How To Recognize Pediatric Gait Abnormalities

In order to treat lower extremity pediatric problems, it is essential to have a sound knowledge of the normal and abnormal development of the child’s lower extremities. As structural and positional developmental changes take place in a dynamic and continuous fashion, you must have a strong grasp of when and how the changes occur during normal maturation. Once you become comfortable with this knowledge, you can successfully diagnose and treat pediatric lower extremity gait abnormalities.
As many have stated, the early years of development represent the golden years of treatment when you may favorably influence lower extremity development and gait. Therefore, you need to be able to identify conditions that may spontaneously improve and resolve over time versus those problems that will require treatment. Although you will see a variety of traumatic or dermatological problems in the pediatric patient, the vast majority of parental concerns regarding the developing child focus on angle of gait, flatfooted gait, and unsteady and unstable gait problems.
Unfortunately, the podiatric and orthopedic literature does not contain any long-term studies indicating whether early treatment of pediatric deformities has any long-term benefits. However, from a practical point of view, I feel many foot problems which occur in the adolescent and adult are attributable to the abnormal mechanics of the individual. In that these changes are recognizable in the pediatric patient population, my personal feeling is early recognition and conservative management of gait abnormalities can only help to improve the overall lower extremity development and function of the child as he or she matures and develops into an adult.

Patient History Essentials
In regard to getting a history, you should spend a moderate amount of time with the parent to develop a profile for the child’s overall development. The salient areas of discussion should include:
• perinatal history;
• neuromuscular developmental history;
• family history;
• sleeping and sitting positions;
• a history of growing pains;
• an indication of shoe wear or replacement patterns;
• the overall level of the child’s activity; and
• the child’s ability to participate in athletic or exercise-related programs.
During the initial discussion, parents may tell you their child has a history of excessive shoe wear; trips, falls and/or fatigues easily; complains of cramping; or is generally unable to participate in normal day-to-day activities. Overall, this typically indicates abnormal lower extremity function and development and should alert you to the probability of conservative management.

What To Look For When Assessing Gait
After getting the initial history, proceed to evaluate the patient’s gait. There are some very specific landmarks. The knees typically should appear on the frontal plane or slightly externally rotated up to the age of approximately 5 or 6. In evaluating a youngster’s gait pattern, be aware that an in-toed gait with a knee functioning on the frontal plane indicates a deformity distal to the knee. This would include tibial torsion, an internal tibial position, metatarsus adductus or the possibility of a rigid forefoot valgus deformity. If the knees are facing internally, then you must assume at least a portion of the transverse plane deformity was attributable to either an internal femoral torsion or internal femoral position.
With regard to the pediatric flatfoot deformity, you should note the apparent continuum of foot development from the time the child initiates ambulation up to the age of 7 or 8. It is not uncommon for the pediatric patient to demonstrate a flattened foot with an everted calcaneus.
There are many opinions as to the degree of normal pronation. My clinical assessment is a continuum of change occurs over the first seven to eight years of life. Then at approximately 8 or 9 years of age, the heel should assume a vertical position plus or minus one to two degrees, and there shouldn’t be any excessive calcaneal eversion. I have felt comfortable using the formula of seven to eight degrees of calcaneal eversion being present at the age of 1, with approximately one degree of eversion lost with each year of development. This typically will cause a normal-appearing foot at age 7 or 8.
This protocol on calcaneal eversion emerged from both available literature on the subject and pediatric muscuoloskeletal screening programs that were conducted through the California College of Podiatric Medicine’s Biomechanics Department from 1980 to 1982. At that time, the college evaluated over 1,200 children, ranging from 3 to 9 years old.
In instances where calcaneal eversion and subtalar and midtarsal joint pronation extend beyond these approximate guidelines, you can initiate treatment. Additionally, when you see extreme degrees of eversion, and subtalar and midtarsal joint pronation exist beyond the age of 8 or 9, this will most likely not improve as the child continues to develop. This may then warrant continued treatment throughout adolescent and adult years.

What Galeazzi’s Test And The Hip Abduction Test Will Tell You
Overall, your clinical assessment of the child should include a complete and thorough examination of hip development. Even when you’re treating an older child, you should check for an idiopathic hip dysplasia.
The two most efficient and straightforward ways of detecting unstable gait in a developing child are performing Galeazzi’s test and a hip abduction test while the patient is lying on his or her back. I have found these tests to be most reliable from the newborn infant up through and including adolescence. To perform Galeazzi’s test, you would have the child in a supine position with the hips and knees flexed. An asymmetrical knee height is indicative of either a dislocated hip on the shorter side or a limb length inequality.
In my opinion, performing the hip abduction test gives you the most consistent clinical sign of unstable gait. If there is a significant decrease in abduction of the child’s hip to the supporting surface, then the possibility of hip dysplasia exists. In all instances, abnormal clinical findings should precipitate further investigation either through ultrasonography or an AP radiograph of the hip.
You should proceed to evaluate transverse plane rotations, including femoral torsion and tibial torsion. Certainly, abnormalities at these levels can precipitate continued problems with foot development and lead to a compensated transverse plane deformity. Extremes in internal or external rotation precipitated by either the femur or the tibia typically will result in abnormal foot function as long as calcaneal eversion is available. Youngsters who are markedly adducted and pigeon-toed will have significant adduction of the talus in stance, which ultimately results in an instable midtarsal joint and a pronated foot type.

