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Introduction

According to Greek mythology, the hero Achilles was said to have been dipped head first in the magical River Styx by his mother, thus making almost his entire body invulnerable to injury wherever the water touched. However, since his mother held him by his heels, as the story goes, the tendon at the back of his heel became his only weak spot and eventually lead to his demise.

From birth, every parent is concerned about his or her child’s feet. In fact, we usually breathe a sigh of relief when we find out that our baby has all ten fingers and all ten toes. We watch in both awe and wonder as our children grow and develop, especially during the first few years of life. Many times we are like Achilles’ mother, doing everything in our power to insure that our children remain healthy and develop normally. However, “normalcy” is difficult to define when it comes to the child’s ability to walk, especially in light of all of the changes that occur during development. This is complicated by the fact that parents are often confused when it comes to “normal” foot development due to conflicting advice from grandparents, family, well-meaning neighbors, general pediatricians, orthopedic doctors, chiropractors, and podiatrists.

The purpose of this article is to offer parents insight into what is “normal” and “abnormal” in regards to a child’s foot health, and to help answer one of the most common questions heard among the pediatric medical community, “Is my child walking the right way?”

The Development of Walking

Seeing a child take their first step is described as one of the most memorable moments in a parent’s life. A child will begin to walk unassisted only when they are ready. This occurs between the ages of eight to eighteen months. It is extremely important not to rush the child into walking since speeding up the “internal walking clock” may actually prove detrimental to a child’s normal development.

As a child grows, parents will notice a change in the knee position. From the first steps until about the age of two, a child will appear to be bowlegged (a condition known as genu-valgum), which means that there will be a gap between the knees when the child is standing with both feet next to each other. This is normal. The child will then go through a stage of being knock-kneed (genu-valgum), where the knees angle inwards when the child attempts to place the feet together. This stage is also normal from approximately age two to six. After six, the condition typically corrects itself. If either of these stages persist or become excessive, it is a good idea to follow up with a foot specialist as soon as possible, since both of these conditions can be associated with other problems.

Will a Walker Help?

The overuse of walkers has been questioned in the medical literature. Many experts feel that this puts a large amount of pressure on the child’s feet at too early of an age and can alter the normal development of the foot, which is considered to be both flexible and plastic in terms of its developing structure. Walkers can prevent a child from experiencing the all-important crawling stage, which is crucial to the development of both coordination and normal muscular tone needed for unassisted ambulation. A walker can hold the child’s hip position at an outward angle leading to a prolonged bowlegged deformity.

According to Dr. R. Saphir, a renowned pediatrician at Mt. Sinai Center in Manhattan, there is no evidence that children who used walkers walked any earlier than those who did not [1]. A number of injuries have occurred with the unsupervised use of walkers, including accidents around stairs, counters, and other dangerous objects.

Common Developmental Concerns

Toe-walking... "My daughter is a natural ballerina!" A dance school's best recruit is a child with a condition known as toe-walking. Actually, it is not uncommon for early walkers to walk on their toes as their muscles learn the correct way to balance the body. Equinus is the medical term for toe-walking and is defined as a foot that does not have enough dorsiflexion (i.e., flexion at the ankle joint bringing the foot toward the front of the leg). Occasional toe-walking is not a concern, especially if the child can voluntarily bring the heel to the ground. However, the child should be evaluated anyhow to rule out any neurological causes if the condition, especially if it becomes persistent.

There are three main reasons why a child may toe-walk. First, and most importantly, it may be caused by a spasticity of the calf muscles (gastrocnemius and soleus). This is due to a neurological problem such as cerebral palsy, the most serious concern for toe-walking. The second most common reason for toe-walking is due to a tight heel cord (Achilles tendon). This can be treated with stretching, bracing, casting and sometimes surgery if indicated. The third reason is habitual toe-walking. For some reason the child just walks on their toes. They can walk on their heels when asked, but prefer to toe-walk. This is best treated with clever parenting and encouragement of heel walking.

Flat Feet

Dr. Robert Salter, a world-famous pediatric orthopedist, once stated, “If children who are flatfooted would walk on their hands, they would be called flathanded” [2]. Although he said this in jest, his statement does provide some insight into what is known about flat-footedness in most children. It is well known that most babies are born with flat feet. This is due to the fact that the musculature that supports the arch has not fully developed yet. There is also a considerable amount of baby fat in that particular area which serves to protect and cushion the baby during the early development of gait (walking), which makes the foot appear flat. This does not usually cause concern among parents unless it persists past the age of three, at which time parents should bring their children to the pediatrician for an evaluation of their feet. In most cases there is generally nothing to worry about.

