Child Physical Therapy

Physical Therapy: In-Toeing and Out-Toeing

The first year of life is full of new beginnings, between crawling, pulling up to stand, and finally walking! Watching your child take their first steps can be both exciting and nerve-racking. The first steps may look different for each child.  While watching your children explore the world on their feet, you may observe that their toes point inward or outward. Learn more about the causes and treatment of in-toeing or out-toeing below.

 Andrew Seaman

Andrew Seaman

In-Toeing or “Pigeon Toe”

            In-toeing, commonly known as “pigeon toe”, is when the toes face into each other while walking or running. This is commonly seen in infants and young children. In-toeing may be caused through hereditary genes or the baby’s positioning in the womb. If a parent demonstrated in-toeing as an infant or child, it is likely they will pass down the gene to their children. An infant may also develop in-toeing due to small feet movement and positioning in the womb. In-toeing is typically not painful for children and does not lead to arthritis.

There are three types of in-toeing: Tibial Torsion, Metatarsus Addactus, and Femoral Anteversion. 

Tibial Torsion

When the shinbone (tibia bone) is tilting inward causing the feet to point in. It is the most common cause of in-toeing in infants and young children typically under the age of two years old. It is typically due to positioning in the womb, and is noticeable at an early age. Tibial torsion frequently straightens out once the child begins to walk, but may take up to 6-12 months to fully correct. Although tibial torsion does not typically require intervention, surgery may be recommended after the age of eight for more severe shin rotations.  

Metatarsus Adductus

When the front half of the foot, or forefoot, is turned inward. Studies have shown that metatarsus adductus may spontaneously recover without intervention in the majority of cases. Manual stretches of the forefoot can improve metatarsus adductus and may be provided by the child’s pediatrician, nurse, or physical therapist. In the rare case that metatarsus adductus does not correct on its own, feet casts can stretch the soft tissues of the forefoot to straighten out the foot. 

Femoral Anteversion

When the upper end of the thighbone (femor), close to the hip, has an increased twist causing the feet to turn in. It is usually not detected before 4-6 years old. A common symptom of femoral anteversion is sitting in the “w- position”. Treatment may include physical therapy to teach the correct positioning of walking, and occasionally, braces to shift the bone. 

Femoral retroversion

The thighbone (femur) is angled backwards relative to the hip joint, resulting in outward feet positioning. Femoral retroversion is less common than femoral anteversion.

Out-Toeing or Duck Feet

Out-toeing is when the child’s feet point outward as they are walking and running. Out-toeing occurs less frequently than in-toeing and may be due to fetal positioning, abnormal growths, and/or underlying neurological problems. Unlike in-toeing, out-toeing may result in pain over time. There are three causes of out-toeing in children: Flatfeet, Hip Contracture, and Femoral Retroversion. 

Flat feet

A child is considered to have flat feet if they do not have an arch in their foot. If an arch does not form, the foot may appear to turn outward. Out-toeing due to flat feet does not require medical intervention and rarely causes pain. 

Hip contracture

An infant’s hip may be externally rotated due to their positioning in the uterus. The external hip contracture may cause hip tightness as they begin to walk resulting in out-toeing. Hip contracture will spontaneously resolve on its own, so out-toeing does not require treatment if it’s due to hip contracture. 

Treatment for In-Toeing and Out-Toeing

 In the majority of cases for in-toeing and out-toeing, braces, special shoes, and surgery are not required. Most children will spontaneously recover if their condition is not associated with an underlying neurological disorder.

Children may require intervention if the following persists:

·     Not improved by the age of three

·     Complaining of excess pain (especially for in-toeing)

·     One foot more turned than the other

·     Other developmental delays such as fine motor, gross motor, and/or language development. 

·     Gait abnormalities (deviation from normal walking)

            Physical therapy can help provide awareness of correct foot positioning when walking. Physical therapy may be recommended if the issue does not resolve on its own in a reasonable amount of time. If you feel like your child would benefit from a physical evaluation for in-toeing or out-toeing, contact Lumiere Children’s Therapy.

 

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References: 

Children's Hospital. (2014, August 24). Metatarsus Adductus. Retrieved from https://www.chop.edu/conditions-diseases/metatarsus-adductus

Children's Hospital. (2014, August 24). Femoral Anteversion. Retrieved from https://www.chop.edu/conditions-diseases/femoral-anteversion

Gupta, R. C. (Ed.). (2015, February). In-toeing & Out-toeing in Toddlers. Retrieved from https://kidshealth.org/en/parents/gait.html

Intoeing - OrthoInfo - AAOS. (n.d.). Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/intoeing/

Media, H. M. (n.d.). Out-Toeing. Retrieved from https://www.chortho.com/common-conditions/out-toeing

Pigeon Toe (In-toeing). (2016, November 07). Retrieved from https://uichildrens.org/health-library/pigeon-toe-toeing

Child Physical Therapy: Treatment for Toe Walking

As children learn to navigate walking, they may initially learn to walk on their toes while cruising along furniture. Toe walking is developmentally appropriate until the age of three. If your child persistently walks on their toes in the absence of any underlying neuromuscular or orthopedic condition, it is considered idiopathic toe walking. 

