oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
During the early years there can be some obvious gait abnormalities in children. While many of these disturbances are quite common and correct themselves on their own, some require medical assistance.
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 age 3 years.
- What are the parent's 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.
The majority of children less than three years of age will have some positive findings. Therefore, these characteristics become more meaningful as children grow older.
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 the lower limbs) should be assessed to rule out neuromuscular disorders.
In-toeing and out-toeing
These are the most common gait disturbances and are common causes of parental concern.
- In-toeing means that the feet point inwards instead of pointing straight ahead when walking or running.
- Out-toeing means that the feet curve outwards instead of pointing straight.
Out-toeing patterns largely result from one of the following:
- 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. The normal range is from 30-40° at birth and decreases progressively throughout growth to about 15° at skeletal maturation Children walk or stand with both patella and feet pointing inward. If found in conjunction with internal tibial torsion it may lead to patellofemoral subluxation.
- A normal neurological examination and normal height and weight for age help exclude most associated skeletal dysplasias, and neuromuscular or metabolic diseases.
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. Nonsurgical 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:
- The child is older than eight years of age.
- There is severe deformity that creates significant cosmetic and functional disability - anteversion in excess of 50°.
- Deformity of more than three standard deviations beyond the mean.
- A family which is 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 8 to 10 years of age.
Bow-legs and knock-knees
A wide range of knee alignment is normal in young children.
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 aged between 1 and 3 years 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 the mid-tibia. Assess the upper third of the tibia in relation to the 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.
Surgery should be performed only after the age of 8 to 10 years, for persistent, severe deformity - ie the child should have more than 50° of measured anteversion and more than 80° of medial hip rotation.
The majority of children will grow out of this condition.
Flat feet are normal in infants and young children. The arch does not develop in a child's foot until at least 2-3 years of age.
If a child is suddenly limping, (walking with an unsteady gait, favouring one leg), it is most likely due to pain caused by a minor, easily treated injury. However, if an obvious cause cannot be found or if the limp does not resolve quickly, a thorough investigation for serious pathology should be undertaken.
Splinters, blisters or tired muscles are common causes.
More serious problems include:
- Developmental, eg hip dysplasia, cerebral palsy.
- Trauma, eg fracture, nonaccidental injury, puncture wound, slipped femoral epiphyses.
- Infections, eg osteomyelitis, septic arthritis, synovitis (viral, bacterial or atypical - Lyme disease).
- Osteochondroses, eg Calvé-Legg-Perthes disease.
- Neoplasia, eg leukaemia.
- Inflammatory, eg juvenile rheumatoid arthritis.
Nonpainful chronic limping may be indicative of a developmental problem, such as developmental dysplasia of the hip or a neuromuscular problem, such as cerebral palsy.
A limp may be secondary to disorders in the abdomen, genitourinary tract, back, pelvis, hip, knee, foot or elsewhere on the body. The assessment focuses on the pain, weakness, or both, surrounding the gait abnormality. The onset, quality, location, resolving or precipitating factors, and duration of pain and weakness are also important. A review of systems may reveal weight loss, night sweats, fever, or psychosocial issues.
- Begin with an overall assessment of the child, including their vital signs.
- The abdomen, pelvis, back, and extremities of the supine or sitting child should be inspected and palpated. Inspection and palpation are best done with the child sitting in the parent's lap.
- Neurovascular status (including strength, sensation and reflexes) can also be assessed while the child is sitting or supine.
- Each digit and joint should be examined for motion, ligamentous stability and occult trauma.
- The child should be observed barefoot and minimally clothed to assess stance and gait. The child should be observed in an open area to observe several gait cycles to elicit the gait abnormality and anatomic location. Running often brings out subtle abnormalities.
- Measure and compare lower leg lengths.
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.
Blood tests should include full blood count (FBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
Blood cultures may be indicated.
Sickle cell tests, Lyme disease titres, lupus antibodies, anti-double-stranded DNA, rheumatoid factor, human leukocyte antigen, creatine kinase are only requested if suggested from the history.
- Plain X-ray should be the initial study. Anteroposterior (AP) radiographs of the pelvis and AP and lateral views of both lower extremities are recommended, particularly in very young children.
- Ultrasound is a valuable diagnostic tool.
- Bone scintigraphy using technetium highlights areas of increased bone metabolism and may help to identify occult fractures, osteomyelitis, and Calvé-Legg-Perthes disease.
- Computed tomography (CT) scanning is effective for abdominal and pelvic pathology (eg sacroiliac trauma) and bony pathology of the hip, knee, spine, and foot.
- Magnetic resonance imaging (MRI) is the study of choice for soft-tissue pathology and for evaluation of bone tumours.
Toe-walking is one of the least common gait abnormalities.
- 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.
Further reading & references
- Developmental Dislocation of the Hip; Wheeless' Textbook of Orthopaedics
- Rang M. Toeing in and toeing out: gait disorders. In: Wenger DR, Rang M. The art and practice of children's orthopaedics. New York: Raven Press, 1993
- Lincoln TL, Suen PW; Common rotational variations in children. J Am Acad Orthop Surg. 2003 Sep-Oct;11(5):312-20.
- Femoral Anteversion in Children, Wheeless' Textbook of Orthopaedics
- Dietz FR; Intoeing--fact, fiction and opinion. Am Fam Physician. 1994 Nov 1;50(6):1249-59, 1262-4.
- Staheli LT; Rotational problems in children. Instr Course Lect. 1994;43:199-209.
- Sass P, Hassan G; Lower extremity abnormalities in children. Am Fam Physician. 2003 Aug 1;68(3):461-8.
- Davids JR, Blackhurst DW, Allen Jr BL; Clinical evaluation of bowed legs in children. J Pediatr Orthop B. 2000 Oct;9(4):278-84.
- Wai Lin B; Pediatrics, Limp, eMedicine, Oct 2009
- Fairburn PS, Panagamuwa B, Falkonakis A, et al; The use of multidisciplinary assessment and scientific measurement in advanced juvenile idiopathic arthritis can categorise gait deviations to guide treatment. Arch Dis Child. 2002 Aug;87(2):160-5.
- Bogey R; Gait analysis, eMedicine, Oct 2009
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Hayley Willacy
Dr Hayley Willacy