Flat feet are fairly normal in infants and toddlers. A persistent flat foot in older children (over the age of six) is usually inherited and runs in the family. For most people, flat feet are symptom free. However, some children may have associated foot or leg pain, which should always constitute a doctor’s visit. A rigid flat foot, meaning the arch is absent even when not bearing weight, can frequently be quite painful. Flat feet often lead to poor foot function which predisposes the child to other foot problems such as bunions, hammertoes, and calluses.

Frequently, doctors will not recommend treatment of your child’s flat feet until the child is over three to four years of age, allowing for sufficient time for the ‘baby fat’ to disappear. Treatment is almost always conservative and consists of special shoe gear and arch supports. In extreme cases, custom molded supports may be necessary to enhance foot function, although these tend to be more expensive since the foot will likely outgrow the support within a short amount of time. In severe cases, a doctor may offer more aggressive treatments including corrective surgery, especially when pain is present, the condition is of sudden onset, one sided, or affects the child’s ability to keep up with their peers. There are some less common and serious variants of flatfoot in infants that should be diagnosed as soon as possible in order to ensure proper treatment. If the parent has any questions about their child’s feet, a foot specialist should examine them to determine if early treatment is necessary.

In-toeing

Another common concern among parents is that their child walks "pigeon-toed". A parent's first response might be, "Oh, no! My child will never be able to play sports in school." It should be pointed out that there is no such thing as "terminal in-toeing". Most children who in-toe will live a happy, normal life. Some sports experts have suggested that sprinters may have an advantage by being in-toed. Occasionally the deformity is severe enough to cause pain, shoe irritation and tripping, and it can predispose a foot to have other problems. Social concerns are also valid due to the "bully" attitude on the playground.

In-toeing simply stated, is a foot that points toward the midline of a person's gait (or walking pattern). At first glance, it might seem like a deformity of the foot, but in-toeing can be the result of any rotational over-growth or under-growth at any bone or joint from the foot up to the hip. For example, a common cause of in-toeing in children under age two is not enough tibial torsion. The main bone in the lower leg (tibia) has a normal growth development that includes a twisting of the leg in an outward direction. If this does not undergo its full rotation, a child can have a foot that appears in-toed. If the leg rotates too much, then the reverse effect will result in an out-toe position of the foot.

The most common cause of in-toeing among children between the ages of two to ten is excessive inward twisting of the bone in the upper leg (femur)—this is referred to as femoral anteversion. The hip joint undergoes rotational changes in an inward direction through adolescence. If the femur is twisted inward too much, then the normal inward twisting of the hips can bring on an in-toed gait around ages two to four. Fortunately, most children will slowly grow out of this deformity.

Another reason a child may have an in-toed gait is due to a deformity in the foot itself. If your child’s foot appears to be curved inward exhibiting a “C-shape,” metatarsus adductus or hallux varus may be the reason. Either the metatarsals (long bones to the toes) or the hallux (big toe) can be pointing inward. These deformities will usually be seen at birth, but can appear to worsen with time. It is good to evaluate this prior to a child's walking because conservative treatment options decrease with age. Initially special shoes, bracing, and casting may suffice. In older children, if these treatments are not satisfactory, surgery may be indicated.

Because the development of the child's leg and foot is a gradual process, it is not uncommon for a doctor to tell a parent, “Your child will grow out of it.” While most of time this is true, there is an occasion when the deformity will not correct itself. Early detection and close monitoring will increase the treatment options and outcomes.

Injuries

Most children at some time will build a tower of pillows and jump off the couch like a superhero. Even though children are super flexible, and super "healers", they are not immune from injury. A child's bones are not fully developed until the late teen years. Because their bones are so plastic, it is more likely for a child to break a bone than to tear a ligament. In other words, ankle sprains are less likely than broken bones.

Signs that a child has broken a bone include walking with a limp, not walking at all, or pain to the injured area. Children are likely not able to consistently fake a limp and should be evaluated by a doctor to rule out a broken bone. The growth plates of the bones are the most frequent area broken, and because injury can cause growth deformity, it is important to get a complete evaluation.

Selecting the Right Shoes

The function of a child’s shoe is to prevent injury from sharp objects, insulate their feet from excessive temperatures, and protect during the stomping or kicking that can occur when they get agitated. These environmental threats are an unfortunate side affect of modern day living. For adults, the shoe industry has become increasingly centered on shoe fashion and the marketing of shoes as a status symbol. However, in children, shoes have maintained their original role of protection from the hazards of the outside world.

According to most experts, shoes are not recommended for pre-walking infants since the bones and ligaments in their feet are still flexible, rapidly developing and prone to deforming forces. In fact, a stiff shoe can decrease a child’s ability to balance and cause frequent falling. A soft warm bootie is the preferred shoe of choice until the child is able to walk unassisted. Once walking, a flexible shoe is preferred to allow for normal foot function. The idea that shoes should be the most expensive for proper function is just a myth. In reality, most of the world’s population of children cannot afford shoes; such is the case in many third world countries. In response to this, the skin on the soles of their feet grows thicker from not wearing shoes—the body attempts to protect itself by forming this thick skin. However, for the above-mentioned reasons, shoe wear becomes necessary as a protective precaution when the child becomes more active.

