There are a number of common foot and lower limb variations seen in children. Occasionally, symptoms are warning signs there may be an underlying condition present.

Here is some advice on when a referral may be needed.

Tip-toe walking

A referral should be made to physiotherapy if:

• toe walking is persistent
• there is associated developmental delay
• the child is unable to squat or stand with their heel/s on the floor, such as tightness of the calf muscle
• the child is over two-years-old and is unable to stand from floor sitting without using their hands
• the toe walking is asymmetrical
• the foot and/or ankle position prevents shoes from being worn.

A referral is not necessary if:

• the toe walking is intermittent
• the child is able to squat to play on the floor and is able to keep their heels on the floor, such as no tightness of calf muscle.

Flat feet

It is normal for babies and toddlers to have flat feet due to the presence of fatty tissue on thier soles. This can continue until they are around four.

A referral should be made to podiatry if:

• there is associated pain in the lower limbs
• there are signs of pressure on the foot, including blistering
• the longitudinal arch does not form normally when the child stands on tip-toe
• the foot is still.

A referral is not necessary if:

• the baby or toddler is under four
• the longitudinal arch forms normally when the child stands on tip-toe.

Pes cavus

This is the opposite of flat feet. Pes cavus is when the arch is extremely pronounced. It is rarely seen and there is usually a neurological cause which may require a referral to a paediatrician.

Knock knees

This is when a child stands with their knees together and their ankles are at least 2.5cm apart. A gap of 6 to 7cm between the ankles is normal between the ages of two and four. Knock knees usually resolve by the age of six as the bones de-rotate with normal growth.

A referral should be made to physiotherapy if the problem is associated with pain in the lower limbs or spine.

A referral is not necessary if the child is under six and the problem does not result in any pain.

Bow legs

This is when there is a small gap between a child's knees when the ankles are together. This is a normal variation in children under two. A physiotherapy referral is generally not required, unless there is associated pain in the lower limbs.

In-toeing (pigeon toed)

In-toeing is a normal variation and is particularly common in toddlers. It is generally due to an excessive twist of the thigh or shin bones. It usually resolves and naturally unwinds itself as the child grows and the musculoskeletal system matures, by the age of 10.

Insoles and exercises will not speed up this unwinding process and surgery is rarely – if ever – required and certainly not under the age of 10. A physiotherapy referral is not usually required, unless it is asymmetrical and there is associated toe-walking.

Out-toeing

This is when a child’s feet point outwards. As with in-toeing, this condition will usually resolve spontaneously and a referral to physiotherapy is not necessary.

Curly or crossed toes

If this condition presents with pain, a referral to an orthopaedic surgeon is requires. Physiotherapy and podiatry treatment will not help.