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== Intro ==
<div class="editorbox"> '''Original Editor '''- [[User:Robin Tacchetti|Robin Tacchetti]] based on the course by [https://members.physio-pedia.com/course_tutor/krista-eskay/ Krista Eskay]<br>
And it really is all about this muscle pull and the movement patterns that we participate in throughout growth and development that cause these changes to happen. e expect these muscles to activate in appropriate ways that cause us to have the alignment we do as adults.  epending on if it's a genetic condition that is causing different activation of their muscles, that's causing abnormal bony alignment then their form and their function can both be directly impacted. This is also really important because whenever these babies have atypical alignment, they're going to practise an atypical alignment thousands of times a day. So if we don't have good alignment, you're going to get potentially an exacerbation of this malformation. It's also really important because again, as they start to stand and weight shift and have these ground reaction forces, if they're placed in the incorrect locations, then again you can get bony deposition in the wrong areas. And it's also really important because it can directly affect how our brain is wired and how much our body is actually mapped in our brain. And we'll go into that a little bit more.scoliosis, muscular dystrophies, trisomy 21, CP (cerebral palsy) if they have decreased tone. All of these things can cause abnormal muscle pull and abnormal alignment of your joints, which directly affects their functional participation.
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


== Introduction ==
The musculoskeletal system is influenced by many different factors as infants and children grow. It can adapt to the demands, or lack of demands, that are placed on it. The major load on bone comes from muscle forces. When muscle pull is altered due to genetic or neuromuscular conditions, alignment may be impacted. Atypical alignment can directly affect functional activities and an individual's participation.<ref name=":0">Eskay K.  Paediatric Musculoskeletal Development Course. Plus. 2023.</ref>


The following sections highlight key stages and changes that occur during musculoskeletal development.
== Rib Cage ==


== trunk ==
* Initially, the rib cage in infants is barrel-shaped and rigid; ribs are elevated and perpendicular to the spine
normal: rounded rounded kyphotic spine. We expect to see that. Their rib cage is actually very rigid and barrel-shaped. So their ribs are actually really highly elevated and their ribs are actually perpendicular to their spine. ibs that are at this 90 degree angle with their spine
* By 2 years, the rib cage is oblong-shaped; the ribs depress and develop an angulation in relation to their attachment with the spine - this is due to the diaphragm pull and forces from sitting/standing/walking; there is also lateral expansion of ribs (caused by breathing, the action of intercostal muscles, gravity)
* Atypical = persistence of the barrel shape


2 years:  old what happens is the sternum, the ribs will actually depress and develop an angulation in relation to their attachment with the spine. And it will also go from this kind of rounded barrel-shaped to a little more oval in its appearance. So there's this lateral expansion that happens to other ribs. o you have this diaphragm that is going to pull the ribs down at its attachment points with breathing. And also our intercostal muscles that are going to help with lateral expansion of our ribs- as a child is sitting for longer periods of time, as they're standing, as they're walking, that force will actually act on the ribcage to cause depression. When you start to have increased use of obliques, when kids are starting to climb and crawl and sit for periods of time, those muscles are going to pull down on the ribs. So all of these developmental actions that we see in typically developing children will cause the rib cage to go from this very rounded perpendicular barrel-shape into a much more oblong with depressed rib shape.
== Trunk ==


abnormal: ut let's say you have a child that isn't doing those things, it's not typically developing. We are more likely to see them have this persistence of this sort of barrel-shaped rib cage with ribs perpendicular to spine. Because they're not having that appropriate loading due to external gravitational forces and those internal forces from muscle pull and from breathing.
* Initially, infants have a [[Kyphosis|kyphotic]] spine
* Overtime this transitions to a more "neutral" spine (as seen in adults)
* Specific activities which encourage this transition:
** Prone push-ups and sitting activate the posterior chain musculature (i.e. the infant is pushing into thoracic extension)
** Crawling creates co-contraction of the anterior and posterior muscles (for stability)<ref name=":0" />


=== upper trunk: ===
=== Changes in Alignment to Consider ===
extension from prone push up, posterior chain muscle activation; sitting, posterior chain activation; crawling-co-contraction: o as these muscles pull and activate over time, infants are going to go from this very kyphotic position to a much more neutral spine-  abnormal: can actually see a change in this spine position because of abnormal muscle pulls.
===== Increased Curvature of the Spine =====
Increased curvature of the spine (i.e. [[scoliosis]]) can affect:<ref name=":0" />


