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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>
As an infant grows, movement patterns develop that affect their bony alignment.  As movement patterns are practiced thousands of times a day any abnormal muscle pull can create atypical alignment.  Abnormal muscle pulls can be caused by genetic conditions and impairments with abnormal tone. Atypical alignment can directly affect form and functional activities and participation.  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


The following sections will highlight typical musculoskeletal development for an infant as well as changes that progress over time.  
== 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 ==
== Rib Cage ==
{| class="wikitable"
 
|+
* Initially, the rib cage in infants is barrel-shaped and rigid; ribs are elevated and perpendicular to the spine
!Rib Cage
* 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)
!Shape
* Atypical = persistence of the barrel shape
!Location of Ribs
!Other
|-
|Infant
|Barrel-Shaped
|Elevated; Perpendicular to Spine
|Rigid
|-
|2 years old
|Oblong-Shaped
|Depressed due to diagragm pull and sitting/standing/walking
|Lateral Expansion
|-
|Abnormal
|Persistence of Barrel-Shape
|
|
|}


== Trunk ==
== Trunk ==


* begins with kyphotic spine moving into a more neutral spine
* Initially, infants have a [[Kyphosis|kyphotic]] spine  
* prone push-up and sitting activates posterior chain musculature
* Overtime this transitions to a more "neutral" spine (as seen in adults)
* crawling creates co-contraction of anterior and posterior muscles
* 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" />
 
=== Changes in Alignment to Consider ===
===== Increased Curvature of the Spine =====
Increased curvature of the spine (i.e. [[scoliosis]]) can affect:<ref name=":0" />


<nowiki>**</nowiki> Abnormal muscle pull can change spine position
* breathing
* lung positioning
* heart location
* visceral function


== Pelvis ==
== Pelvis ==
[[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" />


* begin with rounded pelvis and posterior tilt
== Lower Extremities ==
* sit and stand: activates core muscles and anterior pelvic tilt
Typical joint patterns in infants are as follows:  
* 12 months: 12 degrees of anterior pelvic tilt
* 30 months: 15 degrees of anterior tilt
* with increased gluteal activity, anterior tilt decreases slightly until age 8
* adult: 10 degrees of anterior pelvic tilt
 
== Lower Extremity ==
Lower extremity normal infant pattern:  


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


=== Hip ===
=== Hip ===
* infants 34 degrees of hip extension limitation
Infants are born with:
* more time in prone - stretch anterior capsule
* increased hip external rotation which decreases over time
* 6 weeks-19 degrees of hip extension limitation
* hip adduction limitation
* toddlerhood-7 degrees limited
* 34 degrees of hip extension limitation
* birth- hip adduction limitation
** as infants spend more time in prone, their anterior capsule stretches, decreasing the hip extension limitation
* birth- high external rotation which  decreases over time
*** [[File:Coxa.png|thumb]]at 6 weeks old infants have a 19 degree hip extension limitation
* birth- slight limitation in knee flexion
*** toddlers have a 7 degree hip extension limitation
* five years- knee straight when hip flexed to 90
* increased coxa valga - 140-160 degrees
** as become more ambulatory, femoral neck angle decreases
** decreases over time to 126 degrees in adults


LE norm: hip: flexion, abduction and lateral rotation,  knee: flexion, genu varum, medial rotation of tibia; ankle: dorsiflexion, slight pronation
* anteversion of the femur - 40 degrees
** this decreases to 16 degrees in adults


=== Hip ===
==== Changes in Alignment to Consider (Hip and Pelvis) ====


* newborn: increased coxa valga 140-160
===== Hip =====
* decreases over time to adult 126
* anterversion of the femur newborn: 40 moving to 16 in adult


<nowiki>**</nowiki> 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.
* 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" />


<nowiki>**</nowiki> abnormal: 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.(posterior)
===== 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" />


too much pelvic tilt:
===== 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]]


* abs are too long
=== Knee ===
* hip extensors are too long
* hip flexors and lumbar extensors are too short
* unable to have appropriate muscle pull of both your core muscles and your glute muscles when you're performing functional activities.


* 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" />


too little of a pelvic tilt
==== Changes in Alignment to Consider ====


* ilipsoas is stretched out
===== Increased Medial Tibial Torsion =====
* anterior hip capsule is stretched out
* glute max is short
* hip laxity in the front and hip instability.


* Internal rotation of the tibia
* Not common
* Toeing in
* Most likely associated with medial rotation occurring higher up in the chain<ref name=":0" />


pelvic obliquity.
===== Increased Lateral Tibial Torsion =====


* common in patients with hemiplegia and diplegia
* External rotation of the tibia
* lower side, the side where the hip is dropped down, this is typically a shorter, lower extremity, or there is increased pronation of the foot on that extremity.
* reduced stance time on the short side
* reduced loading on the short side
* functional ankle plantarflexion on the short side so that they are able to reach the ground.
* On the long side we'll often see foot pronation as a compensatory mechanism to allow that leg to be slightly shorter as that foot collapses in.
* medial rotation of the lower extremity and knee flexion to compensate.
* gait asymmetry and we will see that the pelvis rotates as they walk towards that short side.


