by Michelle Place, CRNP-PC
Many parents worry about the appearance of their child’s lower extremities especially if that child is late to walk or seems to be tripping more than the parents think they should. This can result in unnecessary visits to the Orthopedist. Most of these physical variations are pretty common and self correct with normal growth.
Intoeing gait is the most common concern parents have about how their children walk. Nearly 2 in 100 children have toes that appear to turn in when they walk and it usually affects both feet. The three common reasons for intoeing are metatarsus adductus seen in infants, internal tibial torsion which is most common in toddlers, and femoral anteversion which mostly affects school aged children.
- Metatarsus Adductus (MA)
MA is a flexible deformity most likely caused by intrauterine positioning which results in a curved foot appearance. In the majority of cases it is either actively correctable (the child can make the foot point straight) or passively correctable (the foot can be positioned to or past neutral with gentle stretching). The majority of these children improve on their own, in fact, 90% of those diagnosed before age 1 will self-resolve. Surgery for MA is only considered if it is diagnosed late or the positioning is rigid and is typically not pursued until after 4 years of age.
- Internal Tibial Torsion
Before birth the legs sometimes need to rotate to fit in the confined space of the womb. As a result, one of the bones in the lower leg, the tibia, may rotate inwards. When the child begins walking the knees remain straight but the feet turn in because the rotated tibia in the lower leg points the feet inward. The problem becomes more evident with fatigue and fussiness. As the tibia grows longer it usually untwists on its own. Ninety-five percent of children resolve without treatment by the time they are in preschool or kindergarten.
- Femoral Anteversion (FA)
FA occurs when the bone of the upper leg, the femur, is rotated from birth. This allows the hip to have more internal rotation resulting in both knees and toes pointing inward. It is most obvious in children who are 5-6 years old. These children generally do not like to sit with their legs crossed and prefer to sit in the W position with their knees bent and their feet flared out behind them. They may also complain about their knees bumping when they walk. This condition gradually improves in most children by 10 years of age but may never resolve completely. There are no braces or exercises that improve FA. There is also no evidence that W sitting has any impact, so children should be allowed to sit in whichever way they are most comfortable.
2.) Knock Knees
Knock knees are another variation in the alignment of the femur which generally improves on its own with normal growth. While standing the legs angle inward with the knees close together and the ankles farther apart. Knock knees are most exaggerated in toddlers aged 2-4 years old but are considered normal until 7 years of age. In fact, up to 75% of children aged 3-5 years are knock kneed and 95% of these will self-resolve by age 7.
3.) Bowed Legs
Curving of the legs in which the knees are far apart is considered a normal finding in the first 12 months of life. This condition is also caused by intrauterine positioning and straightens out as the child grows, typically starting to improve by 18 months of age. Ninety-five percent of children with bowed legs improve by age 4 years with normal growth.
4.) Flat Foot
Almost all babies have flat feet. There is a fat pad in the middle of the foot that obscures the arch from birth. More than 40% of children aged 3-6 years have flat feet and in about 14% the condition continues into adulthood. It is a normal variant that often runs in families and occurs because of laxity in the ligaments of the foot. Observation is typically recommended in children 8 years and younger because arch development continues as the muscles and ligaments of the arch mature and tighten until then. Research has shown that the use of orthotics, shoe inserts, special shoes, or exercises do not stimulate arch development but can provide support and comfort as needed.
(Frye, S. (2017, September 1). 7 lower limb positional variations. Contemporary Pediatrics. Retrieved May 14, 2018.)
Most positional variations of the lower extremities are common and resolve on their own with normal growth. If you have any questions or concerns about your child’s gait do not hesitate to call us at Potomac Pediatrics at 301-279-6750 to schedule an appointment for evaluation by one of our providers.