=== lower trunk: ===
* breathing
increased thoracic spine extension, we're also going to see increased lumbar spine and hip extension over time  originally they start with this kind of rounded pelvis with this posterior pelvic tilt. And then as they start to sit and stand and play and activate this posterior chain and activate their core muscles, what we see is that originally they're going to have this anterior pelvic tilt and it's going to increase just a little bit. So at 12 months of age, we expect to see that a child will have around eight to 12 degrees of an anterior pelvic tilt. When they get to 30 months up to age three, you're going to see a continued increase in that anterior pelvic tilt to around 15 degrees. And then from there, as the glutes are able to engage more, we will see that that anterior tilt decreases a little bit through around the age of eight years old. At which point they'll be at about an adult angle, which is around 10 degrees of an anterior pelvic tilt.
* lung positioning
* heart location
* visceral function


== lower extremity: ==
== Pelvis ==
lower extremity. So here, what you'll see are some norms. So at birth, we expect that infants should have around a 34 degree hip extension limitation. . As they spend time in prone and they're moving and they're activating their posterior chain and they're in this prone press position, they're going to stretch out that anterior capsule. So by six weeks we'll see that that decreases to 19 degrees of a hip extension limitation. And then really, we're at about seven degrees throughout toddlerhood.
[[File:Anterior and posterior pelvic tilt shutterstock 1952124109.jpg|thumb]]
* Initially, infants have a rounded pelvis with a posterior tilt
* Sitting and standing activate core muscles, which leads to the development of an anterior pelvic tilt
** At 12 months old: an infant has 12 degrees of anterior pelvic tilt
** At 30 months old: a child has 15 degrees of anterior tilt
** Anterior tilt decreases to around adult angles (i.e. around 10 degrees) by age 8<ref name=":0" />


You'll also see that they have a hip adduction limitation at the time of birth. And then as they grow and mature and start to ambulate, we'll see that they're able to bring their leg in and across their body much more. Normalising into the thirties and 20 degrees as they continue to grow and develop through toddlerhood. We see that when infants are born, they have a lot more external rotation and this decreases over time. And that they have this slight limitation in their knee flexion at time of birth with a popliteal angle of 27. And then by five years they should be able to get their knee straight when their hip is flexed at 90 degrees
== Lower Extremities ==
Typical joint patterns in infants are as follows:


LE norm: hip: flexion, abduction and lateral rotation,  knee: flexion, genu varum, medial rotation of tibia; ankle: dorsiflexion, slight pronation
* Hip: flexion, abduction and lateral rotation
* Knee: flexion, genu varum, medial rotation of tibia
* Ankle: dorsiflexion, slight pronation<ref name=":0" />
These joints are discussed in more detail below.


=== hip ===
=== Hip ===
o in the newborn we expect to see an increased angulation of the hip where it goes in the socket. So increased coxa valga between 140 and 160 degrees in the newborn. That decreases some in the adult to around 126 degrees as an average. We also see a change in the way that the femoral shaft is twisted.  o that hip flexion contracture that we have at time of birth we talked a little bit about this. So this iliofemoral and ischiofemoral ligament on the anterior aspects of the hip are tighthis prone position and they continue to kind of push we will actually see those structures start to stretch out.
Infants are born with:
* increased hip external rotation which decreases over time
* hip adduction limitation
* 34 degrees of hip extension limitation
** as infants spend more time in prone, their anterior capsule stretches, decreasing the hip extension limitation
*** [[File:Coxa.png|thumb]]at 6 weeks old infants have a 19 degree hip extension limitation
*** toddlers have a 7 degree hip extension limitation
* increased coxa valga - 140-160 degrees
** as become more ambulatory, femoral neck angle decreases
** decreases over time to 126 degrees in adults


