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In the early stages of life, children may exhibit variations in their gait that usually self-correct. Some may require medical intervention. Gait patterns in children vary, often influenced by familial history.
It is common for Asian children to start walking later than average.
Children’s gait differs from that of adults until the age of 3. Initially, they have a broad stance with short steps.
Toddlers exhibit a wide-based gait for stability, high-stepped movements, flat-footedness, and external rotation of their legs.
Running and changing directions typically begin after the age of 2.
As children enter school age, their step length increases and step frequency slows down.
By the age of 8, children usually develop adult-like gait and posture.
Evaluating gait abnormalities requires an understanding of normal gait and developmental milestones.
Key Motor Milestones
- Sitting without support
- Crawling on hands and knees
- Cruising or shuffling on buttocks
- Climbing stairs on hands and knees
- Walking down steps without alternating feet
- Walking up steps alternating feet
- Hopping on one foot, making broad jumps
- Balancing on one foot for 20 seconds
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Common variations of gait in children include:
- Toe walking up to 3 years of age
- In-toeing possibly due to femoral anteversion
- Common occurrence of internal tibial torsion
- Flexibility in metatarsus adductus, usually resolving by age 6
- Common presence of bow legs and knock knees, often resolving by 18 months and 7 years, respectively
- Resolution of flat feet typically by age 6
- Crooked toes resolving with weight-bearing
If these variations persist beyond the expected age range, a referral may be necessary.
Consider hypophosphataemic rickets in children with bow legs or knock knees.
It is important to monitor the child’s gait patterns and seek medical attention if abnormalities persist. Early intervention can help correct any issues and prevent long-term complications. Regular check-ups with a pediatrician or orthopedic specialist can ensure proper development and address any concerns promptly.
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Abnormal gait patterns in children may require additional evaluation:
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Reduction in weight-bearing on the affected side
Injury or pathology on the affected side
Observation in juvenile idiopathic arthritis (JIA)
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Excessive hip abduction during leg swing
Seen in cases of leg length discrepancy, joint stiffness, or spasticity
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Stiff, foot-dragging gait with foot inversion
Common in upper motor neuron neurological conditions
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Instability with changes from a narrow to wide base, observed in certain conditions
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Weakness or pain in hip abductors leading to specific gait patterns
Noted in conditions such as Perthes’ disease and hip arthritis
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Frequent toe walking, though common, may indicate underlying neurological issues
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Raising the leg at the hip due to weak ankle dorsiflexors
Seen in particular neurological diseases
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Dyspraxia involves motor coordination difficulties
May present as frequent falls and challenges in self-help skills
Rule out neurological or orthopedic problems
Boys are more commonly affected, often with a familial tendency
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Address parental concerns and gather a detailed history
Investigate walking delay, especially in boys over 18 months old
Consider various causes including metabolic, inflammatory arthritis, or neurodegenerative disorders
Keep familial predispositions in mind
Ensure adequate vitamin D intake and sun exposure in at-risk groups
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Inquire about symptoms, pain, and factors worsening the condition
Assess sitting habits in relation to gait abnormalities
Specific conditions like internal tibial torsion and femoral anteversion have distinct associations
Consider onset age of symptoms and potential causes of limping
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Intermittent symptoms could indicate mechanical issues
Consider referred pain and diurnal variations for further assessment
Response to NSAIDs and posture changes aid in diagnosis, especially for conditions like toxic synovitis
Watch for red flags during history-taking such as systemic signs, suspicions of non-accidental injury, and activity limitations
Be alert for recent travel history indicating potential infectious causes
Take note of recent infections impacting symptoms
Sexual and family history can offer valuable insights during evaluation
Observe the child’s gait and conduct specific maneuvers to assess joint function and balance during physical examination
General examination includes vital signs, height, weight, and appearance assessment
Look for any muscle wasting, tone changes, or power alterations to rule out neuromuscular conditions
Additional investigations like blood tests, X-rays, and scans may be necessary if required
Differential diagnosis should consider common gait disturbances and parental concerns
In-toeing and out-toeing patterns may indicate specific conditions requiring further evaluation
An average neurological examination with appropriate growth parameters can help in identifying skeletal, neuromuscular, or metabolic problems
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In most cases, children outgrow these conditions by the age of 8 years
Infants and toddlers with in-toeing and out-toeing can usually walk without discomfort
Severe cases may lead to stumbling, but typically do not cause pain or affect walking
There is no known link between these conditions and arthritis in adults
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As disability from in-toeing is rare and cases often resolve spontaneously, observation and education are essential from diagnosis. For out-toeing, conservative management is more favorable
Consider surgical intervention if the child is over 8 years old, showing severe deformities beyond the norm
Osteotomy may be considered for femoral and tibial abnormalities but is advised only after 8-10 years of age
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A wide range of knee alignments is considered normal in young children
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Early radiographic screening or specialist referral helps differentiate between physiological bow-leg deformity and infantile tibia vara disease in young children
Most cases are physiological, making routine screenings and referrals unnecessary and radiation exposure minimal
The ‘cover up’ test can aid in evaluating bow legs in children aged 1-3 years and assessing lower leg alignment
Valgus alignment is indicative of physiological bowing, while neutral or varus alignment suggests a higher risk for infantile tibia vara
Children with negative ‘cover up’ test results do not require radiographic assessment but should be monitored for resolution
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Children with a positive ‘cover up’ test should undergo radiographic evaluation or specialist referral for further management
Surgical intervention may be considered for severe, persistent deformities after 8-10 years of age
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The majority of children naturally outgrow these conditions
Regular check-ups with a pediatric orthopedic specialist can help monitor the progress of physiological bowing or infantile tibia vara
Physical therapy and bracing may be beneficial in some cases to help correct alignment issues and strengthen muscles
Educating parents on normal variations in leg alignment and when to seek medical advice is important for early intervention if needed
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Flat feet are common in infants and young children, with the arch typically developing by 2-3 years
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Sudden limping in a child warrants investigation, primarily for minor injuries
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Common causes include splinters, blisters, or muscle fatigue
Serious issues such as fractures, infections, neoplasia, or developmental disorders may also cause chronic limping
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Assess the pain, weakness, and surrounding factors to determine the cause of the limp
Look for additional symptoms like weight loss, night sweats, or fever
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Initiate an overall examination, including vital signs assessment
Examine various body parts while the child is in a comfortable position
Evaluate neurovascular status and joint movements for stability
Observe the child’s stance and gait while barefoot
Measure and compare lower-leg lengths
Utilizing scientific gait analysis is essential for providing accurate physiotherapy and orthotic interventions for patients. Various blood tests, such as FBC, ESR, and CRP, should be conducted, with additional tests being considered based on individual medical histories. Imaging studies like X-rays, ultrasounds, bone scintigraphy, CT scans, and MRIs may be necessary for a comprehensive evaluation.
When dealing with febrile unwell children exhibiting acute limp, sepsis should be considered and prompt medical attention sought. Malignancy should be suspected in cases of persistent pain, bone swelling, and systemic upset. Non-accidental injuries require following specific safeguarding procedures if suspected, while inflammatory disorders can manifest with diverse symptoms.
Although toe-walking is less common and usually normal in children under 3 years old, persistent toe-walking after this age requires evaluation. Causes may range from familial tendencies to neuromuscular disorders, developmental dysplasia, or leg length discrepancies. Treatment options may involve observation, therapy, casting, or surgery as deemed necessary.
This leaflet was authored by Dr Mary Lowth.