While there seems to be a large array of opinions regarding shoes, most experts agree that the proper shoe should be flexible, light, and made of breathable materials. If the shoe is too heavy or rigid, the foot will not develop normally. The heel counter should really be the only rigid part of the shoe. This is the part of the shoe that surrounds the heel and provides the greatest amount of support. The shoe should flex at the forefoot and midfoot, but not at the heel counter. Some suggest a high top sneaker to add stability, but there is controversy with this since they can act as a ‘brace’ and disrupt the normal development of the muscles that support the foot and ankle.

Children’s feet grow at a rapid and unpredictable pace due to the fact that they tend to grow in spurts. This is often very frustrating to parents since the cost of quality children’s shoes is about one-half that of the adult’s version. Parents should be advised that saving money by “passing down” shoes from older children can be problematic since every child wears their shoes differently. While the size may be just right, the old wear pattern of the shoe may throw off the normal gait in the new owner of the shoe. Since the support of the shoe is most likely compromised, an older pair of shoes should be carefully inspected prior to being passed down.

Perhaps the most acceptable way of increasing the life of a shoe is to buy the shoe slightly bigger than the child’s measured length since it is better to be too big than too small in terms of shoe fit. There should be about three-quarters of an inch from the longest toe (not always the first) to the tip of the shoe. Also check to see that the child’s foot is not lifting out of the heel and that the child doesn’t trip over the shoe.

Shoe size should be checked as follows:

The Footwear Council offers the following fitting tips:

• If the child is repeatedly taking off their shoes, this may indicate that the shoes are too small.
• Any sign of a limp could mean trouble and shoes must be checked.
• If the shoe lining shows excessive wear in the area of the fifth toe, the shoes are too short. You can feel the inside lining of the shoe for dents for improper toe pressure.
• Watch for any red marks across the top of the foot, over the tops of the toe, or on the sides of the foot. This indicates that the shoe is too narrow or too small.
• If the soles are unevenly worn with excessive wear on the inside or outside edges this could be an indication of improper foot/ankle function. The child should be taken to see a specialist who can determine the best type of treatment to correct for this.
• Be wary of passing shoes down because you may only end up passing down foot problems.

Finally, remember that choosing a shoe for a child is a short-lived activity since they will soon insist on choosing shoes for themselves.

Conclusion

If it were possible to walk the circumference of the globe, would you? Well, your feet travel upwards of 115,000 miles in a lifetime—this is equivalent to walking around the globe four times [3]. Providing some thought and care at an early age can greatly enhance the quality of those walked miles. It is important to remember that when it comes to your child there are no silly questions. Look to your parents for guidance in these matters. Ask yourself some questions. Did you or your spouse have a similar structural problem like in-toeing or out-toeing? Did you “outgrow” the problem or do you still suffer with the same condition? The answers are important since structural problems tend to be inherited.

A foot problem can easily go undiagnosed since the child can develop in ways to accommodate for the problem. It is not until the child becomes a young adult that these problems tend to un-mask themselves. In other words, the child can often outgrow the pediatrician before outgrowing the problem. Remember that most deformities are best treated in the early stages. Waiting can also increase both the seriousness of the problem and the length and severity of treatment. If there are questions or concerns regarding your child’s health, normal development, and concerns about their feet, always seek the advice of a foot specialist.

For the name of a foot and ankle specialist in your area, or for more information about foot and ankle health, visit the American College of Foot and Ankle Surgeons' web site www.FootPhysicians.com.

References

1. Block, B: Foot Talk. Foothealth.com. Kane Communications, Inc. 2000.
2. Sutherland DH et al: The Development of Mature Gait. J Bone and Joint Surg, 62A: 336-357, 1980.
3. American Podiatric Medical Association, 2000.

Additional Reading

• Bleck EE. Matatarsus Adductus: Classification and Relationship to Outcomes of Treatment. J Pediatric Orthopedics, 3:2, 1983.
• Papariello SG, Skinner SR. Dynamic EMG Analysis of Habitual Toe-Walkers. J Bone and Joint Surg, 5: 171-175, 1985.
• Salenius P, Vankka E. The Development of the Tibiofemoral Angle in Children. J of Bone and Joint Surg, 57A: 259-261, 1975.
• Saunders JBDM, Inman VT, Eberhart HD. The determinants in Normal and Pathological Gait. J of Bone and Joint Surg, 35A: 543-558, 1953.
• Staheli LT, Giffin L. Corrective Shoes for Children: A Survey of Current Practice. Pediatrics, 65(1): 13-17, 1980.
• Wenger D, Rang M. The Art and Practice of Children’s Orthopaedics. Raven Press, NY. 1993.

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