Normal gait and common orthopaedic presentations

Development of normal gait and common orthopaedic presentations: advice for health professionals

Development of normal gait

6 Months
Supported walking, foot placed flat with no heel strike, wide base, knees stiff, poor ankle control.

 

12 Months
Stiff knees, little knee flexion on loading so circumducts at the hip to bring leg through, heel strike beginning to develop, wide base persists with hips externally rotated.

 

18 Months 
Increased knee flexion so less circumduction occurs, gait maturing from hip downwards.

 

3 Years
Hip and knee control mature, but not at foot and ankle. Active dorsiflexion developing prior to heel strike. Heel strike influenced more by knee extension and length of stride. Low medial arches of the foot are normal at this age.

 

5-7 Years
Maturing of foot and ankle control and placement.

 

8-9 Years
No more spontaneous correction of femoral anteversion.

 

Statistical Information

• In early walking, the child’s foot remains in contact with the ground for 40% of the gait cycle; in adults this is reduced to 10%.

• In utero, femoral torsion is 60°; by birth it is 30°- 40°.

• The mature angle of 19° is not reached until 8 years of age. Persistent femoral anteversion is present in 1 in 14-16 adults.

• Non-problematic, mobile flat feet are present in 14% of adults.

 

 

Genu Varum (bow legs)

A degree of genu varum in children under 2 years of age is physiologically normal and parents can be reassured without the need for onward referral to either an Orthopaedic Surgeon or a Physiotherapist.

 

If genu varum has not corrected spontaneously by the age of 2 years then they probably won’t and referral for an Orthopaedic opinion is indicated.

 

 

Genu Valgum (knock knees)

Genu valgum presents normally, especially in children of 3-4 years of age.

 

Normal adult alignment occurs by around 7 years of age.

 

Genu valgum in children under 2 years or progressive genu valgum in children after 7 years warrants referral for an Orthopaedic opinion.

 

An intermalleolar distance of 10cm or more at any age, or asymmetrical genu valgum, indicate referral to an Orthopaedic Surgeon.

 

Referral to a Physiotherapist for either of these presentations, in the absence of other clinical findings, is not indicated.

 

 

In-toeing

There are a number of reasons why children present with an in-toeing gait. A common early cause is metatarsus varus/adductus, a moulding deformity which usually improves by 2 years of age if mobile and with no skin creases.

 

Internal tibial torsion may cause in-toeing noticed prior to and once walking. The stimulus of walking causes the tibiae to rotate into more normal alignment. This improves spontaneously up to the age of 5.

 

By the age of 3, the most likely cause of in-toeing is persistent femoral anteversion, which continues to correct until the age of 8-9. In-toeing that persists beyond this age should be referred for an Orthopaedic opinion.

 

 

Out-toeing

External rotation of the hip when first walking is due to contracture of the external rotator muscles present at birth.

 

This improves spontaneously with the maturation of gait. However, there may be more serious causes of out-toeing which should be investigated, e.g. Perthe’s Disease.

 

 

Foot Problems

Flat feet in pre-school age children are within normal physiological range.

 

There may be a family history of flat feet.

 

Flat feet are not a problem if they are mobile, but should be followed up by an Orthopaedic Surgeon if the feet are stiff or painful.

 

Cavus feet are a cause for concern and neuromuscular disorders should be investigated prior to any referral being made.

 

Referrals for other foot problems are more appropriately made to the Podiatry Department.

 

 

Toe Deformities

Overriding or curly toes are common and often improve with weight bearing. If toe deformities are causing pain, the development of hard skin or difficulties obtaining footwear, a Podiatrist’s advice may be sought.

 

 

Toe Walkers

It is normal for children to walk on their toes before the age of 3 years. Persistent toe walking in children who have used baby walkers is common, so families should be advised to discontinue their use.

 

Referral to Physiotherapy is appropriate if the child is absolutely unable to walk with their heels down. This may be a result of tightness of T.A.s, hamstrings or an emerging neuromuscular disorder.

 

 

Frequent Falls

It is normal for children to fall frequently before the age of 3 years, particularly if they have been late to start walking.

 

However, it may be an early sign of Duchenne Muscular Dystrophy in boys and would warrant further investigation prior to referral for Physiotherapy assessment.

 

 

Asymmetry

In general, asymmetries of posture and/or movement should be referred for Physiotherapy assessment.

 

However, asymmetrical crawling may be normal. Any concerns about leg length or hip movement/posture should be referred directly to an Orthopaedic Surgeon.

 

 

Poor Fine Motor Skills

It is appropriate to refer a child with a development coordination disorder for a physiotherapy assessment, provided the key presenting problem is around gross motor skills.

 

If the problems relate more specifically to handwriting or other fine motor skills it would be more appropriate for the child to be referred to Paediatric Occupational Therapy or to the Outreach Teaching Service (via the school).

 

 

Abnormal Gait

A mature gait pattern is not properly established until 7 years of age. Any referrals for the assessment of abnormal gait should be as specific as possible, based upon knowledge of normal child development.

Deciding whether or not to refer and to whom If advice, reassurance or monitoring only are required, it may not be appropriate to refer to physiotherapy.

 

 

If in doubt

Please contact the Paediatric Physiotherapy Department at Soho Health Centre to discuss the case.