Development - When to be concerned

Variants reflect the spectrum of physiological development and do not cause pain. Referral to paediatric physiotherapy or paediatric orthopaedics is warranted if there are concerns. 

TIP-TOE WALKING - Referral is necessary if:

• persists beyond 2 years.
• associated developmental delay.
• unable to squat or stand with heels on floor (tightness of calf muscles).
• over 3 years and unable to stand from floor sitting without using hands.
• asymmetrical.

FLAT FEET - Referral is necessary if:

• signs of pressure on the foot e.g., blistering or callosities.
• longitudinal arch does not form normally when the child stands on tip-toe.
• flat foot is not flexible (i.e., normal arch does not form when stands on tip-toe or big toe is passively extended).
• over 6 years of age.

PES CAVUS - the opposite of flat feet and is when the arch is extremely pronounced. It is rarely seen as an isolated finding and is usually indicative of a neurological cause; therefore a referral to paediatric neurologist or paediatrician is the most appropriate action.

KNOCK KNEES - A gap of 6 – 7 cm between the ankles (intermalleolar distance) is common between the ages of 2-4 years. Knock-knees usually resolve spontaneously approximately by the age of six years. Referral is necessary if:

• pain or functional limitation (e.g., prone to falling).
• asymmetrical or extreme or persistent.

BOW LEGS - in healthy children until 2 years of age. Referral is necessary if:

• pain in legs.
• persistent, extreme or asymmetrical.

IN-TOEING is commonly referred to as ‘pigeon toed’ and has a range of causes. It will usually resolve by 10 years of age. Referral is recommended if:

• the changes are extreme or asymmetrical.
• prone to falling.

OUT-TOEING is when a child’s feet point outwards and usually resolve spontaneously by the age of four.  Recent onset out-toeing in a teenager may be serious. Check the hips for a Slipped Upper [Capital] Femoral Epiphysis.

CURLY / CROSSED TOES - usually resolve spontaneously by 4 years. Referral is necessary if there is difficulty with footwear. 

DELAYED WALKING - There is considerable variation in the way gait patterns develop - such variation may be familial (e.g., ‘bottom-shufflers’ often walk later) and subject to racial variation (e.g., African black children tend to walk sooner and Asian children later than average).  Referral is necessary with any of the following:

• walking delayed (18 months) and especially in boys.
• delay in other milestones (e.g., speech, communication, feeding).
• clumsiness or prone to falling.
• family history of delayed walking or muscle disease.
• muscles appear 'bulky'.
• difficulty getting up from the floor (Gower's sign).

MOTOR MILESTONES of CONCERN - Referral is necessary if there is Delay or Regression of achieved motor milestones.