NHS Camden - Gait Abnormalities in Children
Speaker key
IV Interviewer
MS Madeleine Shidowsky
MS Evening, my name’s Madeleine Shidowsky [?], I work at the Royal Free Hospital and I run
the Paediatric Service for Camden from there. The topic for today that I was asked to talk
about is gait abnormalities, and I’m going to just really talk about five of them; the ones that
I most commonly get from GPs basically, children who are considered to be late walkers,
children who are walking in toeing, children who are very floppy, mostly tonal abnormalities
have low tone, toe walkers and children who have flat feet.
It always helps, I think, to understand how a gait pattern matures; and in your pack I’ve
done a leaflet which actually I’m quite happy for you to share with patients if necessary,
which actually talks about how walking starts. One of the things I always say to parents is no
child under the age of three has an arched foot, children are born with flat feet and they will
remain having flat feet until they’ve walked on them for about 18 months.
First of all you have to ask the parent, when did your child start walking; and then the clock
ticks forward from that point. A child who was late in walking, and late, again, is a variable
feast; a child who is... so didn’t walk, perhaps, until they were 16 months will not have an
arched foot at three. That’s not abnormal, there’s nothing wrong; what I say to the parents
is, look at the foot, if the child goes on tippy toe the arch is going to come. If a child goes
upon tippy toe and there’s nothing there, that’s a flat foot. The other thing that we need to
try and get over to the parents, all children have flat feet until they’re three, at the very
least.
The second is, children don’t get up and walk, and what I say to parents, again, is we have
the name toddler for a very good reason; toddlers aren’t walking, they’re toddling. Toddling,
by definition, means you fall over a lot; so if you got up and then you walked the word
toddler wouldn’t exist, would it? And it exists because there is a stage between getting up
on your feet and walking without falling over; and that’s toddling.
Parents need to hear that the child who falls over a lot isn’t exactly abnormal, it’s part...
there’s even a word for it, that’s how common it is. Then we talk how wide the base of
support is, and we talk about no child will walk with their feet pointing straight, they’ll
either point both feet out or both feet in; so in toeing gaits, again, are part of a normal
variant.
The first thing I would say is, children are dramatically symmetrical; asymmetry is always a
real worry for me. Now, if somebody says a child’s in-toeing on one leg, 2
that will invariably be, for me, a red flag because children should be symmetrical. I need you
to tell me, are they really only in-toeing on one leg; because that’s a red flag, or is it turning
in slightly more on one side than the other? It’s important because children are very
symmetrical, that’s a problem if they’re only doing it on one side.
Hypertonia is also quite a common reason for children being delayed in walking, and has
considerable impact on how well the child will reach their milestones. So a very floppy baby
may just be not having the strength or energy to get up and walk, and they would invariably
always be late walkers.
Children who have a lot of excess mobility in their joints, who have lax ligaments, will also
be very slow to get strength and stability in order to get up and walk. Hyper-mobile children
are more often female, and there often, as is a family history of flexibility. I often say, and
how much can you do, mom? It usually is in the female line of the family. We can’t change
it, I can’t make a hyper-mobile child not hyper-mobile. We can teach people what they
should expect from it, and we certainly can deal with some of the pain effects that come
with it, but it’s not a correctable condition.
Many of the reasons that children walk in-toeing, and I’m talking about children who are still
in-toeing, perhaps, when they’re four or five years old, because they’ve got low core
stability. They often are children, if you go back developmentally, historically, who didn’t
crawl; whatever reason they didn’t crawl, and they got up to walk quite quickly but didn’t
walk particularly well, and started in-toeing. Crawling is a really useful part of a child’s
maturation, because in four point kneeling, they’ve used their gluteal muscles and their
stomach muscles, and they reach forward for things, and they’re doing all the balancing
that’s very important to build those core muscles up.
If a child goes from sitting to being stood at a settee or put in a baby walker, and doesn’t
crawl, the opportunity to build those core muscles is not there. When they come to stand,
they have very low core stability; so they’re weak if you ask them to lie down and sit up.
They’ve got very weak abdominal muscles, and most of them, these are children as they are
four or five years of age, they have very poor single leg balance. They may have come to you
with an in-toeing gait and falling over a lot, and all you have to say is, can you stand on one
leg? And if they can’t stand on one leg, it’s very likely that they’ve got a core stability issue,
which physio can do something about. It’s nothing serious, it just is there.
