Pediatric Gait Development usually follows a natural progression, as early walkers present with:
- Wide base gait for support
- Rapid cadence
- Short steps
- Arms outstretched for balance
- Legs held in external rotation, with a degree of bowing
- Flat feet with little to no arch evident
Heel strike usually develops at around 15 to 18 months with reciprocal arm swing. Running and change of direction occur after the age of 2 years. In the school-age child, step length begins to increase and step frequency slows. As children grow and mature so do their gait patterns. There is a spectrum of unique gait presentations, as clinicians we can assess and evaluate which are within normal limits and which require further intervention.
Thorough evaluation requires understanding and knowledge of typical and atypical gait patterns, underlying considerations and any potential “red flags”.
- What are the family’s concerns? Take a detailed medical history including pregnancy, birth and development. Perinatal events and motor development may reveal important clues. Include family history of similar concerns.
- Duration of complaint and progression. History should clarify if the problem began at birth, or before or after walking. How has the problem changed during the past few months?
- Is there a true concern about gait or is it more a concern of appearance. A toddler’s gait and alignment are markedly different from those of an adult. Family concern may stem from lack of understanding regarding maturation of gait.
- Signs and symptoms; ask about pain, limping, tripping and falling.
- Sitting habits; Internal tibial torsion is commonly associated with sitting on the feet, while increased femoral anteversion is associated with sitting in a “W” position.
- Aggravating factors; torsional deformities become more apparent with fatigue.
- Examine spine for scoliosis or signs of spina bifida.
- Examine lower extremities for Trendelenburg’s sign. Assess pelvis in horizontal plane when weight in borne on affected side.
- Measure leg length. If there is no discrepancy, hip dysplasia can be ruled out.
- Assess range of motion of hips, knees and ankles. Evidence of joint laxity that mimics the appearance of a torsional/angular deformity should be checked.
- Assess for abnormalities in plantar arch (dynamic vs. static).
- Check lateral border of foot. Inward curvature may suggest Metatarsus Adductus.
- Determine if foot deformity is flexible or fixed.
- Assess developmental reflexes and superficial reflexes.
- Assess sensation, tone, balance, spasticity and muscle strength.
- It is important to rule out underlying neurological causes for the gait deviation or presentation.
Common Gait Presentations
It is important to be aware of the different gait presentations and the value of conservative treatment. I hear from families quite often that their Pediatrician referred them to an Orthopedist or and Orthopedic Surgeon before ever looking into less extreme options. Bracing, casting and surgical interventions are not always warranted, and families should be aware of the underlying factors causing their child’s gait presentation and the options available to effectively intervene and help their child achieve optimal functional outcomes.
1. Idiopathic Toe Walking: common in young children up to 3 years, especially in children who were late ambulators.
- Can be attributed to lack of intrinsic plantar arch activation early on, causing child to recruit larger muscles for balance, walking, running and jumping.
- As Pediatric PTs we can make great strides, interventions include range of motion, weight bearing with emphasis on full foot contact and optimal lower extremity alignment, arch activation, promoting sensory strategies to bring base of support down and balance training with lower center of gravity.
2. In-Toeing: can be due to increased Femoral Anteversion, Tibial Torsion, or Metatarsus Adductus. Depending on the origin of the In-Toeing Pediatric Gait presentation (hips, legs or feet), intervention should focus on promoting weight bearing in alignment to address any range of motion or muscular imbalances. Utilization of tactile input to promote neutrally aligned base of support can be effective coupled with addressing dynamic balance, strength and flexibility of lower extremity.
- Femoral Anteversion: characterized by twisting of femur or thigh, with child walking with patellae and feet pointing inward (common between 3-8 years old). Children with femoral anteversion will commonly favor W-sitting, and presentation will be more evident when running or with fatigue.
