What to do if your child has gait abnormalities?

During the first years of life, there may exist some evident gait abnormalities in children. Rotational problems of the lower extremities are a frequent reason for consultation in the daily practice of pediatric orthopedists. Parents are often concerned that their children are not walking correctly; however, gait abnormalities are part of their physical development. While many of these disorders are common and correct by themselves, some do require medical assistance.

There is considerable variation in regular gait patterns and the ages at which changes occur. It seems to be related to family history. From the age of one, children begin to develop balance and leg strength. Between 11 and 16 months, most of them start to walk without support; at two years, they usually climb stairs -one at a time- and hop in place; at three, they can climb stairs and stand on one foot; at four, they manage to walk downstairs consecutively and hop on one foot. It is important to note that each child has his / her own rhythm, not all children reach developmental milestones at the same age; even so, if they go beyond these regular margins, it is necessary to take them for assessment.

The most frequent alterations in gait are walking with the feet turned inwards, pointed, or with the knees apart or together. Several conditions can influence children's feet to turn inward or outward in their early years such as tibial torsion and femoral rotation. 

Tibial torsion can occur due to the baby's position in the womb, is a tendency that runs in families - generally, a child's gait resembles that of his / her parents - and can be internal or external. The former consists of an inward deviation of the shinbones, which are the bones between the knee and the ankle; as the feet point in this direction, the legs appear to be bowed: this posture makes it difficult to walk and maintain balance and can cause falls.

Most children with internal tibial torsion improve without medical treatment (during the first two years, it is regular to a minimal degree; if it persists, it usually corrects by age 7 to 8). Some muscle-strengthening exercises or physical therapy may help improve balance and difficulties with gait; however, if the condition is severe and does not improve with growth your doctor may recommend a surgery called osteotomy. 

As for external tibial torsion, both feet point outward. It is related to tight ligaments and tendons in the upper leg, which causes the lower leg to twist as the child grows. Symptoms of external tibial torsion appear when children are between four and seven years old, although they can become more severe during periods of rapid growth in late childhood and early adolescence, causing them to stumble frequently. Similarly, treatment is usually with rehabilitation or activity modifications for most patients, and surgical management, if required, is indicated for children over eight years of age.

Regarding femoral rotation, femoral anteversion - in which the upper part of the thigh bone (femur) rotates and causes the foot to turn inward - can occur. Children with excessive femoral anteversion will sit in a W-shape because the twisting of the thigh bone allows the hips to rotate inward more than they would rotate outward. 

And although femoral anteversion usually improves on its own with time, if severe cases such as pain and difficulty performing physical activities occur, it is advisable to consult with experts in the field, who will determine the need for orthopedic devices or surgery to help resolve the posture.

Outward twisting of the femur is called femoral retroversion and causes the feet to point in that direction; this position can delay a child's walking, but like the above conditions, improvement is possible without medical intervention. Femoral retroversion is often inherited, although it can occur after a physical trauma such as a femur fracture, and is evidenced by "waddling gait," flat feet, difficulty running, the presence of fatigue with physical activity, lack of balance or coordination, hip pain, and knee pain.

Therefore, although in most cases these alterations represent physiological variations that are corrected at the age of 8-10 years, it is important to know the evolution of the development of the lower extremities in children, to avoid unnecessary treatments. The health professional should follow the child's growth to make sure that these postures have been corrected. Even so, if there are significant alterations that affect children's activities, it will be necessary to visit the pediatric orthopedist to determine the cause, diagnosis and make a plan to manage the condition, which could include surgery at the femur or tibia level or both.