2. Gait Abnormalities in Children Madeleine Szadurski, Head of Children’s Physiotherapy Royal Free Hospital February 2012

3. Late walking Intoeing Tonal abnormalities Toe walking Flat feet

4. Camden very mixed population – racial mix alters range of “normal variants” Maturation of gait pattern – helps parent understand normal development

5. Normal gait parameter Walking age Chronological age is less important than developmental process

6. Questions Is child crawling? Do they pull to stand independently? Can they stand without support? If all are YES, no real concerns – WATCH AND WAIT

7. 13 – 15 months Only stand tiptoed Cannot get into standing without help or being placed Won’t tolerate feet on floor Placed in sitting but cannot move out of position No crawling or bottom shuffling CONCERN – ask for a physio review

8. Late walkers - NO 12-14 months not walking yet –No abnormalities in other areas of development –Watch, wait, reassure Hypermobile 12-16 months –Watch, wait, reassure –If still not walking at 16 months YES refer

9. Symmetry Intoeing one leg only – caution babies/toddlers should be symmetrical

10. Tone Hypotonia may be significantly both delay walking and cause inbalance

11. Hypermobility Too much movement, especially at hips will make early walking difficult. More often seen in females. Usually family history of flexibility Ask parents about family history

12. Low core stability Often seen if child walked early or did not crawl. Trunk stability did not develop so not strong enough to balance in walking. –Poor crawling posture –Weak sit up –Later poor single leg balance 2yrs+

13. Mild abnormal neurology 6 cases in last 2 years of late diagnosis hemiplegia. Referred to foot clinic for: –intoeing on one leg –hip irritability –toe walking –flat feet –unstable gait

14. Toe walker Increase tone – Diplegia? Reduced tone –Muscle disease? Reduction in ankle passive movement –Muscle disease or diplegia? Ideopathic toe walkers –Poor core stability –Sensitive to touch –Often premature babies –Also linked to autism

15. Flat feet Leaflet re normal foot development What is normal for family? Does pain come too? Weight Generalised low tone, poor level of fitness Can you see an arch in toe standing? Is heel straight?

16. Who to send to physio? Tonal abnormality Loss of range Asymmetry Apparent deformity Increased falling

17. Late walking – who does physio want to see? Questions: How late? Are all other developmental milestones normal? Is child alert and curious? Timeframe of other developmental steps – crawling etc. Family norms.

18. Late walkers - YES 14 months and not pulling to stand Not moving on floor at all at 10 months Will stand if placed against furniture but cannot get up themselves at 12 months