 Kristal Kraft

Kristal Kraft

Idiopathic toe walking is defined as habitual toe walking with no known cause. Idiopathic toe walking may lead to tightened calf muscles, decreased range of motion of ankles, and eventually, shortened Achilles tendon. 

 

What is the treatment for toe walking?

            Treatment options vary on the degree and duration of toe walking. It also depends on the flexibility of the Achilles tendon. As with any habit, the longer it persists, the harder it is to break. In extreme instances, surgery to lengthen the Achilles tendon may be most appropriate. For most cases, ankle foot orthosis (AFO) and/or physical therapy are recommended. AFOs are removable braces worn during day and night to help maintain the foot at 90-degree angle. 

Physical therapy creates a program designed for your child’s needs by incorporating a combination of stretches and strengthening. In order to increase the effectiveness of physical therapy, daily home exercises are crucial. Below are a list of at-home stretches and activities you can incorporate into your weekly routine. 

 

At-home Stretches: 

·     Manual calf stretch: This stretch requires help from an adult. Your child will sit on the floor with his/her knees straight. The adult will cuff the child’s heel with their hand as the foot rests on the adult’s forearm. Slowly apply pressure on the child’s foot so their foot points up and towards the child’s body. Hold for 30 seconds on each side. 

·     Wall stretch:  The child is standing for this stretch. They should place their hands on a wall and point both feet at the wall one behind the other. Lean into the wall as the front leg is bent and the back leg is straight. Hold both feet on the ground flat for 30 seconds.  

 

Activities to strengthen muscles: 

·     Sit to stand: While your child sits on a chair or bench, place your hands below their knees with moderate pressure downward to provide tactile cues to keep heels on the floor. With the steady pressure, your child will stand up with heels remaining on the ground. Complete 5 repetitions. 

·     Basketball stretch: Encourage your child to sit on a small ball such as basketball while keeping both heels on the ground. Practice squatting by standing and sitting back down on the ball while keep heels down. 

·     Bear walks: Animal walking is great for stretching and strengthening leg muscles. For a bear walk, place hands and feet on the floor while hips aim towards the air. As one foot moves towards the hands, the other leg stays back while actively pushing the heel to ground. 

·     Penguin walk: Pretend to walk like a penguin by keeping the toes in the air and walking only on the heels! 

·     Crab walk: Start in the bridge position and propel forward by using hands and feet. Keep feet flat on the floor! 

·     Bozo Buckets: Line up three buckets in a row to play bozo buckets. Instead of throwing the beanbags into the buckets, place the beanbag on top of the feet and fling the bean bag by kicking. 

·     Scooter races: Race a friend or sibling on the driveway! Sit on the scooter with feet in front and use the heels to propel forward. 

·     Slide: With parent supervision, have your child climb up the slide. Climbing up a playground slide targets range of motion, strength and weight bearing. 

 

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References:
Beazley, Elizabeth, et al. “Activities for Children Who Walk on Their Toes.” University of Rochester Medical Center, www.urmc.rochester.edu/MediaLibraries/URMCMedia/childrens-hospital/developmental-disabilities/ndbp-site/documents/toe-walking-guide.pdf.
SickKids hospital staff. “Toe Walking, Idiopathic .” AboutKidsHealth, 11 Apr. 2011, www.aboutkidshealth.ca/Article?contentid=946.
“Toe Walking in Children.” DINOSAUR PHYSICAL THERAPY, 5 May 2018, blog.dinopt.com/toe-walking/.
“Toe Walking in Children.” Mid-Maryland Musculoskeletal Institute, 8 Oct. 2015, mmidocs.com/media/blog/2015/10/idiopathic-toe-walking/46.
http://blog.dinopt.com/toe-walking/

Child Physical Therapy: Jumping!

Jumping feet first into muddy puddles as water splashed onto our rain boots is a fond childhood memory many of us experienced. Even though jumping in puddles creates a dirty, wet mess for many parents, jumping is an important gross motor milestone for children. 

 trec_lit

trec_lit

Toddlers first learn how to jump off low surfaces such as the last step or curb around 24 months. Between 26- 36 months, children will gain the strength and confidence to jump up from a leveled surface, the ground. Jumping requires balance, coordination, strength, and courage. The first step to learning to jump is exploration of balance. 2-year-olds may begin by shifting their weight back and forth to experience the sensation of one foot in the air.

