Written by Ms Anne McCoy, Chief Physiotherapist, and Mr. Bob Dickens, Director, Department of Orthopaedics, Royal Children's Hospital, Melbourne.

Fact Sheets for Health Professionals

What is Gait?

Gait is the technical term for walking. Many parents worry about the shape of their child's legs and feet or the way their child walks at one time or another. When an initial assessment is made, the primary health care professional will need to be able to:

• Recognise variations within the normal pattern.
• Recognise conditions that do not follow the normal pattern.
• Determine when to refer for a more detailed assessment.

This fact sheet has been developed as a guide for primary health care professionals involved in this initial assessment of young children.

What is Normal? What Are Variations in the Normal Range?

Acquisition of the significant motor skills and changes in posture that occur in the young child are outlined in Diagram 1: The Development of Normal Motor Skills Diagram 2: The Development of Normal Posture.

When children begin walking, at between 10 and 18 months, they stand walk with a wide base of support. There is usually some bowing of the legs, which are a little externally rotated for stability (diagram 2, 'at 10 months'). The feet are flat in appearance,. Lumbar lordosis (arched back) is evident. The same pattern of posture is seen in both boys and girls.

Less than fifty per cent of one-year-old children demonstrate heel strike (diagram 1, figure 1) on commencement of walking. Instead, the child lands with a flat foot. However, by 18 months, heel strike is present in the majority of children. In this age group, the arms are outstretched for balance.

The reciprocal arm swing (diagram 1, figure 8) of mature gait is not present (indicated by the leg and opposite arm moving forward in symmetry). In one-year-old children, their cadence (steps per minute) is very high, with a slow walking speed and shortened step length, which is directly related to leg length and age.

At 12 months, ninety-five per cent of children can squat (diagram 1, figure 2) to play on the floor without support. The ability to perform this task is present from the onset of walking.

By 18 months, eighty per cent of children can run (diagram 1, figure 3). The difference between walking and running is the presence of a period of 'non-support', when neither foot is in contact with the ground. However, at this age the running child has little control over walking speed or change in direction and falls are frequent. By two years, ninety-seven per cent of children are able to run.

In the two to five year age group, the lower limbs start to show a posture of knock knees (diagram 2, 'at 2-3 years').

By four to five years, the majority of children develop a medial longitudinal arch in their feet and are no longer flat-footed (diagram 2,'at 7-8 years'). About fifteen per cent of Caucasians remain flat-footed, based on familial patterns. African and Aboriginal children often present with flat feet which is culturally and genetically normal for them

By 24 months, ninety per cent of children can 'walk on their tip-toes' (diagram 1, figure 4). However, 'walking on heels' is a more difficult task. Only sixty per cent are able to perform this activity by two-and-a-half years. By four years of age, the majority of children are able to walk on their heels (diagram 1, figure 5).

Only fifty per cent of children aged two-and-a half years can stand on one leg 'for longer than six seconds'. However, by three years, the success rate is ninety-five per cent (diagram 1, figure 6).

The ability to hop is slower to develop than single-leg standing, indicating this skill requires greater balance and coordination. By three-and-a-half years, fifty per cent of children can hop for a distance of three metres. This increases to ninety-two per cent by five years. By six to seven years the majority of children can hop on one leg or both (diagram 1, figure 7).

The knock-kneed posture corrects by the age of seven to eight years (with knees together, ankles should just touch). as the lower extremities grow longer, step length increase and cadence slows. This continues until growth is complete (diagram 2, 'at 7-8 years').

Most adult patterns of movement are present by the age of three to four years, with changes in velocity, step length and cadence, continuing to the age of seven.

By the age of seven, the child's gait and posture is nearly identical to that of an adult.

Baby Walkers

Baby walkers are not recommended for infants because of the danger of childhood injury, but some parents still believe that their use will encourage the child to walk sooner. Walking is only achieved after the preliminary skills of sitting, crawling and sideways walking have been acquired. A playpen gives the baby, when developmentally appropriate, the opportunity to practise pulling to stand and to cruise around the sides of the playpen. These activities must be achieved before independent walking occurs.

