Guidance for Parents
Parents often attend The London Podiatry Centre concerned about the way in which their child walks. At other times, parents may be concerned about the shape of their child’s legs and/or feet or their tendency to fall, trip or develop at what appears to be a slower rate compared to other children of the same age. Normal paediatric development is not an exact science and children progress and develop in a variety of ways without falling outside of the normal range. In the vast majority of cases the problems encountered are within normal development with no reason for concern. However, on occasion abnormalities are encountered which fall outside of what would be considered ‘normal’ development. This is when specialist examination and gait assessment is essential to identify and diagnose an abnormality to ensure treatment is delivered early. All children attending the London Podiatry Centre undergo an extensive examination and where necessary the expertise of other specialists such as Consultant neurologists, paediatricians and paediatric orthopaedic specialists is included.
Often, computerised gait analysis is undertaken and this has the additional benefit of allowing us to build a scientific, objective and quantitative picture of your child’s gait for future comparison so that growth and development of your child can be monitored.
Common parental concerns include:
Flat feet or fallen arches
Curly / deformed toes
Children with in-toe or out-toe walking patterns
Toe walking / early heel lift (bouncy gait)
Genu valgum (knock knees)
Genu varum (bow legged)
Some of these conditions can be a normal feature at certain times of a child’s development and below is a “paediatric development summary” which will help parents to track their child’s progress. However, when in doubt its best to contact the London Podiatry Centre for more specialist advice.
The following guide can help parents to determine if their child is developing normally.
Great toe position: During the early stages and onset of walking, the great toe may claw and bend excessively to help aid balance and stability. The position of the great toe after the first three months of walking should be relativity straight and in line with the foot.
When the child begins to walk, the great toe should be in line with the foot and not pointing towards or away from the midline of the body. However, during the early stages of walking the great toe may claw and bend excessively as the child learns to improve their balance and stability. After three months of walking the great toe should remain relatively straight.
Small toe position: As with the great toe, the small toes may claw and bend during the early stages of walking. However, they should only bend in the forward plane (up and down), any deviation where the toes bend toward each other is generally not normal. A small degree of bending / curly toes, especially of the 4th and 5th toe (the 5th toe is the one furthest from the great toe) is common and may not require treatment, although it is best to obtain an opinion from the London Podiatry Centre if in doubt. Toes that are elevated away from the floor are not considered normal and in such instances the 5th toe is most commonly effected.
Arch height: The term flat feet is often used to label feet with a lowered medial (inner) longitudinal arch. This occurs as a normal part of development and babies have no detectable arch because of the fatty padding that is present at this time. It is more important to assess the ankle position than the arch height in very young children, especially in the first one to two years of walking. A rigid, fixed flat foot (often caused by an abnormal fusion of some of the bones in the foot) is abnormal and can best be assessed by asking / or assisting the child to stand on their tip toes. If a normal arch forms at this time, then a more rigid type of flat foot deformity is less likely to be present. If in doubt, then it is always best to seek a specialist opinion with our Centre. Where the child is old enough, their ability to walk on their heels and toes is a good way of assessing muscle strength, foot function and development. A positive family history for painful flat feet is another clue that may prompt parents to seek a specialist opinion regarding their child’s foot posture.
Lower leg position (bow leggedness and knock knees): Bow leggedness and knock knees are part of normal development at certain ages. Babies are born bowlegged and when a child first learns to walk they tend to be a little bow legged and this may persist until the age of two years. However, the "knock knees" position during the first few years of walking is never normal and requires a further medical opinion. Most children begin to develop "knock knees" between the ages of three to six and this is often accentuated by large medial knee condyles (inside and end of the femur bone) which is a completely normal stage of development. Usually, by the age of seven the configuration of the lower limb and knee is in its ‘normal’ anatomical position, however girls can often go through a further temporary “knock knee” stage as they go through puberty and their hips widen. Bow leggedness and knock knees will occur in both legs, is pain free and usually of no concern when it occurs at a certain ages. However, if your child develops pain in association with this presentation, or if the conditions persists, or a knock knee or bowed leg position in one leg only, then this is not normal and further medical opinion is required.
Feet that point outwards (i.e. "ten to two" or “Charlie Chaplain” style of gait): Most children have this type of foot position to some extent during the early stages of walking. A wide, outward rotated hip position aids stability in the early stages of walking and the position can also be exaggerated by the wearing of nappies in early childhood. By the age of 6-8 years old, the position should have normalised so that both feet are pointing about 15 degrees outwards. If the "out toe" position persists or the angle of the out pointing toe is extreme, then there may be a number of causes (e.g. abnormal pronation and torsions / bony rotations of the femur (thigh bone) and tibia (shin bone). Through biomechanical assessment and gait analysis, the causes can be accurately identified and treated.
Feet that point inwards (i.e. "in-toe gait" or "pigeon toe gait"): In-toeing is common and usually part of normal development and in most cases it resolves spontaneously. In-toeing is considered a torsional (twisting) deformity and may result from medial femoral torsion (ante-version), medial tibial torsion or forefoot adductus (forefoot pointing inwards). It is only considered abnormal when your child falls outside of 2 standard deviations when assessed through a rotational profile examination where the level of the problem can be identified. This condition is common in early childhood from the ages of three to six years, but can persist in some children until the age of 10. It is more common in girls and can be hereditary. It is not uncommon for only one side to in-toe more than the other. The imbalance can worsen during growth spurts, when the hamstring tightens to pull the hip in. This condition occurs normally, however if your child is experiencing persistent tripping, falls or pain associated with this condition, then an opinion is recommended. A Specialist examination and computerised gait analysis will help to identify the cause and will determine the best method of treatment.
A note about tight muscles: Children will vary in their levels of flexibility and, at the more extreme end, this can lead to problems. Children with benign joint hypermobility syndrome may be so flexible as to suffer from a variety of muscle and joint pains, whilst also being susceptible to falls. Marked inflexibility (hypomobility) is a less frequent problem, although reduced flexibly can be marked in children who sit excessively or who undergo rapid growth spurts. A rarer cause for hypomobility is dystonia, where an alteration in normal muscle tone requires further follow up with a consultant neurologist. In all cases, our advanced assessment and gait analysis can establish the level of muscle function, both from a flexibility and a strength perspective, so that treatment can be initiated as required and where required specialist opinion may be sought.