026.
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    PMID 42698309.“Six of the papers were included in a meta-analysis on vibration perception threshold that failed to reach significance (p = .12).”; “a meta-analysis for atypical scores from parent-report sensory processing survey data yielded significant differences between children with ITW and typical controls (p < .0068).”; “Children with ITW, however, represent a diverse group of individuals with significant between-subjects variability in which senses are impaired, and which outcome measures best capture these differences.”.
38. Centers for Medicare & Medicaid Services, Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (benefit page). Checked October 23, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis.”; “When a screening examination indicates the need for further evaluation of an individual’s health, diagnostic services must be provided.”.
39. Electronic Code of Federal Regulations. 34 CFR Part 303, Early Intervention Program for Infants and Toddlers with Disabilities (IDEA Part C): §303.13(b)(9), §303.303(a)(2)(i) and (c), §303.521(b). Checked October 23, 2026.
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    “for referring a child under the age of three to the part C program.”; “Physical therapy includes services to address the promotion of sensorimotor function through enhancement of musculoskeletal status, neurobehavioral organization, perceptual and motor development, cardiopulmonary status, and effective environmental adaptation.”; “Provide for referring a child as soon as possible, but in no case more than seven days, after the child has been identified”; “Primary referral sources. As used in this subpart, primary referral sources include—”; “(3) Parents, including parents of infants and toddlers;”; “(8) Other clinics and health care providers;”; “The following are required functions that must be carried out at public expense, and for which no fees may be charged to parents:”; “(2) Evaluation and assessment, in accordance with § 303.320”.
40. Barkocy M, Muir N, Le Cras S, et al. Parent perspectives regarding care delivery for children with idiopathic toe walking to inform an American Physical Therapy Association clinical practice guideline Pediatric Physical Therapy 2021;33(4):260–266 (U.S. parent survey). doi:10.1097/PEP.0000000000000820. Checked October 23, 2026.
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    PMID 34432760.“Data from 98 respondents were compiled through descriptive statistics of item responses and review of comments.”; “Parents reported variability in timing of diagnosis and intervention, ITW care, and extent they felt educated and involved in decision making.”; “Clinicians should be knowledgeable about ITW diagnosis, prognosis, and treatment options, educating families and engaging them in shared decision making around ITW care.”.
41. U.S. Department of Health and Human Services, HIPAA Privacy Rule. 45 CFR 164.508, Uses and disclosures for which an authorization is required (§164.508(a)(1) and (a)(3)(i)). Checked October 23, 2026.
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    “Except as otherwise permitted or required by this subchapter, a covered entity may not use or disclose protected health information without an authorization that is valid under this section.”; “a covered entity must obtain an authorization for any use or disclosure of protected health information for marketing, except if the communication is in the form of:”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. It does not diagnose any child or choose a treatment; the evaluating therapist and the child’s physician make those decisions, and referral and coverage rules differ by state and payer.