            Each child learns to jump differently as they explore one’s body weight and balance. Some may jump with both feet on first jump, and others mays jump with one foot in front of the other. Most children learn to jump through exploration, but for children that seem reluctant or uninterested, here are some tips to encourage their first jump!   

·     Model

Make jumping look fun and adventurous by squatting really low and jumping off the ground. Model jumping over a toy, jumping to touch the ceiling, or jumping on a trampoline. Your child will begin to show more interest after watching family members model the skill. 

·     Teach squats

The first step to learning to jump is bending your knees low to the ground and standing back up. Squats not only mimic the movement of jumping, but they provide strengthening of the necessary muscles.

·     Frog jumps

The next step to learning to jump is squatting low and hopping off the ground. This version is slightly easier than jumping from standing tall, and provides more visuals. Pretend to be frogs jumping from one lily pad to the next! Make it more fun by dressing in green and shouting “ribbit ribbit”.

·     Hold hands

Holding your child’s hand as they jump off a small step or sidewalk curb can provide a steady support. Jumping off of a higher ground requires less strength and skills but allows the child to explore jumping. 

·     Motivate

Provide targets such as neon tape around and encourage your child to jump from spot to spot. Draw a line with a chalk on the sidewalk for your child to jump over or draw a full hopscotch board!

·     Feedback

As with any new skill, give your child positive accolades along the way. “Wow, look at you bend your knees” or “Look how high you jump” can go a long way!

·     Make room

Clear an open space in the house or spend time outdoors for your child to explore gross motor activities without fear of hurting oneself. 

Read more about physical milestones in our post Gross Motor Development.If you feel your child is behind in gross motor development, contact Lumiere Children’s Therapyfor an evaluation. 

 

 

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References:

Drobnjak, Lauren. “CHILD DEVELOPMENT QUICK TIP: LEARNING HOW TO JUMP.” The Inspired Treehouse, 24 Sept. 2014, theinspiredtreehouse.com/child-development-quick-tip-learning-how-to-jump/.

WhattoExpect. “Running, Climbing, Jumping and Kicking.” Whattoexpect, WhattoExpect, 21 Oct. 2014, www.whattoexpect.com/toddler/run-jump/.

Child Physical Therapy: Autism and Physical Therapy

Children with autism spectrum disorder present with challenges related to social skills, repetitive behaviors, speech and language, and sensory processing. Speech, behavior, and occupational therapy is recommended to improve communication, behavior, and sensory deficits in children with autism spectrum disorder. Along with these disciplines, physical therapy is a crucial component of an autism treatment team. Physical therapists focus on improving a child’s balance, posture, and incoordination to improve engagement and participation in everyday activities.

 Jake Guild - Flickr

Jake Guild - Flickr

What is physical therapy?

Pediatric physical therapists help guide children through physical milestones. Areas of intervention include gross motor skills, balance/coordination skills, strengthening, and functional mobility. 

What are common physical deficits in ASD?

Children with autism spectrum disorder may experience some of the following physical challenges:

·      Decreased eye-hand coordination

·      Difficulty controlling posture

·      Lack of Coordination

·      Poor balance and instability

·      Low muscle tone

Research has shown that children with autism may also demonstrate toe-walking ankle stiffness, and motor apraxia.

Physical Therapy treatment for ASD

Pediatric physical therapy utilizes play and therapy techniques to improve balance and posture in children with autism. Improving posture in sitting, standing, and walking can build endurance and increase attention during school-time activities. Once a child feels secured and balanced, they can focus on other areas such as socializing, interacting, and playing. Physical therapists improve the lives of Children with ASD by improving their day-to-day functioning.

 

Learn more about Autism on our blog: Autism and Sensory Integration, Autism Awareness, Art and Autism, and many more articles!

 

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Resources:

“Autism Spectrum Disorder.” American Physical Therapy Association, 31 Oct. 2014, www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=a6482e75-65c6-4c1f-be36-5f4a847b2042.

“The Role of the Pediatric Physical Therapist for Children with Autism Spectrum Disorder.”Center for Autism Research, www.carautismroadmap.org/the-role-of-the-pediatric-physical-therapist-for-children-with-autism-spectrum-disorder/.

Wang, Judy. “Physical Therapy for Children with Autism.” North Shore Pediatric Therapy, Judy Wang, PT, DPT Http://nspt4kids.Com/Wp-Content/Uploads/2016/05/nspt_2-Color-logo_noclaims.Png, 13 Jan. 2015, nspt4kids.com/autism/physical-therapy-children-autism/.