Assessment of Gait

When a parent or health professional is concerned about a child's gait that is not following the normal pattern, an assessment needs to include:

Child's history, including the chronological age, past and present medical history and the age

• that motor skills were achieved.

Family history:

• Has anyone else in the family (parents, siblings) had problems with walking?
• Has anyone else in the immediate family (parents, grandparents or extended family, uncles or aunts) been treated for problems with their legs, or the way they walked?
• Did a parent or anyone else in the family wear leg braces, or corrective footwear, or have surgery performed as a child?

An assessment of the child's gait, which involves observation of the child's walk noting whether:

• Heel strike is present or whether the child is walking predominantly flat-footed or up on their toes.
• Reciprocal arm swing is evident.
• The child can squat to play.
• The walk is symmetrical - the child moves left and right sides equally.
• The child falls and if so whether falls are occurring less, or more frequently.

This assessment is seen in the light of the child's chronological age.

When To Refer

Although the majority of children demonstrate normal gait, a very small group will exhibit features that require closer assessment. Persistent absence or difficulty performing the above tasks in a child of two years or older may be a highly significant pointer to pathological gait due to conditions such as cerebral palsy or muscular dystrophy. In such a case, referral to a general practitioner is required for coordination of a specialist referral and more comprehensive assessment.

The Child With a Limp

Acute or Sudden Onset

A physical examination may reveal something as simple as blisters on the feet from ill-fitting shoes, however, a more serious cause can be enlarged inguinal glands. If this is the case, the underlying source of infection needs to be diagnosed and treated.

A history of acute and rapidly worsening pain might suggest infection such as osteomyelitis, septic arthritis or synovitis of the hip. In the older child, a slipped femoral epiphysis or Perthe's disease may be the underlying cause. The history taken needs to include details such as the child's recent eating and sleeping patterns, state of health, behaviour, presence of temperature, and whether any body part is red, swollen or painful.

The parent may report the child has limped since the commencement of walking. In this case, as well as taking a detailed history, the assessment needs to include measurement of leg lengths. Conditions such as a missed congenital hip dysplasia or cerebral palsy need to be excluded.

Intermittent Limp

Another type of limp may be of an intermittent nature. In this case the parent might report the child's limp is worse on rising in the morning but lessens during the day and the joints in the legs appear warm from time to time. In this situation, a diagnosis such as juvenile chronic arthritis needs to be considered.

When To Refer for Concerns About Limp

Only a very small proportion of children will have problems with limp in infancy. If there is concern about the presence of an acute or persistent limp, which may be due to a variety of underlying causes, referral to a general practitioner is required for coordination of a specialist referral and more comprehensive assessment.

Variations in Gait

The most common postures that concern parents are those involving rotation of the lower extremities particularly in-toed gait (pigeon-toed, bandy legs) knock knees and flat feet. Often when one or more of these postures occur beyond the normal age range, there is a familial pattern. In times past, it was common for children to be placed in leg braces or corrective footwear, or perform exercises to try and correct these deformities. However, these interventions have not been found to be helpful, as the underlying cause of these postures is the way the bones are positioned in relation to each other and are not due to soft tissue problems. In these circumstances an explanation should be given, together with the reassurance that there is no reason the child should be any more symptomatic than their parents.

1. In-Toed Gait

This may result from one of the following three postures caused by anatomical variations at one of three levels - hips, legs and feet.

• Inset Hips

This is explained by the angle of the thigh bone (femur) into the hip socket, referred to as femoral anteversion. Due to this angulation in inset hips, the range of internal rotation exceeds that of external rotation. Inset hips is common between the ages of three and eight years. However, as the thigh bones grow, the range of internal rotation decreases. By adolescence, the thigh bones take on an oblique shape, understandably greater in girls, due to the greater breadth of pelvis and relative shortness of the thigh bones.

• Leg (internal torsion of the tibia)

This is commonly present from the age of walking up to two-and-a-half years.

• Feet (metatarsus adductus)

Commonly present from birth to four years and frequently seen after the child has begun to walk. It improves slowly over a variable period of time up to the age of fix or six years - although most have corrected spontaneously before that age.

