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SMO's for Tippy Toes


SMO's (supramalleolar orthosis) are thin, flexible orthotics that promote natural development while providing support for low muscle tone. They provide compression around the foot so they are more support than a shoe insert and are less bulky than AFOs (ankle foot orthotics). SMOs aim to prevent the development of harmful habits including knee hyperextension and joint laxity at the ankle. They allow for the child to develop a healthy and normative gait pattern that lays the foundation for other movements.

SMOs are indicated for use with mild toe walkers! These are children who are just starting to walk and have a tendency to move onto their toes during movement. If your child strictly walks on their toes and has difficulty even getting their heels to touch the ground due to tightness in the calf muscles and tendons, the may need more supportive orthotics which we can also provide.

Toe Walking

When children walk on there toes they tend to lock our their ankles and knees for support instead of relying on their muscles. This leads to weaker muscles through the legs and even the abdominal muscles. If children continue to walk on their tippy toes it can lead to permanent tightness and contractures of heel chords which can require surgical intervention if severe.

Toe walking can be caused by sensory processing differences. Some children toe walk if they have a tactile sensitivity and want to avoid their heel striking the ground. This can be linked to children that have had a history or heel pricks from an extended hospital stay. Other babies are looking for vestibular input and enjoy the bouncing they feel from being on their tippy toes.

Toe walking could also simply be a habit that is formed early on. Whatever the reason, there are several signs that your little one may need intervention to prevent long lasting muscle and tissue damage from toe walking.

Signs Intervention Is Needed

  • Child continues to toe walk 6 months after they have started walking

  • Child toe walks more when running or walking across unstable surfaces

  • Child is unable to set feet flat on the floor

  • Child continually has redness from toe walking in shoes or refuses to wear shoes so they can toe walk


Interventions can include physical therapy, orthotics, and home exercises to address muscle tightness, weakness, and to encourage a heel-toe gait pattern.

Some home activities you can do include:

  • Have the child walk up hill or on an incline so their weight is shifted back into the heel

  • Challenge the child’s balance by having them play catch or dance on a slightly unsupportive surface like a mattress, yoga mat, or cushion (be close by if you aren’t sure how they will do with balancing! You’d be surprised how much this can challenge little ones).

  • Stretch your child by having them sit with their legs out on the floor. Put a cushion or rolled blanket under their knees so they don’t hyperextend. Slowly bring their toes from pointed forward to pointed up at the ceiling. Hold the stretch for 10 seconds 3 times. Then do 30 reps once of slowly moving back and forth. Never push if the child is in pain or you feel you can stretch them to fully pointed up.

While AFOs are also recommended for toe walking, SMOs are a better choice for very early orthotic intervention. SMOs for toe walking allow the child’s muscles to strengthen through the foot, ankle, and legs. SMOs prevent toe walking and encourage a typical gait pattern to develop.

Casting for SMOs

At Orthopedic Motion, we make the casting process as simple and child friendly as possible. On the day of your casting appointment try to pick a time of day where your child is usually awake and in a good mood. It can also be helpful to bring a familiar toy, blanket, or music. If you know your little ones going to have a particularly tough time, it might also be beneficial to bring a special treat.

First, we have your child sit comfortably on your lap or the exam table. We have you remove their socks and shoes and then we place liners over their feet so that the casting tape doesn’t get on their skin.

Next we position yellow strips along your child’s legs, ankles and feet. These will be key for when we go to cut the cast off.

Now, the fun part! We wrap your child up like mummy with our casting material. Round and around until we have captured the parts we need to make the SMOs. This usually includes the toes up to a little beyond the ankle.

We smooth the material as it dries and then it is time to cut the casts off.

Our skilled practitioners use what is called a hook knife to carefully remove the casts. The hook knife is quiet, unlike a cast saw, and most children are unafraid of the knife and remain calm. Once the casts are removed your child's SMOs will be custom made from the casts.

To book your free consultation, call 702-697-7070 and we can help you and your family decide if your child would benefit from SMOs for Tippy Toes.

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