=== Knee ===
* Individuals present with crouched posture<ref name=":0" />


* baby: genu varum
===== Increased Genu Valgum =====
* toddler: knock-knee to genu valgus (max out around 2 1/2) that decreases over time
Possible impairments:
* adult: neutral
* pain in calf, thigh and/or knee
* birth- 30 degree knee flexion contracture
* increased fatigue with activities
* resolves first few months of life
* less efficient gait
* infant: medial rotation of the tibia
** decreased gait velocity
* 12 months- medial rotation of tibia is resolved
** decreased balance
 
* increased Q-angle
<nowiki>**</nowiki> too much lateral tibial torsion, crouched posture.  
**[[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]]
<nowiki>**</nowiki> 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.
* collapse of the medial foot arch
 
* protective in-toeing<ref name=":0" />
Too much genu valgus:
 
* calf, thigh and knee pain
* fatique more quickly with activities
* less efficient with gait
* increase Q-angle makes quad less efficient secondary to abnormal muscle pull
* lateral subluxation of the patella,
* medial arch of the foot collapse in
* protective in-toeing
* decreased gait velocity
* decreased balance.


=== Ankles/Feet ===
=== 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" />


* baby-straight forward or slight toeing out
== Role of Paediatric Physiotherapy ==
* adulthood-toeing out increase
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:
* birth- nice arch
* adult- moving to flat foot
* hindfoot varus: birth (bowing in of heel)
* standing moves it into valgus


important because depending on what disease process a patient has. Depending 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.
So idiopathic 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.
Now, there are some things that we can do as physical therapists that will have an impact on their alignment to improve both their form and their function as they continue to grow and develop. As we talked about already, you have from birth through those first couple years, and then a little bit of influence all the way up until 25. We can have some interventions that we apply to these children to allow them to have more appropriate biomechanical alignment, and the earlier we can have appropriate biomechanical alignment, the better their function is going to be.
So if we can find ways to influence the alignment of that child then what we can do is they will then practise movement patterns because we know they weight shift thousands of times a day in appropriate alignment. And the more they can do that, the better off their form is going to be going forward.
So one, we know that movement is essential. So we've got to get them in appropriate alignment and then we have to get them to move because this is going to be what changes how that skeletal system is modeled.
* static positioning device
* splinting/bracing
* weight shifts
* weight shifts
* loading
* loading
* surgery
* static positioning devices
* So we want them to do this in the right alignment. If we have them in inappropriate alignment, they're going to reinforce aberrant muscle pull, reinforce atypical movement patterns, which doesn't help them in the long run.
* [[splinting]]
 
* [[Bracing for Clubfoot|bracing]]<ref name=":0" />
 
.children who cannot walk more than 10 steps by the age of 30 months we really need to watch their hips. We really need to watch their spine. So if you have a child that you are treating who has cerebral palsy and they are non ambulatory, or walking very, very little by the age of 30 months. Know that we need to get them in for hip X-rays because we know that if they don't have this appropriate loading force, if they don't have appropriate weightbearing, they're going to have that coxa valga that persists or increases. We know that they are going to have hip anteversion. And both of these things together really put them at a very high risk of dislocating their hip posteriorly, which is painful and bad for alignment. So we want hip X-rays to measure the migration of their hip. So how much that hip is moving in the socket every six to 12 months until the age of seven.
 
So for children that are unable to stand by the age of five, we want to have imaging of their spine. Do they have scoliosis that's developing? What is their ribcage doing? Are they able to maintain appropriate alignment? Because if you have too much curvature in your spine, it affects your breathing. It can affect your lung position, it can affect where your heart is at. So it can affect visceral function if they have too much compression on those organs due to a curved spine.it's really important to make sure that you know what that child is doing and what they look like functionally because it can have significant impact on pain, on mobility, and even on things like breathing and cardiac function as they continue to grow and develop.
 
cortical plasticity: So it's really important that we provide opportunities for our patients to be able to use these body parts that they might have deficits in so that they continue to have good neural mapping to those areas.


The video below by Pathways demonstrates a 2-month-old typical vs. atypical development side by side:
{{#ev:youtube| _0cErYu3A8Q}}


Muscle pull over time


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.
== Resources ==


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.
* [[Biomechanics]]
* [[Infant Development]]
* [[Coxa Vara / Coxa Valga]]
* [[Valgus 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.
== 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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