My child has been diagnosed with low muscle tone. What does this mean?

Who gets a diagnosis of low muscle tone?

An infant or child will get a diagnosis of low muscle tone when:

  • The muscles appear to be less firm than usual
  • The child appears to be floppy and to have loose joints
  • The child appears to be less alert and have poor posture and attention

For a more technical discussion please see Rethinking Low Muscle Tone

Often a child gets a diagnosis of low muscle tone because of one or more movement difficulties

  • May be late learning to sit and walk - but not always
  • Has trouble sitting erect and working at a table - tends to sit with back rounded, may lean on one hand when drawing and writing
  • Has difficulty sitting still, tends to fidget, does not complete school tasks
  • Has difficulties with handwriting and drawing 
  • May tire very quickly, not like walking far, have trouble going up stairs
  • May be good at games that involve short bursts of running, but have difficulty with posture in sitting, drawing and handwriting - these tasks require sustained activity in the postural muscles
  • Sit between legs on floor (w-sitting), does not like cross legged sitting
  • Appear to have poor attention span or concentration, gives up easily
  • Cannot hang on the monkey bars, does not like climbing on the jungle gym, is fearful

The first thing to understand is that low muscle tone is a not a condition or a diagnosis

Low muscle tone does not cause any of the behaviors or difficulties listed above.

Low muscle tone cannot be measured. Nowhere will you find a good reason for why your child has low muscle tone. You will also not find any effective treatment being described.

So what is causing my child’s movement difficulties?

Children who have been labeled as low toned usually have one or more of the following three underlying conditions:

None of these conditions can be cured. They are there for life

Hypermobile joints, difficulties with learning new skills and an anxious nature are all part of a person’s makeup. They are there for life. 

But here is the good news

Joint hypermobility does not stop a person from doing anything. It just means that you may need to work a little harder to get fit and stay fit. It is just a matter of training.

Children with joint hypermobility often have an anxious nature – so they need to learn about courage and overcoming the tendency to avoid difficult tasks.

Children with coordination difficulties are also able to learn new skills – it takes more time and patience and they may be a little slower at performing some tasks. Having an anxious nature is a challenge but children can be taught ways to deal with their fears and anxieties and not be tripped up by them.


Recognizing joint hypermobility

finger extension_0.jpg

Fingers that bend back to 90 degrees

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Wrist can be bent so that thumb touches the forearm 

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Knees and elbows  bend backwards 

Hypermobile joints and tight muscles as a cause of movement difficulties

Sometimes joint hypermobility is missed because the child appears to have tight muscles. It is important to understand tight muscles is a common feature of joint hypermobility, especially in the muscles crossing the back and sides of the hips.  It is also important to understand that this muscle tightness if often an important underlying cause of some of the difficulties experienced by children with a diagnosis of low muscle tone. 

ben longsitting slumped.jpg w sitting.jpg sitting slumped hips abducted.jpg
Tight back and hip muscles affect sitting posture in children with joint hypermobility

Shifting from "Oh my gosh!" to "Lets get moving" 

Let’s go back to the reason your child was labeled "low toned".  Most probably there are age appropriate activities that your infant, toddler or child has difficulty performing. It may have been delayed milestones, difficulties with classroom or playground activities, drawing and handwriting or perhaps learning to ride a bicycle. Your child may have attention difficulties. 

The only effective way to overcome these performance difficulties is task based training which pays attention to muscle strength and flexibility, fitness and stamina, coordination, persistence and a sense of I-can-do-this.

This allows you as parent to make an important mental shift from a sense of “There is something fundamentally wrong with my child” to a more positive sense of “There are some things my child cannot do today – but with some training these difficulties can be overcome “.

What can I as a parent do to help my child – starting today?

  • Make a list of your child’s strengths and weaknesses and discover that there is more that is right than wrong with your child.
  • Become very knowledgeable about task based training – and become your child’s coach. Read more

More about muscle tone

The term muscle tone refers to two aspects of muscles' structure and function.

  1. The inherent stiffness of a muscle - its resistance to being stretched and firmness when palpated (squeezed).
  2. A muscle's (or groups of muscles') readiness for action - the muscle's responsiveness to signals from the brain and to sensory feedback.

    The term low muscle tone is used when the muscles' stiffness is less than usual (ie it is low) and the readiness for action is also low (muscles respond slowly).

How is a muscle's firmness (tone) tested?

The clinician may make a judgment about a muscle's firmness and inherent stiffness by:

  • Squeezing the muscle to feel the resistance to compression
  • Lifting up and moving the limbs and feeling the resistance to this movement 

The trouble with these tests is that they are not reliable and do not provide any useful information.

What determines a muscle's firmness? 

The firmness of a muscle is determined by its inherent stiffness and this in turn depends on the stiffness in the connective tissue sheaths that encase each muscle fiber, hold the bundles of muscle fibers together and connects the muscle to the tendons.

In children with hypermobile joints  the connective tissue is less stiff than usual. (It has more give and is more easily stretched).

This tendency for less stiff connective tissue which results in hypermobile (lax)  muscles and joints is genetically determined. About 10-15% of people are hypermobile.

The other very important structure that that determines a muscle's firmness and resistance to being stretched is the giant molecule titin. 

Titin is a very large elastic molecule found within the muscle cell.  The size and strength of the titin molecules is determined by the  amount of work a muscle is made to do on a regular basis. Strong muscles have larger and stiffer titin molecules - and this makes the muscle firmer and stiffer.  The muscle has better tone.

