Cutest legs ever!

It's so common for parents to be concerned about baby's feet and legs during the first 3 years of life. Why, you ask? Because little ones are all over the map in the way they walk until the muscles and supporting structures necessary to carry them fully through life develop.  After all, baby spends 9 months in the womb in a pretty confined position, and it takes time, walking and weight bearing to "unwind" those positions the feet and legs so naturally fall into! So, I wanted to give you all a good primer on Baby Feet and Legs....and obviously, if you have concerns, please bring them to your health care provider! 

What are some of the major motor milestones in babies and toddlers?

Normal motor milestones (and these are averages only - some babes achieve them earlier and some, later)

Sits without support - 6-8 months

Creeps on hands and knees - 9-11 months

Cruising or shuffling on the bottom - 11-12 months

Walk independently - 12-14 months

Climb up stairs on hands and knees - 15 months

Run stiffly - 16 months

Walk down steps (one step at a time) - 20-24 months

Walk up steps (alternate feet) - 3 years

Hop on one foot, broad jump - 4 years

Skipping - 5 years

Why do babies walk so funny? 

There is a considerable variation in normal gait patterns and the ages at which the changes occur, and these appear to be family-history related.

·       Until a child is approximately 3 years old, their normal gait doesn't resemble that of an adult. Initially there is a wide-based stance with rapid cadence (rate of steps/minute) and short steps.

·       Toddlers have a broad-based gait for support, and appear to be high-stepped (bringing knees up) and flat-footed, with arms outstretched for balance. Legs are externally rotated (turned out), with a degree of bowing. I call this the "orangutan phase."

·       Heel strike develops at around 15-18 months with reciprocal arm swing. So instead of walking on toes with arms up,  all parts of the foot impact the ground while walking, with arms now at the sides.

·       Running and change of direction occur after the age of 2 years. A tot can now pivot and turn pretty quickly.

·       In the school-aged child, the step length increases and step frequency slows (ie the stride is longer, resulting in the need to take fewer steps).

·       Adult gait and posture occur around the age of 8 years.

What are the most common parental concerns?

The following are considered normal variations of gait in children, but parents will often consult us for advice:

·       (Habitual) TOE WALKING is common up to 3 years. The solution: time. That said, if a child can't walk with the heel touching the ground, this may indicate tight muscles or increased tone in the legs - a possible cause for concern.

·       INTOEING can be due to persisting femoral anteversion. This condition is due to an inward twist of the femur (upper thigh bone) causing the whole leg to rotate inward. Children walk with knees and feet pointing inwards (this is most common between ages 3-8 years and may look most prominent between 4-6 years of age). These are the kids who sit in a “W” and may have some laxity in the  muscles that typically rotate the entire leg out. The solution: sitting cross legged (which encourages strengthening those bootie muscles), and promoting activities like yoga, skating, ballet. This way the external muscles on the sides of the hips and legs get a chance to strengthen, thus rotating the leg and lower leg out. Even without intervention, the majority of kids with femoral anteversion self correct.  For extreme cases when tripping impairs function into the teens, the femur is cut and rotated outward - but this is a rare, and extreme fix.

·       INTERNAL TIBIAL TORSION is also common. This condition occurs when the shin bones (tibias) rotate inward causing the knees point forwards but the feet to point in.  All babies are born with this condition due to uterine positioning, but when it persists beyond a year of age, it's called internal tibial torsion or ITT.  75% of the time both legs are affected, but typically one more than the other.  This condition self resolves without intervention (back in the day kids had to wear shoes with a rigid bar attached at night - not any more).  Extreme cases that don't resolve may require surgery (cutting and rotating the tibias) - but again this is a rare event.

·       METATARSUS ADDUCTUS is a flexible 'C-shaped' lateral border of the foot resulting in a foot that resembles a kidney-shape. Most resolve by the age of 6 years. The solution: time, no special shoes as long as the lateral border of the foot is flexible. Doctors may recommend gentle massage in the first several months of life. With weight bearing and strengthening of the muscles of the feet with crawling and walking, this self resolves.  However, if the curvature is rigid (can't be straightened), a child may need orthopedic intervention, typically involving serial casting to gradually correct the deformity.

·       KNOCK KNEES (genu valgus) are common and associated with in-toeing. Most resolve by the age of 7 years. Again with muscle development and activities like biking, skating, ballet, and field sports the balance of muscles and rotation tend to fall into place.

·       BOW LEGS (genu varus) are common from birth to early toddler-hood, maximum at age 1 year, often with out-toeing. Most resolve by 18 months. In the womb, babies sit cross legged, knees up like yogis. Until they are weight bearing the medial muscles of the legs aren’t well developed, giving a “scooped out appearance” to the legs. The bonus? - room to walk with a diaper on! With squatting, climbing, and time those muscles develop more, balance the legs and start to rotate the ankle and foot into a more neutral position. Progressive bowing or asymmetric (unequal) bowing require investigation. If symmetric there may be metabolic reasons (like rickets) or genetic reasons, and asymmetric bowing may indicate that the growth plate of one shinbone is growing unevenly. These conditions require input from both orthopedists, and if metabolic or genetic, experts in those realms.

·       FLAT FEET (pes planus) are common. Most children have a flexible foot with a normal arch on tiptoeing. Flat feet usually resolve by the age of 6 -8 years. It’s rare that orthotics(supports within the shoe) are needed in the shoe (they won’t cause an arch to form - so don't buy into that if promised by a provider)…unless there is pain with sports or excessive pronation of the ankle (collapsing toward the center) inserts aren't necessary.

·       CROOKED TOES. Most resolve with weight-bearing and are a result of the cramped condition in the womb.

Here's the important point!  If these normal variations persist beyond the expected age range, are progressive or asymmetric (only occur on one side), or if there is pain and functional limitation (or evidence of neurological disease) then referral is needed.  Similarly, if your child's way of walking (gait) changes literally overnight or over a few days, this is a reason to seek immediate consultation.

An accurate diagnosis can be made with careful history and physical examination. Treatment of the majority of conditions is usually conservative - meaning that watching and waiting, with a few tips for exercise and activities, are usually all that is needed. Special shoes, casts, or braces are rarely beneficial and have no proven efficacy for developmentally normal variations. Surgery is reserved for older children with deformity that severely impairs function.

Again, follow your gut....if something feels wrong or worries you, or if a gait change abruptly impacts your child's comfort or ability to function, to your doctor you go!

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