2. Knock Knees

Knock knees occurs because of the way the upper thigh bone (femur) and lower limb bone (tibia), relate to each other. Therefore, in the older child, no amount of exercise to stretch or strengthen muscles will alter the relationship of the bones of the upper thigh to the lower limb.

The knock-kneed posture of the young child usually corrects by the age of seven to eight years (with knees together, ankles should just touch). However, a knock-kneed appearance continues into adulthood for some children (diagram 2 at '7-8 years').

3. Flat Feet

Persistent flat feet over six years of age will not improve through exercise or the use of special inserts or shoes. Arch supports may restore the medial longitudinal arch, but the posture of flat fleet returns, once the footwear is removed. Therefore, expensive footwear will not correct flat feet.

When To Refer for Concerns About Variations in Gait

Again, few children will present with variations in posture that require intervention. If postures such as in-toed gait, knock knees and flat feet persist beyond the normal age and are painful, or cause personal stress to the child or family, then referral to the child's general practitioner is required for coordination of a specialist referral and more comprehensive assessment.

Curly Toes

Another common concern of parents is curly toes. The natural history of curly toes is not clear, but often a family history is present. In practical terms, if a child presents with toes that cause pain or show possible deformity, further assessment and possibly surgery may be necessary.

When To Refer for Concerns About Curly Toes

If in doubt refer to a general practitioner for review and referral to a paediatric orthopaedic surgeon.

As the natural history of the condition is not well known, orthopaedic surgeons may differ in their opinion as to when is the most appropriate time for surgery. Surgery is not usually undertaken under the age of three years as recurrence may occur.

Variations of Muscle Tone

In children there are also variations within the normal range of muscle tone which may cause gait variations. At one end of the spectrum, the child may walk with a normal heel-toe gait and a spring in his or her walk, and appear well coordinated. At the other end of the spectrum, a child can present with a 'floppy' walk and may appear awkward. This latter group of children often walk with an in-toed gait, mainly due to an increased range of internal rotation of the hips. This allows these children to sit between their heels on the floor, in the characteristic position referred to as W-sitting.

For this group of children, reassurance and explanation for parents needs to be given and the child encouraged to sit cross-legged. The child should be encouraged to pursue physical activities that he or she enjoys, with the understanding that they may not excel in some competitive sports due to their lack of coordination. Alternative physical activities should therefore be explored, such as swimming, or riding.

When To Refer for Concerns About Muscle Tone

A comprehensive assessment is required if the child's muscle tone extends beyond the normal range. This would be demonstrated by walking consistently on toes, or walking with a floppy in-toed gait that interferes with physical function and causing regular or constant falls. Assessment may initially be conducted by a paediatrician, who can then refer to the most appropriate specialist such as a paediatric physiotherapist, orthopaedic surgeon or neurologist.

Conclusion

When an initial assessment is made by a primary health care professional, careful consideration is needed when concerns are raised about a child's gait or posture. Parents can be overwhelmed with differing opinions, complicated by different types of intervention offered by a range of health professionals.

The primary health care professional needs a good understanding of normal gait and posture in young children and the variations that occur in both, to ensure that parents have accurate information. In this way realistic expectations can be conveyed to parents and in turn parental anxiety can be allayed.

If the child's development is within the normal variations for gait and posture, then parents can expect normal development in this area to proceed through mid-and-later-childhood and adolescence.

References

Sutherland D, Olshen R, Biden E, Wyatt M. The development of mature walking. Clinics in Devel. Med. 104/105, Mackeith Press: Oxford Blackwell Scientific Pubs. Ltd, Philadelphia, 1988.

Williams P.F. Orthopaedic Management in Childhood: Blackwell Scientific Publications 1982.

Written by Ms Anne McCoy, Chief Physiotherapist, and Mr. Bob Dickens, Director, Department of Orthopaedics, Royal Children's Hospital, Melbourne.

 

Developed by the Centre for Community Child Health & Ambulatory Paediatrics Royal Children's Hospital, Melbourne for the Victorian Government Department of Human Services.

Produced by the Office of the Family, Youth and Family Services Division, Victorian Government Department of Human Services.

April 1997