Until a child is approximately 3 years old, normal gait doesn’t resemble that of an adult. At 1 year old there may be a wide-based stance with rapid cadence and short steps, but this normally develops into a recognisable adult gait by 3 years.
- What are the parents concerns?
- Take a detailed medical history including pregnancy, birth and development. Perinatal events and motor development may reveal a diagnosis of cerebral palsy.
- Duration of complaint and progression. History should clarify if the problem began at birth, or before or after walking. How has the problem changed during the past few months?
- Family history; there is frequently a familial tendency.
- Is there really concern about the gait or is it appearance? A toddler’s gait and legs are different from those of an adult. Parental concern often stems from a lack of understanding regarding the maturation of the gait.
- Signs and symptoms; ask about pain, limping, tripping and falling.
- Sitting habits; internal tibial torsion is commonly associated with sitting on the feet, while increased femoral anteversion is associated with sitting in a “W” position.
- Aggravating factors; torsional deformities become more apparent with fatigue.
Assessment of height and weight
- The spine should be examined for scoliosis, hairy patches or sinus openings.
- The lower extremities should be examined for Trendelenburg’s sign. This is when the pelvis tilts toward the normal hip when weight is borne on the affected side.
- Leg length should be measured. If there is no discrepancy hip dysplasia can be ruled out.
- The range of motion of the hips, knees, and ankles should be determined. Evidence of joint laxity that mimics the appearance of a torsional/angular deformity should be checked.
- Presence or absence of flat feet should be determined.
- The lateral border of the foot should be checked. If it is curved inwardly, the child has metatarsus adductus.
- Normal ankle dorsiflexion above the neutral position should be checked to determine if the foot deformity is flexible.
Muscle wasting, sensation, tone and power (particularly in lower limbs) should be assessed to rule out neuromuscular disorders.
- In-toeing means that the feet point inward instead of pointing straight ahead when walking or running.
- Out-toeing means that the feet curve outward instead of pointing straight.
Out-toeing patterns largely result from either:
- External rotation hip contracture
- External tibial torsion
- External femoral torsion
In-toeing in otherwise normal newborns and infants may result from:
- Metatarsus adductus – the diagnosis if a “C” shaped curve, rather than a straight border, is present on the lateral aspect of the foot. About 90% of cases resolve by one year of age. Treatment usually involves special exercises, applying casts or special corrective shoes and has a high rate of success in babies aged 6-9 months.
- Internal tibial torsion – although a normal finding in the newborn, this is usually a matter of concern at walking age. When the child is walking or standing, the patella can be seen to point forward, with the foot pointing inward.
- Excessive femoral anteversion – the most common cause of in-toeing. Children walk or stand with both patella and feet pointing inward.
Advice to the parents
Children outgrow the condition naturally in the majority of cases.
- Infants and toddlers with in-toeing and out-toeing can go barefoot without causing problems to the feet.
- Severe in-toeing or out-toeing may cause the child to stumble or trip.
- They usually do not cause the child pain or interfere with the way the child learns to walk.
- Neither problem has been linked to arthritis in adulthood.
Since disability from in-toeing is extremely rare and most cases resolve spontaneously, observation and parental education are important from the time of diagnosis.Non-surgical treatment of in-toeing, with the exception of casting in children with metatarsus adductus, has not been shown to be effective.
Conditions that support considering a surgical approach include:
- Child is older than eight years of age
- Severe deformity that creates significant cosmetic and functional disability Anteversion in excess of 50 degrees
- Deformity more than three standard deviations beyond the mean
- A family who are aware of the risks of the procedure
Osteotomy, the only effective treatment for rotational abnormalities of the femur and tibia, has high complication rates and should not be considered until the patient is eight to 10 years of age.
Early radiographic screening and/or referral to a clinical specialist is often used to distinguish between physiological bow leg deformity and infantile tibia vara disease in young children.
Because the great majority of these children have physiological bowing, routine radiographic screening and referral are not cost effective and expose children to unnecessary radiation.
The ‘cover up’ test is an effective screening tool for the assessment of bow legs in children between 1 and 3 years of age and qualitatively assesses the alignment of the proximal portion of the lower leg relative to the thigh or upper leg. It is performed with the patella pointing up and the hand perpendicular to the thigh, covering mid tibia. Assess upper third tibia in relation to femur:
- Obvious valgus alignment is considered a negative test and is indicative of physiological bowing.
- Neutral or varus alignment is considered a positive test and suggests that the child is at greater risk for having infantile tibia vara.
- Children with a negative ‘cover up’ test do not require radiographic evaluation and should be followed clinically for resolution of the bowing.
Children with a positive ‘cover up’ test should have radiographic evaluation of the lower extremities or be referred to a specialist for further evaluation and treatment.
The majority of children will grow out of this condition.
Splinters, blisters or tired muscles are common causes.
More serious problems include:
- Joint infection
Non-painful chronic limping may be indicative of a developmental problem, such as developmental dysplasia of the hip or a neuromuscular problem, such as cerebral palsy.
Thorough clinical examination of the whole leg and foot.
It is difficult to identify the range of gait deviations associated with juvenile idiopathic arthritis using simple clinical observations. Scientific gait analysis allows accurate targeting of physiotherapy and orthotic interventions to suit each individual.
- If the child walks on his or her toes and is under 3 years old, the problem can be normal.
- After age 3, if the problem persists, it requires careful evaluation.
- Most cases of persistent toe-walking are familial or are simply secondary to tight muscles.
- Toe-walking may indicate a neuromuscular disorder such as cerebral palsy or it could denote developmental dysplasia of the hip or leg length discrepancy (if it involves one foot only).
Treatment may involve observation, physical therapy, casting or surgery.
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