=== knee ===
* anteversion of the femur - 40 degrees
So that knee flexion contracture as they can get hands to feet and stretch out is really going to allow them to reduce that knee flexion contracture over time.  So at birth we would expect to see when it comes to knee flexion now, so that they would have about a 30 degree knee flexion contracture. This often resolves in the first few months of life. We really see this resolve with a lot of hands to feet activity. Gravity that's pulling down on their legs to be able to stretch out that posterior capsule of the knee.
** this decreases to 16 degrees in adults


f you have too much lateral tibial torsion, what we'll often see is crouched posture. The other thing that we can see is too much medial tibial torsion. And so this is when we don't have a resolution of the torsion and it stays in that internal twist. This is really not as common to see. A lot of times when we think about our kids that toe inward most of the time that medial rotation is happening a little higher up and not so much at the tibia.
==== Changes in Alignment to Consider (Hip and Pelvis) ====


===== Hip =====


* Femoral neck angle remains high - high femoral anteversion: increased risk of posterior hip dislocation
* Please note that it is especially important to consider the hips in children who are non-ambulatory at the age of 30 months<ref name=":0" />
===== Increased Anterior Pelvic Tilt =====
* Abdominals and hip extensors are long
* Hip flexors and lumbar extensors are short
*'''Leads to''' difficulty activating abdominals and [[Gluteal Muscles|gluteus]] muscles, which can make it difficult for children to engage in functional play / activities<ref name=":0" />


Muscle pull over time
===== Decreased Anterior Pelvic Tilt =====
*[[Iliopsoas]] and anterior hip capsule are long / stretched out
*[[Gluteus Maximus|Gluteus maximus]] is shortened
*'''Leads to''' anterior hip laxity and hip instability<ref name=":0" />


already, you have this greater trochanter as weight shifts happen, there is increased pull on the greater trochanter because there's so many muscle attachment points in that region. And as those muscles pull and attach, what we get is both compression and a laydown of bone on the uppermost border of the femoral neck. And this can actually change the angle of inclination over time. So you have these muscles like the piriformis which does a lot of external rotation and abduction. The gluteus medius that's going to do abduction, external rotation and internal rotation depending on its angle. And then the gluteus minimus it's going to be doing abduction and internal rotation. So as these muscles are all firing, as they're activating, as infants are starting to stand, as they're starting to do weight shifts, we get this compression on. So you think about all these muscles pulling in on the greater trochanter so that's going to cause laydown of more bony tissue. And as that does that we're going to see changes in the angle of inclination.
===== Pelvic Obliquity =====
* Common in individuals with [[hemiplegia]] and diplegia
* Depressed hip side (shorter side):
** shorter, lower extremity or increased pronation on this side
** reduced stance time
** reduced loading, resulting in less bony deposition, so the [[Bone|long bones]] of this leg tend to grow at a slower rate
** sometimes functional ankle plantarflexion (i.e. so can reach the ground with this foot)
* Longer side:
** often have compensatory foot pronation
** there may be medial rotation of the lower extremity and knee flexion to compensate
*'''Leads to''' gait asymmetry, pelvic rotation on the shorter side<ref name=":0" />
*'''Significant increase in pelvic obliquity''' might contribute to:<ref name=":1">Karkenny AJ, Magee LC, Landrum MR, Anari JB, Spiegel D, Baldwin K. [https://journals.lww.com/jbjsoa/Fulltext/2021/03000/The_Variability_of_Pelvic_Obliquity_Measurements.13.aspx The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis]. JBJS Open Access. 2021 Jan;6(1).</ref>
**imbalances in sitting
**pain due to "impingement of the pelvis on the ribs"<ref name=":1" />
**ischial [[Pressure Ulcers|decubitus / pressure ulcers]]


Next, let's look at those torsional forces on the femur. So we know that originally there's this medial twist on the femoral shaft. In newborns it's around 40 degrees. This decreases over time into adulthood to around 10 to 16 degrees. And what we're really looking at when we measure this is drawing a line that goes through the femoral head. And then another line that is going to go along the condyles of the femur distally. And we're looking at the angle between those two. So if you look at this change here, so what we're really looking at is we have that femoral head, that femoral neck, how much that is rotated on the shaft is really what is causing that change between the positioning of the femoral head and then that twist downwards to where the condyles are at. This changes over time due to, again, function. So this form is directly related to function and vice versa. So all of these activities that require stabilisation by the glute med will help to resolve not only the coxa valga, but also this antetorsion, this anteverion. This also helps to resolve the hip flexion contracture. So as babies are starting to crawl, as they're extending their hips, as they're using their glute max all of these things will cause different muscle pulls on the femur, on the femoral head. And then also we'll start to see some activation of the adductors along the thigh. And all of these loading forces will actually help to extend and laterally rotate the hip.
=== Knee ===