Abnormalities and neurology, I just refer this as going back to my ideas that children should
be symmetrical. In the last year we have had four diagnosis of hemiplegia in children, who
obviously had the hemiplegia as a baby but didn’t get diagnosed until they were nearly
three or four years old.
One was referred in because they were in-toeing with one leg, one was referred in because
they’re supposed to have an irritable hip, one was referred in because they were toewalking, and they were toe-walking on both legs until they stood up and stopped, and then
they only stood on one leg up and the other leg flat, because the drive was to be
symmetrical so he toe-walked on both sides; but as soon as he stopped, only one foot
stayed in the air. 3
Another child was referred because they had flat feet and he was very obviously a hemi, so
abnormalities which are asymmetrical, they’re the things that are red flags to me. Is this a
mild hemi that we need to see quickly?
Why do children toe-walk? And it’s quite a common problem, it isn’t one necessarily that we
can do a huge amount about. But the first problem, I think, is are they toe-walking because
they’re diplegics? If they are, and is he a pathic toe-walker, they will be incredibly good at it;
so they will be very efficient. If they’re diplegics they won’t be because they’ve got the
neurology which is driving this, which is an abnormality of tone. So a toe-walker who falls
over a lot has probably got a neurology, a toe-walker who is just getting stiffer and stiffer
probably is an idiopathic toe-walker.
But why else could a child be toe-walking? They might have a neurological condition, it’s
one of the first signs of muscular dystrophy; so you have to be aware that that’s another
reason why they may be toe-walking, or some other kind of muscle wasting disease. We
need to know, are they idiopathic toe-walkers; we don’t really know what the driver is;
there are several reasons why children may do it. Some of them are on the autistic
spectrum, and there’s a big correlation between toe walking and being autistic. We believe
it’s to do with the fact that they are sensitive to touch, and therefore almost coming off
their feet because they don’t like the sensation of being on the floor.
We don’t know this for certain, but they do tend to be tense in other areas of their body.
They may be children who have such poor core stability or such poor tone in their body,
actually have to generate everything to get up because they actually are quite floppy. So in
order to move they over-do it, and actually have to keep on that high level in order to move
forward; and if they relax they fall over because they haven’t got any gradation so they’re
up on their toes or they’re down, they have nothing in-between.
Quite a lot of premmie babies end up as toe-walkers, I don’t know what the percentage is,
but it is quite a high number. We link this to their not actually being finished off quite right;
that there are still some raw edges because of their prematurity. They have tended to be
babies who may have been a bit sickly, a bit low weight, and therefore may have been a bit
slower on many of their other milestones; and there certainly is a number of those who
actually end up being toe-walkers.
What we do for toe-walkers, our primary thing is to find out what’s driving it, if it’s
neurology then we have to treat it neurologically as if it’s cerebral palsy. If it’s to do with
idiopathic toe-walking we have to try and find out, do we have to strengthen the core,
strengthen the child, and increase the range of movement that is available. The main
problem with toe-walkers is that their Tendo Achilles does get tight; it can get tight to the
point that you cannot get the foot to 90°, and it will get to that point very quickly.
IV What is quickly? 4
MS Quickly, they’ve been a toe-walker from birth and by the age of three or four I can’t get
their foot to 90°. It’s quite serious then because the child’s growing at the same time as not
stretching; so you have some who will come to stand with their foot almost down, but as
soon as they move it goes up. Those who don’t come to rest, then they probably have got
an actual contracture at that point, which in a child who is growing quite fast at three or
four is very significant.
We treat that by putting the child into plaster to try and bring them down forcibly, serial
casting, which is changed every week. The first week we just plaster them as neatly as we
can, so we don’t stretch it, we just let it rest; and the second week we give it a bit more
stretch, and the third week we give it more stretch. If there isn’t anything neurologically
driving that, that often will bring the child down.
However, if the child is very sensitive to touch they won’t tolerate this, they’ll go absolutely
bananas; so we have to treat them by getting their tone better and their sensitivity down
before we can start the plastering.
