Gait assessment in older children

--What is abnormal gait?

The way someone walks is called their gait and there are a wide range of different walking styles that are normal. Your child’s gait will change over time as they develop.

• A one-year-old takes lots of little steps and does not swing their arms. When their foot lands on the ground, often the ball of the foot touches first, instead of the heel.
• By 18 months, most children will step and land with their heel first on the ground and begin to swing their arms, but still walk with their legs wide apart to help with their balance.
• By three, the walking pattern looks a lot more like an adult as they bring their legs closer together, but still have more knee bending and twisting of the hips.
• By seven to nine, an adult walking pattern occurs.

Normal walking relies on vision, inner ear, brain, spinal cord, muscles, joints, bones and nerves all working properly. If there is a problem with any of these body parts or systems, it may cause abnormal walking, such as a limp or being wobbly. Some causes may be ‘acute’ or short term, such as a sprained ankle. Others may be ‘chronic’ or long term, such as being born with legs of different lengths.

It is important to work out if the abnormal gait is affecting function—the way your child can do daily activities such as going to school, playing with friends or going out to places like the park or shops. There are gait abnormalities that are just cosmetic, meaning they look different but there are no serious medical issues or impact on function. Some abnormalities can also cause pain or affect function if your child is tripping over and falling, slower than their friends or if their walking pattern uses a lot of energy and makes them very tired.

--What causes abnormal gait?

Common causes of abnormal gait include:

Pes planus or flat feet

Before the age of five to six, most children will look like they have flat feet (no natural arch) when standing, as young children’s feet are very flexible and have a fat pad over the arch. If the flat feet persist beyond the age of eight, are stiff or are causing foot pain, you should have an assessment by a paediatric physiotherapist, paediatric podiatrist or doctor. There is no need for orthotics in flexible flat feet that are not causing any pain.

Intoeing or pigeon toed gait

A child with intoeing walks with their toes pointing inwards. The most common reasons for this are:

• Femoral anteversion or inward twisting of the femur (thigh bone) between the hip and knee. This is common in children and usually goes away by the age of 10.
• Internal tibial torsion or inward twisting of the tibia (shin bone) between the knee and the ankle. This is the most common cause of intoeing. It usually gets better by eight years old without any treatment.
• Metatarsus adductus or inward turning of the foot. This is more common in younger children and usually goes away by the age of five. Gentle exercises given by a physiotherapist may help.

Genu varus or bow legs

This is when the knees are further apart when the legs are straight and the feet are together. It is normal for children to have bow legs up until three years old. If your child has not grown out of it by three, or it starts to get worse, they are in pain, one leg is worse than the other, they are limping or they are particularly short in height, see your GP or a paediatric physiotherapist. In some cases, bow legs can be caused by vitamin D deficiency or nutritional rickets. This needs medical attention.

Genu valgum or knock knees

This is where the knees come together when the legs are straight. When the child’s knees are touching, it blocks them from being able to stand with their feet touching. Knock knees can be a normal phase of growth for children, which usually fixes itself by eight years old. If one leg is more bent than the other, or if it gets worse as the child gets older, makes it difficult to walk or run, causes any pain or is still there after eight years old, then you should see your GP or have an assessment by a paediatric physiotherapist.

Antalgic gait

Children will commonly experience an abnormal gait if they have an injury to any part of the leg causing pain. Examples include:

• Severs disease: this causes heel pain from the calf muscle tendon pulling on the heel bone and is often related to a growing child being very active.
• Sprained ankle: this occurs when a ligament in the ankle is overstretched, causing swelling, bruising and pain.

The ‘limping child’ is a common complaint. This can be due to many causes, some of which can be serious:

• Transient synovitis or irritable hip: usually seen with three to eight year olds after a viral illness, causing pain and stiffness in the hip. A specialist doctor needs to make this diagnosis after ruling out all other possible causes.
• Perthes disease: this mostly affects four to eight year olds. It occurs when there is a problem with the ball and socket joint at the top of the thigh bone, due to poor blood flow.
• Slipped Upper Femoral Epiphysis (SUFE): this affects the growth plate of the hip, but pain may be felt at the knee instead of the hip. Children often have one leg slightly shorter than the other and will walk with this leg turned out to the side. This might need an urgent operation. The average age it affects boys is 13.5 years and 12 years for girls, but it can happen in younger children. It is more common in children that are overweight.
• Stress fractures or overuse syndromes in children older than 10 years.

Cerebral palsy

Cerebral palsy (CP) is a physical disability that impacts the way a child moves, their muscle tone (increased stiffness or floppy muscles) and their posture. CP is due to damage to the developing brain in an infant, during pregnancy, during or just after birth. It is usually diagnosed in the first few years of life and can range from very mild to more severe. CP is a life-long condition that requires the coordination of a team of specialists to optimise a child’s health and wellbeing. If you are concerned your child can move one side of their body more easily than the other or has stiffness in their muscles, a paediatric physiotherapist can do a comprehensive assessment and help determine if you need to be referred on for more medical tests.

For more information visit the Cerebral Palsy website. 

Rarer causes of abnormal gait include:

• infections
• cancer or a tumour in the brain or bones, leukaemia
• rheumatoid arthritis affecting joints and causing pain
• conversion disorder—where the abnormal walking pattern is due to a mental health condition instead of a problem with the brain or muscles
• neuromuscular disorders such as Duchenne muscular dystrophy where muscle weakness causes difficulty walking
• problems with the brain or spinal cord (from stroke or traumatic brain injury, for example) that affect the way the brain can control movement.