As that is done, what we will see is that twist decreases over time. Now, what happens if this doesn't go right? This is really looking at femoral anteversion. So they're looking at this femoral neck angle, axis of the femoral neck in relation to that trans condylar line. And so typically we would expect to see that this anteversion is changing and decreasing over time. But what we see is that for infants who have cerebral palsy so this is looking at the GMFCS (Gross Motor Function Classification System) which is a scale that we use to be able to classify level of involvement of individuals who have cerebral palsy. So a GMFCS level of one is the most independent, and a GMFCS level of five is the least independent when we're talking about our children with cerebral palsy. So you can see that those children who are more ambulatory, more independent will have a mean femoral neck angle that is lower than those who are more involved and less ambulatory. So their femoral neck angle remains quite high, so they remain with this femoral anteversion. And this is a really big deal because what this can do is it can actually increase risk of hip dislocation.
* Genu varum<ref>A El-Hak AH, Shehata EM, Zanfaly AI, Soudy ES. Genu Varum in Children; [https://ejhm.journals.ekb.eg/article_231636_f5bc851645db9d787fadaa87cf381506.pdf Various Treatment Modalities for Bowleg's Correction.] The Egyptian Journal of Hospital Medicine. 2022 Apr 1;87(1):1858-63.</ref>
** infants born in genu varum (i.e. bow-legged position)
** by toddlerhood, knees are in genu valgum (i.e. knock-knee position) - genu valgum peaks around 2 1/2 years old and then decreases over time<ref name=":0" /><ref>Ganeb SS, Egaila SE, Younis AA, El-Aziz AM, Hashaad NI. [https://erar.springeropen.com/articles/10.1186/s43166-021-00082-1 Prevalence of lower limb deformities among primary school students]. Egyptian Rheumatology and Rehabilitation. 2021 Dec;48:1-7.</ref>
** by adulthood, knee should be in neutral[[File:Genuvarus.jpg|thumb]]
* Knee flexion
** infants born with 30 degree knee flexion contracture
** resolves in the first few months of life
* Infants are born with medial rotation of the tibia
** this resolves by 12 months<ref name=":0" />
 
==== Changes in Alignment to Consider ====
 
===== Increased Medial Tibial Torsion =====
 
* Internal rotation of the tibia
* Not common
* Toeing in
* Most likely associated with medial rotation occurring higher up in the chain<ref name=":0" />
 
===== Increased Lateral Tibial Torsion =====
 
* External rotation of the tibia
 
* Individuals present with crouched posture<ref name=":0" />
 
===== Increased Genu Valgum =====
Possible impairments:
* pain in calf, thigh and/or knee
* increased fatigue with activities
* less efficient gait
** decreased gait velocity
** decreased balance
* increased Q-angle  
**[[Quadratus Femoris|quadriceps]] less efficient secondary to abnormal muscle pull<ref name=":0" /><ref>Çankaya T, Dursun Ö, Davazlı B, Toprak H, Çankaya H, Alkan B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344134/ Assessment of quadriceps angle in children aged between 2 and 8 years]. Turkish Archives of Pediatrics/Türk Pediatri Arşivi. 2020;55(2):124.</ref>
* lateral subluxation of the [[patella]]
* collapse of the medial foot arch
* protective in-toeing<ref name=":0" />
 
=== Ankles/Feet ===
Infants are born with:
* hindfoot varus
** with weight bearing, transitions to valgus
* feet straight forward or slight pointing in
** toeing out increases in adults
* high arch<ref name=":0" /><ref>Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, Sanpera-Iglesias J. [https://eor.bioscientifica.com/view/journals/eor/6/6/2058-5241.6.210021.xml How to manage pes cavus in children and adolescents?]. EFORT Open Reviews. 2021 Jun;6(6):510.</ref>
** adults tend to transition to flatter feet<ref name=":0" />
 
