Many changes occur throughout the lower extremities as a child begins to develop and walk. What is the normal progression?
One Year of Age: Begin walking with a wide base of support, knees face forward and flexed or may be slightly externally rotated (until age 5 or 6). The hips are abducted and externally rotated. The pelvis is anteriorly tilted, feet appear flat (until age 3 to 5), and the arms are held in “high guard.”
18 months of age: Reciprocal arm swing emerges and the base of support begins to narrow. A heel strike becomes more consistent.
Two Years of Age: The pelvic tilt decreases, as well as abduction and external rotation at the hip. Increased knee flexion is still present.
Three Years of Age: The base of support begins to look more mature. They continue to demonstrate increased knee flexion and anterior pelvic tilt.
Possible causes for concern:
Toe Walking: Occurs when a child walks on their toes and is more prevalent in boys than girls. There is often no cause for toe walking and it can resolve itself during childhood. Tight gastrocnemius muscles may be a cause, in which a stretching program is indicated. Serial casting and dynamic splints may be necessary, but surgery is rare.
Intoeing: Walking with the toes turned inward can be caused by various conditions including: Femoral anteverison: an internal rotation of the hip causing the feet to appear to be turned inward. Ligament laxity in the hips is often a cause as well as the tendency of a child to “W” sit. Children who prefer to “W” sit often have difficulty sitting cross-legged. Stretching the internal rotator muscles of the hips and avoiding a “W” sit position will help to decrease femoral anteversion. The condition often resolves itself between 7-9 years of age. Internal Tibial Torsion: an internal twist of the tibia. It is normal in newborns but can often be seen in children who are walking. It may resolve itself by 4-6 years old. Metarsus Adductus: a problem that occurs in the foot. It is characterized by a curve of the forefoot, or toes, inward. It may be rigid or flexible. Stretching can be used if the foot is flexible. For rigid feet, reverse last shoes, or serial casting may be used. Surgery may be necessary for rigid metatarsus adductus.
Outtoeing: May be caused by increased tightness of the hip external rotators, in which case the problem resolves itself. In other cases it may be due to femoral retroversion characterized by outward facing patella. It may also occur in the lower leg caused by external tibial torsion, which often resolves by 2-3 years of age.
Bowlegs (Genu Varus): Bowlegs is normal in a young infant and should correct itself by the age of two as increased weight bearing and walking occur. If it does not correct, surgery or bracing may be necessary.
Knock Knees (Genu Valgus): Common at 2-6 years of age. Should resolve by age 7 as a more mature gait pattern emerges.
Michelle Maynard, DPT
References:
Keen, Mary MD, Early Development and Attainment of Mature Gait; American Academy of Orthotists and Prosthetists; Journal of Prosthetics and Orthotics 1993;5:35-38.
Valmassy, RL, How to Recognize Pediatric Gait Abnormalities; Podiatry Today; 2002;15.
www.pediatric-orthopedics.com/topics/in-out-toe/in-out-toe.html. Accessed 4/26/09.
Bellett PS, The Diagnostic Approach to Symptoms and Signs in Pediatrics. Lippincott Williams & Wilkins, 2006.