Some people will bring us toe-walkers who have always toe-walked and they’re eight or
nine years old, and really there isn’t very much you can do at that point, I have to say
because it’s become a huge pattern with the child. If they are still toe walking at nine or ten,
they probably won’t be doing it quite as high, but they will be doing it all of the time. Short
of surgery there isn’t really a huge amount that can be done for those children.
We do a lot of core stability work with them to make their balance better, but we probably
will not be able to influence the range of movement that’s at their ankle. In some very
strong situations when the range of movement is, we’re losing it basically, we have used
botulinum and toxin to inject calf muscle as long as we’re sure there is no muscle disease
there. We do a lot of tests to make sure that they haven’t got a muscle disease which is
driving the increased tension in their calf muscle. We can give botulinum and toxin to the
calf muscle and then plaster, because toxin weakens the muscle, it accepts the plastering
much more effectively. In itself it doesn’t stretch the muscle out, but it calms the muscle
down so the child will accept the plastering.
Flat feet are normal in quite a number of families and I always ask to see the parents’ feet
when somebody comes to me with flat feet. I also have a booklet here, which should be in
you pack, which is how feet are, so going back to the idea that you have to be three before
you’re considered to have flat feet.
Does it hurt? That’s important, if your flat feet are flat but it doesn’t cause you any trouble
at all, then it really isn’t a problem. If it’s straight, is the heel chord straight, does the foot
become divergent as they stand up? That’s important to actually going to have a misaligned
foot.
Are you generally very low toned? The reason you’ve got an arched foot is the spring
ligament sits there holding those two side elements up. If all of your ligaments are stretchy
and you’ve got hyper-mobility, that ligament too is going to be stretchy, and therefore your
body weight is going to press down on there; and there isn’t really a lot of chance that
you’re not going to have flat feet, but is it hurting you? 5
Sometimes parents just need to know, yes, they are, but it won’t cause them any trouble.
What we don’t do, particularly if they’re asymptomatic is give them orthotics. The orthotic
will actually push up against the spring ligament and make it even longer.
If you think about the spring ligament, there are the two posts, and the spring ligament
keeps those two posts apart. If you push up underneath they’ll move further apart, won’t
they? Because the ligament will get longer, and that will just make the situation worse than
it is at the moment; also you’re giving the foot artificial support and what it really needs is to
work even harder, not less.
So we put these children onto trampolining games, we put them into very hard exercise
routines to try and raise the muscle power within their bodies so that the chance of making
the foot work is more. I can’t change lax ligaments into non-lax ligaments, but we can make
some of the muscle power a bit better. If the child is very over-weight then, obviously, it’s
going to be a big problem; the foot’s taking all the pressure, and what we try to say is, is the
arch there or not? Again, we do a lot of work as opposed to the toe-walkers getting these
children to stand on their toes, because that’s when you can see the arch come. If you just
push your body weight up and stand on your toes and the arch will be there, but they find it
very hard because the muscles are weak.
Who should you send to physio? Children who have tonal abnormality; yes, I want to see
because I want to know where it’s coming from. Children who haven’t got a good range of
movement, they’re losing range, they’re toe walkers and their foot won’t go to 90°. Children
who have asymmetry, they’re a worry, children should be symmetrical, there’s something
going wrong. Children who have an apparent deformity, so their foot doesn’t look straight;
you don’t have to say why, you need to send it because it actually doesn’t look just flat,
there’s a twist somewhere, or the knees are both facing in, or the knees are both facing out.
If the child is falling more, so this is going back to what I was saying at first, it’s not about the
toddler falling over, it’s about someone saying, he’s falling over more and more. As we know
children start by falling over, and then they get better at it, not the falling, the walking; so if
you’re hearing a history of he’s falling over more and more, then that’s a worry because it
should be going in the other direction.
If children are late walking, because this is the other worry group, isn’t it? They’re bringing
into surgery and saying, my child isn’t walking. How late is late? And this is something,
again, in a sort of mixed population like Camden, I think, again, these milestones do have to
shift a little bit. We used to talk about 14 months, but more importantly, I’m more
concerned is what else are they doing? Are they crawling around floor quite happily, are
they pulling to stand, they’re just not walking yet? That mom I would reassure and say, it’s
all coming together, it’s just going to be a couple of months.