== Role of Paediatric Physiotherapy ==
Physiotherapists can help facilitate correct movement patterns to improve biomechanical alignment. Early intervention is associated with better functional outcomes. Some interventions that paediatric physiotherapists use are listed below:
 
* weight shifts
* loading
* static positioning devices
* [[splinting]]
* [[Bracing for Clubfoot|bracing]]<ref name=":0" />
 
The video below by Pathways demonstrates a 2-month-old typical vs. atypical development side by side:
{{#ev:youtube| _0cErYu3A8Q}}
 
 
== Resources ==
 
* [[Biomechanics]]
* [[Infant Development]]
* [[Coxa Vara / Coxa Valga]]
* [[Valgus Knee]]
 
== References ==
<references />
[[Category:Paediatrics]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Course Pages]]
[[Category:Plus Content]]

Latest revision as of 14:54, 14 January 2024

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti, Jess Bell and Naomi O'Reilly

Introduction[edit | edit source]

The musculoskeletal system is influenced by many different factors as infants and children grow. It can adapt to the demands, or lack of demands, that are placed on it. The major load on bone comes from muscle forces. When muscle pull is altered due to genetic or neuromuscular conditions, alignment may be impacted. Atypical alignment can directly affect functional activities and an individual's participation.[1]

The following sections highlight key stages and changes that occur during musculoskeletal development.

Rib Cage[edit | edit source]

  • Initially, the rib cage in infants is barrel-shaped and rigid; ribs are elevated and perpendicular to the spine
  • By 2 years, the rib cage is oblong-shaped; the ribs depress and develop an angulation in relation to their attachment with the spine - this is due to the diaphragm pull and forces from sitting/standing/walking; there is also lateral expansion of ribs (caused by breathing, the action of intercostal muscles, gravity)
  • Atypical = persistence of the barrel shape

Trunk[edit | edit source]

  • Initially, infants have a kyphotic spine
  • Overtime this transitions to a more "neutral" spine (as seen in adults)
  • Specific activities which encourage this transition:
    • Prone push-ups and sitting activate the posterior chain musculature (i.e. the infant is pushing into thoracic extension)
    • Crawling creates co-contraction of the anterior and posterior muscles (for stability)[1]

Changes in Alignment to Consider[edit | edit source]

Increased Curvature of the Spine[edit | edit source]

Increased curvature of the spine (i.e. scoliosis) can affect:[1]

  • breathing
  • lung positioning
  • heart location
  • visceral function

Pelvis[edit | edit source]

Anterior and posterior pelvic tilt shutterstock 1952124109.jpg
  • Initially, infants have a rounded pelvis with a posterior tilt
  • Sitting and standing activate core muscles, which leads to the development of an anterior pelvic tilt
    • At 12 months old: an infant has 12 degrees of anterior pelvic tilt
    • At 30 months old: a child has 15 degrees of anterior tilt
    • Anterior tilt decreases to around adult angles (i.e. around 10 degrees) by age 8[1]

Lower Extremities[edit | edit source]

Typical joint patterns in infants are as follows:

  • Hip: flexion, abduction and lateral rotation
  • Knee: flexion, genu varum, medial rotation of tibia
  • Ankle: dorsiflexion, slight pronation[1]

These joints are discussed in more detail below.

Hip[edit | edit source]

Infants are born with:

  • increased hip external rotation which decreases over time
  • hip adduction limitation
  • 34 degrees of hip extension limitation
    • as infants spend more time in prone, their anterior capsule stretches, decreasing the hip extension limitation
      • Coxa.png
        at 6 weeks old infants have a 19 degree hip extension limitation
      • toddlers have a 7 degree hip extension limitation
  • increased coxa valga - 140-160 degrees
    • as become more ambulatory, femoral neck angle decreases
    • decreases over time to 126 degrees in adults
  • anteversion of the femur - 40 degrees
    • this decreases to 16 degrees in adults

Changes in Alignment to Consider (Hip and Pelvis)[edit | edit source]