Generally speaking, strong muscles are firmer and have better tone. It is a common fallacy that you can have strong muscles which are also "low toned".  Strengthening a muscle makes it firmer and changes the form of the titin which is component of a muscle fiber which provides the tension and recoil in the muscle.  

Muscle tone, alertness and readiness for action

The term muscle tone is also used to describe the a muscle's readiness for actionThis is set by the child's alertness,  general level of arousal and readiness for action.  

The brain primes the muscles for action by sending signals to the muscles’ sensory receptors.  In effect the sensory receptors become more alert and provide more effective sensory feedback and respond more quickly. This allows for the rapid adjustments needed for maintaining balance and postural stability.

  • When a child is alert and engaged,  the muscles are primed for action.  The muscle tone is good and the posture is erect.
  • When a child is over-aroused, the muscles may become twitchy and overactive.  This makes the child less able to focus attention on a task.
  • If a child is anxious, finds a task difficult and is having trouble focusing his attention, the normal alertness for action signals do not reach the muscles. They become less responsive and provide less sensory feedback.  Muscle tone is lowered and the child's posture becomes less erect and alert..

What next?

How to help your child - starting today

Infants and toddlers with joint hypermobility



stands on one leg and lean towards any substance

My 6 old autistic son always stands on one leg and lean towards any substance or he walks here and there. Nowadays, i never see him standing erect on 2 legs. He seems to be clumsy. Please advise.

Hi, We were just told that my


We were just told that my 12 year old son has loose muscles in his shoulders, he is being scheduled for ultrasound but what can we as parents do in the meantime to strengthen the muscles. Would physio or massages help.

Physio for a program of exercises


I suggest that you consult a physio for a full evaluation and a  program of strengthening exercises for your son. Look for a physio who has an interest shoulder disorders if possible. 

Massage would not be of any use. 

Best wishes 


Bad posture

I have a 11 year old girl who is very "flexible". I notice that her posture is getting worse as she ages. She is always leaning on you or hanging on one when you hold her hand and walk. I am not sure where to start a physio or occupational therapist. Please can you advise some courses of action.
Can this still be addressed?

Physio - and it is important

Hello and thank you for your question

It sounds like your daughter really need a good strengthening program with carefully targeted stretching exercises and a postural training. This is important for her self confidence as well as avoidance of back and knee pain in the future. 

Find a physio who understands hypermobility and is clued up on postural reeducation. It may be that the best person is an adult rather than a paediatric physio. 

You can expect a full evaluation of your daughter's muscles, joints and posture to check what the underlying issues are. Also make sure that the physio checks for idiopathic scoliosis. .This is particularly important if there is scoliosis in the family. 


Tight muscles in leg

The doctor has said that my brother's muscles in his legs are tightening up which are causing many problems such as his inability to sit cross legged or even walk straight as his right foot seems to be facing towards the right when he walks which makes it out like he has a limp. I wanted to know what exercises can be used to improve this situation as he is only 9 years old and this is slightly worrying

You need to consult a physiotherapist

Hello and thank you for your question.

Tight muscles can be caused by many things, and a full assessment is needed before exercises can be prescribed.

 Can you perhaps get a referral to a physiotherapist for an evaluation?



I have a 2 year old boy who trips over a lot when walking & has poor posture he arches his back a lot.. How do I help him I've been so worried since he was 18mths and it really hasn't improved. I went to my local physiotherapist and she said he had mild peripheral joint hypermobility & decreased central tone. I have took up swimming with my son & also purchased a little play gym for him to use at home but still he keeps falling over. He isn't able to balance either like on a trampoline he can walk slowly but not jump. Is there anything else I can do. He is very active and can climb no problem it just seems to be walking & running he also walks a lot on tip toes or with knees locked & won't walk down steps but will walk up holding onto a rail..

Several causes for frequent falls and toe walking


Thank you for your interesting question. 

Your child's tendency to frequent falls and toe walking may be caused by a number of conditions. It may be due to a condition called idiopathic toe walking.  I find that this is usually associated with generalized joint hypermobility with associated tightness in the hip and calf muscles. 

Did you see a physiotherapist with pediatric experience and did she rule out any other reasons for your child's walking difficulties? If not I would suggest that you see a developmental pediatrician to rule out any other possible explanations for the frequent falls and toe walking. 

Whatever the underlying cause your child will need physiotherapy for loosening tight muscles, strengthening weak ones and improving balance when walking.  This is important so you need to find a developmental physiotherapist who recognises and deals with the problems effectively.


Bike riding

My 9 yr old autistic son learned how to ride a bike at 8 yrs of age. We live on a main road so it was difficult to take him out as the traffic is so distracting. I heard form a local person at the park about an indoor bike park. We arranged for him to have lessons two nights in a row and it was amazing as this place had ostacle courses and beams and it looked really interesting and fun. The instructor was fairly young himself and he took the training wheels and the pedals of immediately and set the seat lower so that my son could put his feet on the floor. The lesson was an hour long on both nights but you could stay and ride after the lesson was over. After the second lesson my son was doing just fine riding quite well. It was also good that they taught him proper positioning of the bike and manoeuvering around things. After that experience he was confident at riding his bike. It was a great experience and well worth the money. Hope this helps

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