Flat feet, intoeing, out-toeing, bowing legs and knocked knees are common in children and depending upon age are normal developmental variants. A careful history, examination and knowledge of normal development allow a Podiatrist to treat where necessary or in most cases reassure the parents.
The new-born infant’s skeleton consists of mainly cartilaginous bone which alters with external stresses. The hips of a new born face outwards at birth and are flexed due to a ‘close packed’ position in utero. Hip screening is done at birth and again at 6 weeks by the paediatrician and GP for developmental hip dysplasia (DDH). A condition where there is misalignment of the hip joint.
A podiatrist with a specialist interest in paediatrics would be able to assess the hip for DDH and associated pathologies.
As the child continues to develop the legs appear to be bowed from the age of 10 months to 14 months, the average age when children start to ambulate. This continues up until the age of two and they then become maximally knocked knees at the age of three, a normal pattern of development.
However, there is a resurgent of nutritional rickets secondary to Vitamin D deficiency. Bowed legs are typical of rickets and needs to be excluded. Obesity is also a growing concern and has been proposed to increase the incidence of flat feet and conditions such as ‘Blount’s Disease’, a disturbance of the tibial growth plate.
Features that raise concern and warrant specialist referral:
- Knocked knees in a child aged less than 2 years
- Bowed knees in a child aged more than 3 years
- Any asymmetrical findings
90% of concerns to GP’s are regarding flat feet. Toddlers and neonates have flat feet due to the presence of a fad pad under the arch, ligamentous laxity, lack of neuromuscular control and normal rotations of the one of the foot bones (talus). This typically resolves between the ages of 4-8 years of age. Treatment before this age can result in a premature arrest of the normal rotations of the foot bones. Treatment therefore is dependent on several factors predominately symptoms of pain and severity of deformity.
However a specialist podiatrist would be able to determine the difference between a flexible and rigid flat foot, i.e. one that would require further examination, x-rays and onward referral.
Intoeing (pigeon-toed gait), tripping and falling is another concern that often results in a podiatric referral. There are 4 main causes of intoeing 2 of which relate to rotational variants of the femur and tibia. 30% toddlers present with intoeing which continues in only 5-9% school age children and proceeds to only 1-3% adults. Treatment for intoeing therefore remains debatable. We as podiatrists treat when symptomatic with simple inserts that encourages the child to rotate the foot out.
Parents are also encouraged to monitor the child’s sleeping and sitting positions as they are both influential over the rotation of the femur. ‘W’ or ‘reversed tailor’ positions and sleeping on their tummy is discouraged.
Milestones are a good gauge of development and must always be discussed during examination. A delay of the milestones could be indicative of a neurological condition.
Head Control : 1-2 months lift and turn head briefly – 3-4 months stronger – Looks around – Rolls from front to back
Sits Alone : 8 months – Can raise self to sitting
Crawling : 8-10 months
Stand, Walks Run : 9-15 months – 12months- stands/walks with support – 15 months creeps upstairs
Hop Alternate Feet : 4 years old
In the foetus the foot grows quickly until the eight week and slows down until week 14 when it rapidly grows to week 26 and then till term. The average weekly foetal foot growth is 3mm. Foot growth is rapid until the child is 5 years of age then reduces up until skeletal maturity which is around 12 in girls and 14 in boys.
Musculoskeletal symptoms are one of the leading reasons of referrals to general practitioners accounting for over 10% of the referrals. To manage the problem effectively, it is essential to determine the level of the deformity, as it may occur anywhere between the foot and the hip.
A podiatrist who specialises in paediatrics is able to assess from birth for hip pathologies and conditions. They are able to assess and treat where necessary knee pathology, in-toeing, out-toeing, growing pains, toe-walkers, flatfeet, juvenile bunions, verrucae etc.
Manju Mital (Paediatric Podiatrist)