- Internal Tibial Torsion: characterized by twisting of tibia or lower leg, with child walking with patella facing forward and toes pointing inward (common from onset of walking to 3 years old). Some cases can be attributed to position in utero, but is really just a variation of typical anatomy in young children. Promoting neutrally aligned base of support and addressing early motor patterns with attention to alignment and weight bearing is helpful.
- Metatarsus Adductus: characterized by a “C-shaped” lateral border of the foot. Most resolve by age 6. Many children have a flexible metatarsus adductus, meaning you can passively correct foot to a neutral alignment. Range of motion and weight bearing activities in neutral alignment can help to address this presentation.
3. Genu varum (also referred to as “bow leg” presentation): common from birth to early toddlerhood, as a result of pathologic loading to the lower extremity. Usually resolves 6 months after independent walking begins (around 18-24 months). If presentation persists can lead to musculoskeletal concerns later on, so intervention early on in course is important.
4. Genu valgum (also referred to as “knock knee” presentation): often associated with circumduction Pediatric gait pattern, swinging leg outward while walking to take a step. Causing issues with efficiency and fluidity of gait, as well as strain on lower extremity joints in particular the knee. Commonly seen after child begins walking, between 2-6 years of age.
5. Pes Planus (also referred to as “Flat Feet”): commonly seen Pediatric Gait characteristic in children who were late ambulators. Interventions include dynamic standing balance activities to develop and strengthen intrinsic plantar muscles. Recommendations include proper footwear to support medial arch and heel cup for better alignment. For more information about shoe recommendations read our post here.
- Persistent (beyond the expected age range)
- If changes are progressive or asymmetric OR
- If there is pain and functional limitation or evidence of neurologic disease.
“Red Flag” Gait Deviations
1. Antalgic Gait
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- Reduced time spend weight bearing on affected side.
- Many possible causes including: trauma, osteomyelitis, septic arthritis, toxic synovitis, Legge-Calve-Perthes disease, slipped capital femoral epiphysis.
2. Circumduction Gait
- Excessive hip abduction as the leg swings forward.
- Typically seen with a leg length discrepancy, with stiff/restricted joint movement as in JIA, or with unilateral spasticity as in hemiplegic cerebral palsy.
3. Spastic Gait
- Stiff, foot dragging with inversion. This gait pattern is often seen in upper motor neuron neurologic disease, including: diplegic or quadriplegic Cerebral Palsy or stroke.
4. Ataxic Gait
- Characterized by instability with an alternating narrow to wide base of support.
- Seen in Ataxic Cerebral Palsy, affecting the cerebellum, Cerebellar Ataxia and Friedreich Ataxia.
5. Tredelenberg Gait
- Presentation includes, while weight bearing on ipsilateral side, the pelvis drops on contralateral side, rather than rising as is typical. With bilateral hip involvement, this results in a waddling gait with hips, knees and feet externally rotated.
- May be observed in Legge-Calve-Perthes disease, slipped capital femoral epiphysis, hip dysplasia, JIA involving the hip, myopathies, and neurologic conditions (spina bifida, cerebral palsy and spinal cord injury).
6. Toe Walking Gait
- Habitual Toe Walking is a common Pediatric gait pattern in typically developing children, and associated with normal tone, range of movement around the feet and heel toe walking on request.
- However, persistent Toe Walking is observed in spastic upper motor neurologic disease such as diplegic Cerebral Palsy, and may be a presentation of mild lysosomal storage disorder.
- It is important to assess range of motion, neurologic reflexes and tone to determine underlying cause of toe walking in children.
7. Steppage Gait
- Presents with entire leg lifting at hip to assist with ground clearance. Occurs with weak ankle dorsiflexors, compensated for by increased knee flexion (i.e., a foot drop gait).
- Observed in lower motor neurologic disease like spina bifida, as well as peripheral neuropathies like Charcot-Marie-Tooth disease.
While many pediatric gait abnormaties are benign and resolve over time, it is still important to be able to recognize presentations that denote a more serious underlying condition, and require more extensive work up and treatment.
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