Analyzing a child's gait: What's normal and what's worrisome

Concerns about gait and leg alignment in children are common.

It's hard to tell when to worry and when to just be reassured.

Here are four of the most common gait and leg alignment concerns in children and when you need to do something.

Intoeing

Intoeing means that when a child walks or runs, the feet or knees point inward instead of straight ahead, and is caused by differences in the inward rotation of bones in the thigh or lower leg.

Most children have no pain or symptoms, but the appearance may be concerning to parents. There may be an awkward appearance when the child walks or runs, and they may also sit differently, in a W-position with the knees in and feet out to the side.

Fortunately, most children grow out of this on their own. Intoeing from the lower leg usually resolves by age 4-5, whereas intoeing from the hip/thigh takes a bit longer to resolve, by age 8-10.

Whether to worry depends on your child's age. If your child is younger than age 10, most intoeing will get better without any treatment.

Treatments such as restrictions on sitting position, orthotics or braces, and exercises with physical therapy have not been shown to improve the natural process of correction that occurs with growth. Nothing is needed other than time, patience, and normal growth of the bones in the thigh and leg.

It may be worth seeing a specialist if the intoeing is severe, diagnosis is unclear, treatment is being considered, or when intoeing is causing pain or associated with developmental delays (e.g. not meeting normal milestones).

Rarely, some children do not outgrow their intoeing. For an older child (over age 10) with persistent intoeing, evaluation by a specialist is recommended, especially if there are associated symptoms, pain or functional limitations. In rare cases, corrective surgery may be considered, but fortunately, these situations are less common.

Consider seeing a doctor about your child's intoeing if it is:

• Severe: e.g. concerning to your pediatrician, more than what is typically seen

• Painful or disabling: e.g. pain, tripping, falling, or not keeping up with peers or milestones

• Persistent beyond age 10

Flat feet

Flexible flatfoot is a common condition seen in children. Both feet are affected, so this is commonly described as having "flat feet."

In this condition, the arch of the foot flattens when the child stands, due to the flexibility of the foot joints. The arch reappears when the child stands on tiptoes or sits with the feet hanging down.

Parents often worry about flat feet, and whether treatments such as inserts or orthotics are needed. The good news is that most children outgrow this with time, and treatment is not necessary if the child does not have symptoms.

The foot arch forms by age 5-10 in most children with normal growth. For more than 80% of young children with flat feet, the condition will eventually resolve and a normal arch will develop by early adolescence.

Studies have shown that wearing inserts, orthotics or corrective shoes does not make it more likely for an arch to develop, or make arch development occur at a faster rate.

Whether to worry depends on the child's symptoms. For a child with no symptoms, no treatment is needed. With time and growth, the arch will usually develop on its own.

However, flat feet can cause foot pain or discomfort in the medial arch, especially with long walks or strenuous physical activity. This usually responds to properly fitted and good-quality shoes, calf stretching at home or with a physical therapist, and arch support or orthotics.

If pain persists despite this, surgery can be considered, and occasionally is necessary for severe flat feet in older children or adolescents with refractory symptoms. Some flexible flat feet will become stiff and rigid over time, and this requires further evaluation to see if other problems are present (e.g. tarsal coalition).

Consider seeing a doctor about your child's flat feet, if it is:

• Painful: causing foot pain, trouble with shoe wear, or limiting participation in physical activities

• Severe: e.g. concerning to your pediatrician, more than what is typically seen

• Stiff and rigid: the foot does not correct with toe rise or sitting with the feet free, or has lost flexibility over time

Bowed legs

Bowed legs are common in infants and toddlers. When a child with bowed legs stands, the feet are together but a large space is noted between the knees. One or both legs may be affected.

Most cases of bowed legs in infants and toddlers will naturally straighten with time and growth. If bowed legs are not resolved by age 3, there may be an underlying pathologic cause, such as Blount's disease or rickets. Adolescents may also present with bowed legs, usually in a child who is significantly overweight.

Whether to worry depends on your child's age and the severity of the bowing. Mild bowing in an infant or toddler under age 3 is typically normal and will get better over time. However, bowed legs that are severe, worsening or persisting beyond age 3 should be referred to a specialist.

A timely referral is important. Correction of vitamin D deficiency in rickets leads to resolution of bowed legs if started before severe deformity has developed. Blount's disease may respond to brace treatment and avoid surgery if started before age 3-4. For older children with bowed legs, surgery will be needed, but this is better done earlier than later after the deformity has gotten worse.

Surgery for bowed legs falls into two main types:

• Guided growth: This is a simple outpatient procedure in which a small metal plate/screws or single screw are placed at the growth plate to tether its growth. Over time, the leg will grow straighter in the opposite direction.

• Osteotomy: This is a more complex procedure in which the bone is divided and repositioned to correct a bowed leg. The bone is then fixed in place using a plate and screws internally, or externally using a frame. This is needed for severe cases, or those without growth remaining to allow guided growth to be successful.

Consider seeing a doctor about your child's bowed legs if it is:

• Present beyond age 3

• Severe or getting worse over time

• Associated with a family history of bowed legs or abnormal diet (e.g. not drinking milk or dairy)

Knock knees

Knock knees are commonly seen in children. When the child stands, the knees touch and the ankles are far apart.

This may cause an awkward appearance to the child's gait, with the knees hitting when the child walks and runs. Most mild cases have no symptoms. However, persistent or severe knock knees can cause knee pain or kneecap problems and may increase the risk of arthritis in older age.

Physiologic genu valgum refers to the normal pattern of knock knees that appear after age 2 in most children. This initially gets worse and is most notable at about 3-4 years of age, and then starts to get better with time, with most children reaching a normal alignment by age 8-10.

Shoe inserts, leg braces, and physical therapy have no effect on this natural process of knee growth. For children following this normal pattern, no treatment is needed other than observation over time.

Children with knock knees outside of this pattern should be referred for evaluation by a pediatric orthopedic surgeon. Surgery may be considered to correct their knock knees, especially if causing pain, gait symptoms, or associated with a family history of bone diseases or knee arthritis.

A timely referral is important. Guided growth, similar to use in bowed legs, is the preferred treatment, but is best done while there is still enough growth remaining for correction to occur (before age 12 in females, and age 14 in males).

Osteotomy, in which the bone is divided and corrected using a plate and screws, is reserved for severe cases, referred too late after knee growth has naturally ended (females over age 14 and males over age 16).


Consider seeing a doctor about your child's knock knees if they are:

• Severe or getting worse over time

• Present beyond age 8-10

• Painful or causing significant gait problems

• Associated with short stature, metabolic bone disease or family history of arthritis

• Dr. David Roberts is a pediatric orthopaedic surgeon at NorthShore Orthopaedic & Spine Institute.