Pediatric Gait Abnormalities

Gait abnormalities are abnormalities in the way a person walks. Gait abnormality is a common parental concern in the pediatric population. Primary gait concerns include: intoeing, out-toeing, limping and toe walking. 


  • Intoeing is a normal variant that is often caused by tibial torsion or femoral anteversion. Tibial torsion often improves up to the age of 6 years. Femoral anteversion, also a normal variant, can improve with growth up to the age of 10 years and can be monitored 
  • If the child is over the age of 10 years, has persistent tibial torsion or femoral anteversion that limits walking function or causes excessive tripping, a surgery to correct the rotation (cutting the bone and rotating it) may be a treatment option to discuss with your child’s orthopedic surgeon 
  • There is no evidence that bracing, special shoes or physical therapy improves or changes the lower extremity rotational profile 


  • Out-toeing can be caused by flat feet, rotational malalignment of the tibia (tibial torsion) or femur (femoral retroversion)
  • A flexible flat foot is a normal variant (the foot arch does not typically develop until at least 6 years of age) and usually does not require special shoes, orthotics, or surgical intervention 
  • Occasionally, children with flexible flat feet may have symptoms of fatigue or foot pain. If this occurs, the recommendations include a good supportive shoe with a stiff sole, an over-the-counter soft cushioned shoe insert or a custom soft cushioned shoe insert with built-in arch support 
  • Surgical intervention in a child with flexible flat feet is not recommended until all other measures for pain management have been attempted and not until the child has reached skeletal maturity
  • A rigid flat foot is atypical and should be assessed by an orthopedic surgeon with imaging to assess for a tarsal coalition or other osseous abnormality 
  • Another cause of out-toeing may be a slipped capital femoral epiphysis (SCFE), which occurs when there is a displacement of the proximal metaphysis of the femur 


  • The most common diagnoses for a child with a limp include temporary inflammation of the joint space (transient synovitis), joint infection, fracture, leg length differences, hip dysplasia, Legg-Calve-Perthes or SCFE
  • In addition to a physical examination, work-up for a child with a limp may include x-rays, a joint specific ultrasound and inflammatory labs (CBC, ESR and CRP) to evaluate for fracture, effusion and infection
  • A difference in leg lengths can also cause a limping gait and should be evaluated by an orthopedic surgeon 
  • Legg-Calve-Perthes disease is caused by a disruption in the blood supply to the femoral head which can cause pain and limp.  Perthes is diagnosed with AP and frog lateral x-rays of the pelvis and may require an MR of the hip in the early stages  
  • A limping child at any age is a significant concern and should warrant immediate referral to a pediatric orthopedist or the emergency department depending on the acuity 

Toe Walking

  • Toe-walking can be idiopathic (no known cause), but it can also indicate other conditions such as hip dysplasia, cerebral palsy, tethered cord or other muscular disorders
  • If the toddler intermittently toe walks bilaterally and can walk with a heel-toe gait bilaterally with good ankle range of motion, this is typically idiopathic and may resolve as they age, but this should be monitored
  • If the child has unilateral toe-walking, the hips need to be assessed with imaging (such as an X-ray) for a possible hip dislocation or hip dysplasia and should be referred to a pediatric orthopedic specialist
  • If the child has unilateral toe-walking and no hip dysplasia is noted, further workup is indicated due to the child’s asymmetry and should be referred to an orthopedic surgeon
  • Diagnostic tests may include a magnetic resonance image (MRI) of the spine, MRI of the brain, neurology evaluation and possibly genetics evaluation depending on the child’s medical history and physical examination

Referral Information

Referral for gait analysis at the Shirley Ryan AbilityLab for computerized motion analysis is a tool used by the orthopedic surgeons to further evaluate gait abnormalities and provides both surgical and non-surgical treatment options. Click here for more information.

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