--What problems occur if a child has an abnormal gait?

In rare cases, an abnormal gait can be a sign of a serious medical condition. If your child’s walking pattern changes very quickly when there has been no obvious injury, they are falling over and tripping more than usual, not using one side of their body as well as the other or have problems talking or swallowing you should seek urgent medical attention.

For less serious conditions, it is still important to have a thorough assessment of the problem to work out what is causing the abnormal gait. If left untreated, the child may develop problems in their joints or have limited ability to run, jump or play sports depending on what the issue is. It is always best to start treating a problem when it first occurs rather than leaving it too long.

--How can I tell my child has an abnormal gait?

If you think your child walks differently from other children their age, or from their siblings when they were a similar age, this is a sign they may have an abnormal gait. It could be things like, having knock knees, walking on tip toes, limping, walking with feet wide apart, flat feet, pigeon toed (feet turning in) or not being able to walk as fast as their peers.

Sometimes abnormal gait patterns get worse as your child becomes more tired. It is also important to look at your child walking with and without shoes on, on uneven surfaces and up or down hills and stairs to see if you think they are walking normally.

Let your doctor or physiotherapist know if you think your child has any difference between the strength or movement in each of their legs.

--How do I know if my child’s condition requires physiotherapy or other medical attention?

For concerns such as flat feet, pigeon toed, knock knees, heel pain, ankle or knee pain a physiotherapist would be a great place to start.

For any changes to your child’s walking that happen in a short space of time, such as developing a limp with no trauma or accident, being very wobbly, or weakness in the arms or legs, it is best to see your GP or present to the emergency department quickly. Once any serious medical conditions are ruled out, your doctor may recommend you see a physiotherapist. In the event of a serious medical condition, a physiotherapist will also work with your child alongside your treating doctor to help your child’s recovery.

--Should I be worried?

If your child is doing any of the following things, it would be good to have them checked by a medical professional.

• Limping (not putting as much weight through one leg): always get this checked right away, as letting a child walk on the limping leg may cause long-term damage to the hip joint if it is a SUFE (see above)
• A new change in their walking that wasn’t there before
• Asymmetrical (there is a difference in the way their right and left leg moves or looks): this could be a sign of something wrong with the brain or spinal cord in some cases, so it is best to get this checked out straight away
• Appears to be in pain in the legs or feet
• Is unbalanced, wobbly or falling more than usual or more than other kids the same age: some children are more uncoordinated than others, especially if they were born pre-term or with a very low birth weight, this is still important to get checked out even if it has been a long-term problem. If your child normally has good balance and coordination and this changes, this needs urgent medical attention as it could be a problem with the brain or spinal cord.
• Their walking pattern is getting worse (their in-toeing is getting worse not better, for example)
• Toe walking past the age of three

--How can physiotherapy help with my child’s abnormal gait?

Physiotherapists work closely with doctors to get the best outcome for your child. A paediatric physiotherapist is highly skilled in analysing a child’s gait and can help determine if you need to seek further medical advice. They can also help with improving a child’s gait once the reason for any gait problems has been worked out.

The treatment will depend on what’s causing the problem. Physiotherapy can help build strength, stretch muscles, and improve balance and endurance, allowing children to achieve their highest level of function to be able to walk, run, dance, swim and play sports.

Education

A physiotherapist will explain to you and your child what is causing the problem and may give you advice about how to help it. This may include:

• resting from sport until the pain gets better
• using ice or massage
• suitable sports or hobbies
• if you need to see a specialist doctor.

Stretching

As children grow, their bones can grow faster than their muscles, leading to tight muscles. If this is causing problems, a physiotherapist can show you how to do stretches at home to help. It is important to do the stretches every day for the best results.

Strengthening

Sometimes children can get a muscle imbalance where some muscles are stronger than others in the back, abdomen or legs, which leads to problems walking. A physiotherapist can work out which muscles are the weak ones and will often use games to help build up the strength of the muscles. It is important for children to have strong core muscles in the abdomen, back and hips, so exercises and games targeting these muscles may help.

Examples of what you might try at home are:

• throwing bean bags into a bucket or hula hoop while balancing on knees
• wheelbarrows (someone holds the child by the ankles and they walk forward on their hands)
• games where you have to squat down to the ground to pick up toys or reach up to get toys by going on to your tip toes to strengthen your legs.

--How do I get my child to do their exercises?

Sometimes it can be difficult to get children to do stretches or strengthening exercises as they can be hard or uncomfortable. Here are some ideas to help.

• Have a picture chart of the exercises on the fridge or in their room as a reminder
• Use a sticker chart for younger children (the child gets a sticker when they have done their exercises for the day)
• Do the exercises in front of the TV—every ad break has to be used for exercises
• Get the whole family involved doing them too.
• Make them as fun as possible—singing songs, playing games…be creative!
• For older children, have them take ownership of the task by deciding with them what is the best way to remind them each day to do their exercises, such as a reminder alarm or calendar.
• It’s often easier to do exercises when children aren’t over tired, so picking your time of day is important.

Gait aids

In some cases, a physiotherapist may teach your child to use a piece of equipment, such as a walking stick, crutches or a walking frame, to make walking easier while an injury gets better.

Footwear

Supportive, good footwear is important to support a child’s growing feet and legs. A physiotherapist may look at a child’s current shoes and make suggestions of better ones to help.

Orthotics

Sometimes, when good shoes aren’t enough, a physiotherapist may recommend an insert to go in the shoes or leg braces to help with a child’s walking. When this happens, they would refer you to a paediatric podiatrist or orthotist.