1. Atypical Sitting Posture
W-sitting:
- Most children have enough flexibility to assume a w-sit; however, preference for w-sitting can be a sign of atypical development, or can lead to atypical development in an otherwise healthy child
- May indicate decreased postural control or low muscle tone
- Very stable position with wide base of support, so little energy is needed to maintain this position
- May cause orthopedic concerns
- Hips are placed in extreme internal rotation
- Overstretched ligaments can lead to instability
- Risk of dislocation in children with undetected hip dysplasia
- Muscle Shortening
- Hamstrings, adductors, internal rotators and heel cords are at risk for contractures
- May cause other concerns
- Delayed development of balance reactions and postural control
- Discourages trunk rotation and midline crossing
Signs of Low Muscle Tone:
- Thoracic Kyphosis
- Next Extension
- Open Mouth
- Wide base of support
- Propping with UEs
2. Atypical Standing Posture
Orthopedic Concerns:
- Scoliosis
- Toe in / Toe out
- Genu Varum / Valgum
- “Bowlegged” / “Knock-kneed” Varum / Valgum
- Knee Hyperextension
Signs of Low Muscle Tone:
- Increased Thoracic Kyphosis
- Increased Lumbar Lordosis
- Protruding Abdomen
- Wide base of support
3. Over-reliance on UEs for Support/Mobility/Balance
Floor to Stand Transition:
- Typically begin to stand up independently at 12 months, through “bear position”
- By 18 months, child should be able to stand through ½ kneel without needing UE support
- Continuing to require UE support could be a sign of decreased core or LE strength, low muscle tone, or decreased balance
Stair Climbing:
- Using railing to pull self up the stairs (rather than simply for balance) is atypical at any age. Likely a sign of LE weakness.
- Should be able to ascend/descend stairs without a rail marking time by 24-26 months
Using UEs for Balance:
- High UE guard when walking/running is a sign of decreased balance (should display reciprocal arm swing by 18 months)
- Difficulty carrying objects
- Constantly seeking UE support when stepping up/down/over familiar obstacles vs. “bear position” ½ kneel
4. Gait Deviations
Toe Walking:
- Occurs in 7-24% of population, males > females, correlates with family history, language delays, and learning disabilities
- Consistent heel strike typically develops by 18 months of age
- Causes: Muscle tightness, sensory avoidance, compensatory muscle weakness or instability
- Negative effects: decreased ankle ROM due to adaptive shortening of gastroc/soleus/Achille’s tendon, difficulty with descending stairs and other activities that require closed chain dorsiflexion, decreased balance, increased risk of ankle injuries and foot pain
- Treatment: ankle stretching/strengthening, AFOs, night splints, serial casting, taping, botox injections, gait training, auditory feedback, surgical intervention may be needed if conservative treatment fails.
Left / Right Asymmetry
- Joint Position
- Step Length
Signs of Decreased Balance
- Should “walk well” by 18 months
- Walk should be adult-like by 7 years
- Wide base of support (feet should be less than shoulder width apart)
- High UE guard rather than reciprocal arm swing
5. Delayed Milestones
Red Flags….refer to PT if: Typical
- Not sitting independently by 7 months
- Not walking independently by 14 months
- Not walking well by 18 months
- Not standing up from the floor without UE support by 18 months
- Not running by 24 months (with visible double flight)
- Not jumping by 2 ½ years
- Not alternating feet on stairs by 3 ½ years
- Not hopping on one foot by 4 years