Hip[edit | edit source]
  • Femoral neck angle remains high - high femoral anteversion: increased risk of posterior hip dislocation
  • Please note that it is especially important to consider the hips in children who are non-ambulatory at the age of 30 months[1]
Increased Anterior Pelvic Tilt[edit | edit source]
  • Abdominals and hip extensors are long
  • Hip flexors and lumbar extensors are short
  • Leads to difficulty activating abdominals and gluteus muscles, which can make it difficult for children to engage in functional play / activities[1]
Decreased Anterior Pelvic Tilt[edit | edit source]
  • Iliopsoas and anterior hip capsule are long / stretched out
  • Gluteus maximus is shortened
  • Leads to anterior hip laxity and hip instability[1]
Pelvic Obliquity[edit | edit source]
  • Common in individuals with hemiplegia and diplegia
  • Depressed hip side (shorter side):
    • shorter, lower extremity or increased pronation on this side
    • reduced stance time
    • reduced loading, resulting in less bony deposition, so the long bones of this leg tend to grow at a slower rate
    • sometimes functional ankle plantarflexion (i.e. so can reach the ground with this foot)
  • Longer side:
    • often have compensatory foot pronation
    • there may be medial rotation of the lower extremity and knee flexion to compensate
  • Leads to gait asymmetry, pelvic rotation on the shorter side[1]
  • Significant increase in pelvic obliquity might contribute to:[2]

Knee[edit | edit source]

  • Genu varum[3]
    • infants born in genu varum (i.e. bow-legged position)
    • by toddlerhood, knees are in genu valgum (i.e. knock-knee position) - genu valgum peaks around 2 1/2 years old and then decreases over time[1][4]
    • by adulthood, knee should be in neutral
      Genuvarus.jpg
  • Knee flexion
    • infants born with 30 degree knee flexion contracture
    • resolves in the first few months of life
  • Infants are born with medial rotation of the tibia
    • this resolves by 12 months[1]

Changes in Alignment to Consider[edit | edit source]

Increased Medial Tibial Torsion[edit | edit source]
  • Internal rotation of the tibia
  • Not common
  • Toeing in
  • Most likely associated with medial rotation occurring higher up in the chain[1]
Increased Lateral Tibial Torsion[edit | edit source]
  • External rotation of the tibia
  • Individuals present with crouched posture[1]
Increased Genu Valgum[edit | edit source]

Possible impairments:

  • pain in calf, thigh and/or knee
  • increased fatigue with activities
  • less efficient gait
    • decreased gait velocity
    • decreased balance
  • increased Q-angle
  • lateral subluxation of the patella
  • collapse of the medial foot arch
  • protective in-toeing[1]

Ankles/Feet[edit | edit source]

Infants are born with:

  • hindfoot varus
    • with weight bearing, transitions to valgus
  • feet straight forward or slight pointing in
    • toeing out increases in adults
  • high arch[1][6]
    • adults tend to transition to flatter feet[1]

Role of Paediatric Physiotherapy[edit | edit source]

Physiotherapists can help facilitate correct movement patterns to improve biomechanical alignment. Early intervention is associated with better functional outcomes. Some interventions that paediatric physiotherapists use are listed below:

The video below by Pathways demonstrates a 2-month-old typical vs. atypical development side by side:


Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 Eskay K. Paediatric Musculoskeletal Development Course. Plus. 2023.
  2. ↑ 2.0 2.1 Karkenny AJ, Magee LC, Landrum MR, Anari JB, Spiegel D, Baldwin K. The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis. JBJS Open Access. 2021 Jan;6(1).
  3. ↑ A El-Hak AH, Shehata EM, Zanfaly AI, Soudy ES. Genu Varum in Children; Various Treatment Modalities for Bowleg's Correction. The Egyptian Journal of Hospital Medicine. 2022 Apr 1;87(1):1858-63.
  4. ↑ Ganeb SS, Egaila SE, Younis AA, El-Aziz AM, Hashaad NI. Prevalence of lower limb deformities among primary school students. Egyptian Rheumatology and Rehabilitation. 2021 Dec;48:1-7.
  5. ↑ Çankaya T, Dursun Ö, Davazlı B, Toprak H, Çankaya H, Alkan B. Assessment of quadriceps angle in children aged between 2 and 8 years. Turkish Archives of Pediatrics/Türk Pediatri Arşivi. 2020;55(2):124.
  6. ↑ Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, Sanpera-Iglesias J. How to manage pes cavus in children and adolescents?. EFORT Open Reviews. 2021 Jun;6(6):510.
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