Pediatric Gait Deviations: Assessment of In-toeing, Out-toeing & Limping

"Is my child walking correctly?" is one of the most common questions parents ask. Gait deviations like In-toeing (Pigeon toes), Toe Walking, and Bow Legs are frequent reasons for referral. While the majority are normal developmental variations that resolve spontaneously, a clinician must be able to differentiate physiological alignment from pathological conditions. This guide covers the assessment profile and management strategies.

1. In-toeing (Pigeon Toed Gait)

The most common rotational deformity. It can originate from the Foot, the Shin (Tibia), or the Hip (Femur). Diagnosis depends on the child's age.

Level	Condition	Typical Age	Clinical Sign
Foot	Metatarsus Adductus	Birth - 1 year	Curved lateral border of the foot ("Kidney bean shape"). Usually flexible.
Tibia	Internal Tibial Torsion	1 - 3 years	Thigh-Foot Angle is internal (negative). Patella faces forward, feet turn in.
Femur	Femoral Anteversion	3 - 10 years	"Kissing Knees" (Patellae face each other). Excessive hip internal rotation (>70°).

2. How to Assess: The Rotational Profile

To pinpoint the source of the rotation, perform these tests in the prone position:

• Hip Rotation (Prone): Compare Internal (IR) vs. External Rotation (ER). High IR (>70°) indicates Femoral Anteversion.
• Thigh-Foot Angle (TFA): Angle between the axis of the thigh and the axis of the foot.
  • Negative value = Internal Tibial Torsion.
  • Positive value (>10-15°) = External Tibial Torsion.
• Foot Progression Angle (FPA): Observed while walking. The angle of the foot relative to the line of progression.

3. Angular Deformities: The Normal Evolution

Children go through a predictable cycle of knee alignment. Knowing this prevents unnecessary treatment.

The Rule of Thumb:
0 - 2 Years: Genu Varum (Bow Legs) is NORMAL.
2 - 4 Years: Genu Valgum (Knock Knees) develops.
4 - 7 Years: Legs straighten out to adult alignment (mild valgus).

When to worry (Pathological):

• Asymmetry (one leg bowed, one straight).
• Severe bowing persisting after age 2-3 (Suspect Blount’s Disease or Rickets).
• Associated short stature (Skeletal dysplasia).

[Image of genu varum vs genu valgum age progression chart]

4. Toe Walking: Habit or Pathology?

Walking on tiptoes is common in early walkers but should resolve by age 2-3.

• Idiopathic Toe Walking (ITW): Diagnosis of exclusion. Child can stand flat if asked. Normal tone/reflexes. Often sensory-related or familial.
• Pathological Causes:
  • Cerebral Palsy: Spasticity, hyperreflexia, clonus.
  • Muscular Dystrophy (Duchenne): Pseudohypertrophy of calves, Gower's sign.
  • Tethered Cord: Check lower back for dimples/hair tufts.

5. The Limping Child

⚠️ RED FLAGS for Limping:
• Pain at night or rest (Tumor/Leukemia).
• Fever + Refusal to bear weight (Septic Arthritis/Osteomyelitis).
• Age 10-14 + Hip/Knee pain (SCFE - Slipped Capital Femoral Epiphysis).
• Age 4-8 + Painless limp (Perthes Disease).

6. Physiotherapy Management

"Tincture of Time": Most rotational and angular issues (anteversion, tibial torsion, physiological bowing) resolve spontaneously by adolescence. Avoid expensive orthotics for these as they don't speed up bone remodeling.

Specific Interventions:

• W-Sitting: Discourage it! It reinforces femoral anteversion and tibial torsion. Encourage cross-legged sitting ("Criss-Cross Applesauce").
• Toe Walking: Stretching of gastroc/soleus, serial casting, sensory integration, AFOs (if contracture present).
• Flat Feet: Treat ONLY if painful or rigid. Flexible flat feet are normal in toddlers due to fat pads. Supportive shoes/orthotics for symptomatic older children.

7. Revision Notes for Students

In-toeing Causes: Metatarsus Adductus (Infant), Tibial Torsion (Toddler), Femoral Anteversion (School-age).
Alignment: Varum (Bow) is normal until age 2. Valgum (Knock) is normal age 2-5.
SCFE: Obese teen male with knee/hip pain = Immediate X-ray (Slipped Epiphysis).
Perthes: 4-8 year old male with painless limp (Avascular Necrosis).
Red Flag: Asymmetry, Night pain, Systemic signs (fever/weight loss).

8. FAQs for Parents

Q1. Does my child need special shoes or braces for pigeon toes?

Generally, no. Research shows that braces, special shoes, and twister cables do not speed up the natural correction of bone torsion (twist) and can be uncomfortable or cause social stigma. The bones untwist naturally with growth.

Q2. Is it bad if my child has flat feet?

Most children under 6 have flexible flat feet because the arch hasn't fully formed and a fat pad hides it. Unless the child has foot pain or the foot is stiff (rigid), treatment is rarely needed.

Q3. Why is W-sitting bad?

W-sitting places the hips in extreme internal rotation and the knees in valgus stress. It prevents the natural "untwisting" of femoral anteversion and limits core muscle development because the wide base provides passive stability.

9. 10 Practice MCQs

Q1. A 5-year-old child presents with significant in-toeing. She often sits in a "W" position. The most likely cause is:

Answer: B) W-sitting and school-age presentation are classic for femoral anteversion.

Q2. Genu Varum (Bow Legs) is considered physiological (normal) up to what age?

Answer: B) By age 2, legs usually straighten before moving into valgus.

Q3. A positive Thigh-Foot Angle (e.g., +20 degrees) indicates:

Answer: B) External rotation of the tibia creates a positive angle.

Q4. Which condition is a Red Flag in a limping adolescent (12yo male, obese)?

Answer: C) Needs urgent surgical fixation to prevent avascular necrosis.

Q5. A 6-month-old infant has a C-shaped foot lateral border. The heel bisector line passes through the 4th toe. Diagnosis?

Answer: A) Classic sign of forefoot adduction. In Clubfoot, the heel is also varus and equinus (tight).

Q6. Which gait deviation is commonly associated with Cerebral Palsy?

Answer: B) Due to spasticity in hamstrings/calves.

Q7. Blount's Disease is characterized by:

Answer: B) A growth disorder of the medial tibial physis causing progressive bowing.

Q8. Idiopathic Toe Walking is a diagnosis of exclusion. What must be ruled out first?

Answer: C) Always check tone, reflexes, and Gower's sign before calling it idiopathic.

Q9. "Kissing Knees" while standing is a sign of:

Answer: B) The femurs are internally rotated, causing the patellae to face inward ("squinting patellae").

Q10. Legg-Calvé-Perthes Disease involves:

Answer: C) Idiopathic loss of blood supply to the hip, common in boys 4-8 years old.

References

• Staheli, L. T. (2008). Fundamentals of Pediatric Orthopedics. Lippincott Williams & Wilkins.
• Tecklin, J. S. (2015). Pediatric Physical Therapy. Lippincott Williams & Wilkins.
• Sass, P., & Hassan, G. (2003). Lower extremity abnormalities in children. Am Fam Physician.