Development - When to be concerned

Normal variants reflect the spectrum of normal development. Normal variants 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 normal 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 - normal in 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 normal 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).

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