Be Aware Of Significant External Forces That May Affect Gait
Although adolescents eventually outgrow 90 percent of internal gait abnormalities, it is my opinion that abnormal foot function often persists into adult life and may cause postural symptomatology. Although we often focus on internal gait patterns as causing this type of problem, we also must respect the significant forces applied to the developing child’s foot by an external femoral torsion or external tibial torsion.
In these cases, the majority of body weight falls medial to the subtalar joint axis of motion and will maintain the foot in an everted, abducted and pronated fashion throughout normal development. In many cases, this type of gait pattern will result in delayed ambulation for the pediatric patient.

Key Examination ‘Hallmarks’
When you are evaluating a pediatric patient’s sagittal plane, be sure to check for tight posterior muscles, including the hamstrings and Achilles. Ankle joint dorsiflexion should be approximately 75 degrees at birth. This reduces to approximately 20 to 25 degrees by the age of three. Fifteen degrees at the age of 10 is noted, while five to 10 degrees at the age of 15 is acceptable. Any significant deviation from these values often results in significant compensatory changes in gait.
It is not uncommon for a congenital tightness of the posterior muscle group to cause abnormal foot pronation as the child gains increased mobility of the foot at the level of the unlocked midtarsal joint. In cases where conservative treatment fails, you should consider surgical intervention to reduce the congenital contracture.
In cases in which there is a significant posterior muscle group contracture, you initially should measure the angle of genu recurvatum and then evaluate it through the course of conservative treatment.
In many cases of congenital posterior muscle group contractures, I have found that a child may tolerate the corrective forces of a functional foot orthosis. If there is a congenital tightness and the orthotic device is tolerated, some form of compensation must occur at some point. In these instances, genu recurvatum will occur over a six-month period of time, leading to knee instability. For this reason, it is essential to monitor the progress of the child once you have prescribed functional foot orthoses.
Be sure to check for frontal plane deformities (valgus deformities of the knee, rearfoot deformities, and forefoot varus or valgus deformities) during the course of your examination. You should also perform careful gait evaluation, muscle testing and a neurological examination at this time.
Once you have established whether the child has developed in a normal fashion, you must decide on an appropriate treatment course. For a congenital or positional problem, such as a transverse plane deformity of the hip or knee, or a foot deformity, such as a metatarsus adductus or calcaneal valgus, you should reduce these deformities as soon as possible in order to ensure normal development of the foot.
In cases in which a talipes calcaneal valgus deformity persists, this typically will result in a delayed onset in ambulation. When treating an older child who has this deformity, I go with the functional foot orthosis. I feel many children who possess undiagnosed and untreated talipes calcaneal valgus deformities often go on to develop a significantly symptomatic flatfoot. In many instances, these children are best served by surgical intervention if they fail to respond to conservative therapy.

Which Orthotic Device Gives You The Best Results?
Typically, orthotic devices which are more aggressive in nature seem to work best for the flexible type of pediatric flatfoot deformities. I favor the Blake inverted type of functional foot orthosis with a Kirby skive. When you combine this with a deep heel cup, it seems to work quite well for children. Others may prefer to utilize a UCBL or heel stabilizer, but I feel both of these have limited capacities to control the child’s foot as he or she becomes older and more active.
In any event, successful management of flexible flatfoot deformities in pediatric patients requires careful monitoring, annual checkups and appropriate replacement of orthotic devices when the child outgrows them. Certainly, considerable discussion with regard to shoe gear is also an essential aspect of successful treatment. Shoes with a stiffer heel counter and midsole are favored, whereas shoes which are flexible in the midsole typically do not allow the orthotic device to function in a beneficial fashion.

Final Notes
Hopefully, once you become comfortable with assessing and managing the flexible flatfoot deformity in pediatric patients, you can provide effective care, helping to ensure minimal lower extremity pathology as the youngster matures into his or her adult years.

Dr. Valmassy is a Professor and Past Chairman of the Department of Podiatric Biomechanics at the California College of Podiatric Medicine. He is a staff podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco.

For a related article, see “Essential Tips For Treating Pediatric Trauma” in the October, 2001 issue of Podiatry Today or check out our archives at www.podiatrytoday.com.