Is the child sitting on the floor, not moving at all, and they’re 14 months old? That’s a
concern; so are they alert and curious, are they wanting to get somewhere, they just don’t
know how to move. How long has it taken them to get to the other milestones before you
got to the expectation that these children are not walking. Walking always 6
seems more important than crawling and sitting to parents, it’s the one they can remember.
So if you say, when did he walk? They nearly always will give a stab at that; and you say,
when did he crawl? They’re, oh, I can’t remember that. When did he sit up? They can’t
remember those milestones, but, for me, they’re more important than when he walked. If
the child is just late, they’re 14, 15 months old, but everything else looks completely normal,
then we watch and wait.
The late walker who’s not pulling to stand, who won’t move on the floor, and has been like
that since they were ten months old, they can stand if they’re placed against a piece of
furniture, but they don’t know how to get up into that piece of furniture, so you have to
place them into standing and then they’ll stand, but they have no idea how to get there.
These are the children the physio needs to see; they probably have motor planning
problems as well as some tonal issues. So they can see, that’s where I want to be, but the
don’t have the capacity to plan how you get from one position of your body to another.
These children need a lot of help because it’s really quite a key thing. Motor planning is seen
in later years if it isn’t sorted out then, children who are scared of doing many things
because they don’t know how to get out of it or into it.
Who do I don’t really want to see? The children who are 12 and 14 months who aren’t
walking, but there’s no other abnormalities in them. Watch, wait, tell them you’ll see them
again in two months time; and then I will send you to physio if you really need to go; but I
don’t... I think everything’s fine just now.
Children who are hyper-mobile, they’re going to take longer to walk. As they try to stand up
their hips just get further and further apart; you can hold their legs and they can do the
splits. You can’t stand on legs like that, they need time to get the other muscles to
compensate for the fact that they’ve got all this hyper-mobility; and they may not because it
delays until they’re 16 months old. Now, if they’re 16 months old and still nothing’s
happening then, yes, we’ll be very happy to see them; but, generally speaking, they will walk
at 16 months, but they won’t be walking at 14; so it does vary a lot.
Children who have gait problems need good shoes, and they need shoes that fit. We send
them to physio if they’re painful, if they’re not the kind of feet that the whole family have.
So if you look at the parents feet and say, what are your feet like? Some of them will say,
I’ve had flat feet all my life, and so has my gran; and then you talk about the fact that some
of this is hereditary, it’s like trying to cure bunions really, to a certain extent.
But for a child, how functionally impairing are they? I don’t think we should think about flat
feet as a detrimental thing necessarily, why are they flat? Are they flat because a child is
very hyper-mobile, are they flat because a child’s got very low tone, are they flat because a
child’s very over-weight? If you’ve asked the child to nip on their toes, can they? I think, all
children over the age of four should be able to stand on their tippy toes. If they can’t stand
on their tippy toes, that may well be the reason they’ve got flat feet; and they should come
to me, yes, because the child can’t stand on their tip toes, not because they’ve got flat feet,
it’s a side effect of something else. 7
So if everything else is normal, but you just happen to have slightly flat feet, and do they
cause any trouble? No, then it’s not an issue; but some flat feet make the feet roll in, and if
the feet roll in, so do your knees, and then they’re standing with this sort of in-turned
position and knock knees, and that’s bad.
You have to look at what flat feet are causing, rather than thinking, all flat feet are a
problem; and why are they a problem? Quite often you’ll say to the child, why do you think
you’ve come to see me today? I don’t know, and she’ll ask mom; because she’s got flat feet,
and what do they cause you a problem with? They’re out playing football, running in the
park, and you think, they’re not really a problem, are they, because you can do all of these
things. If they’re hurting and you have tiredness, then they are, so it’s a symptom of
something that could be more serious.
What are growing pains? There’s a whole pile of books written about what they are. I don’t
actually think they exist, personally. I think children get tight; I know bones grow faster than
muscles, so if you have a growth spurt the bone grows faster, particularly your joints, and
the muscle has to catch up. The muscle is attached to bones, it’s not going to necessarily
catch up as fast, and in the stretch that happens you get discomfort. Basically, we would
teach children to stretch if the time comes with growing pains, they normally are tight
somewhere.