1. A limping child requires investigation 

Limping in children should be investigated.

Limping is a symptom, not a diagnosis. 

A limp is never ‘normal’ and always warrants clinical reasoning. 

It reflects an underlying issue that may be musculoskeletal, neurological, inflammatory, infectious, developmental, metabolic or even systemic. 

Careful observation of gait (antalgic versus Trendelenburg versus stiff-knee versus toe-walking) provides valuable early diagnostic clues. 

However, physiotherapists must remain alert to the fact that some causes of limping are serious and require urgent medical referral. 

Features suggestive of serious pathology include inability to weightbear, fever or systemic illness, night pain, unexplained weight loss, severe joint restriction and suspicion of septic arthritis or slipped capital femoral epiphysis. 

Early identification and referral can prevent joint destruction, long-term disability or life-threatening complications. 

The likely causes of limping differ significantly by age group. 

In toddlers, it may be trauma, developmental dysplasia or infection. 

In school-age children, it may be transient synovitis, Perthes disease or inflammatory conditions. 

Common causes for adolescents are slipped capital femoral epiphysis and overuse injuries. 

Not all limping is purely structural. 

Functional gait changes may be influenced by fear, deconditioning, weakness, fatigue or psychosocial stressors. 

Physiotherapists should assess strength and endurance, motor control, balance and coordination, movement avoidance behaviours and participation restrictions at school and in sport. 

Management should be individualised, goal-directed and collaborative. 

2. Knocked knees may need management in children and adolescents 

Knocked knees may need management.

Many concerned parents seek physiotherapy review for knocked knees in their children. 

However, most of the time, this is physiologically typical and does not require any intervention. 

Genu varum is observed in infancy and progresses towards a neutral tibiofemoral angle by approximately 18–24 months (Espandar et al 2010). 

This is followed by a phase of genu valgum, most prominent between three and five years of age.

 At its peak, the mean lateral tibiofemoral angle reaches approximately 12 degrees (Arazi et al 2001). 

With continued growth, lower limb alignment typically transitions towards adult expectations by around eight. 

Distinguishing physiological from pathological genu valgum is essential for physiotherapists to determine when further investigation is warranted. 

Further investigation would be needed if the deformity is unilateral, associated with pain or secondary to a traumatic event or infection. 

The degree of genu valgum can be measured using serial intermalleolar distance over a period of growth. 

An intermalleolar distance greater than eight centimetres at any age has been suggested as a threshold for potential abnormality (Heath et al 1993). 

The persistence of valgus alignment beyond eight years of age may also indicate a deviation from normal development. 

Identifying the aetiology of persistent or excessive valgus alignment is central to guiding appropriate management. 

3. Toe walking calls for targeted intervention 

Toe walking can require targeted intervention.

Persistent toe walking in children is a gait pattern that has biomechanical and neuromuscular implications requiring targeted intervention. 

It may be idiopathic or associated with neuromuscular conditions such as cerebral palsy, autism spectrum disorders or sensory processing disorder (Ruzbarsky et al 2016). 

Toe walking in autism spectrum disorders is often associated with sensory regulation difficulties. 

It is important for clinicians to consider the likelihood of intervention success alongside the long-term implications of toe walking when making clinical decisions. 

Prolonged toe walking places the ankle in habitual plantarflexion, increasing the risk of shortening the triceps surae/Achilles complex over time. 

This adaptive shortening reduces ankle dorsiflexion range and alters gait mechanics (De Oliveira et al 2021). 

Massage alone does not provide sufficient stretch or sustained lengthening of the calf musculature to restore typical gait mechanics. 

Instead, evidence supports prolonged, maintained stretching (such as serial casting or orthotic positioning) to lengthen the gastrocnemius–soleus complex, followed by strengthening through the new range to reinforce dorsiflexion control and functional walking patterns (Caserta et al 2019). 

Physiotherapists should combine prolonged calf stretching with functional strengthening (eg, dorsiflexor strengthening, balance and motor control tasks) to optimise gait outcomes, monitor for underlying conditions and consider referral for orthopaedic or multidisciplinary intervention when equinus contracture persists (Ruzbarsky et al 2016). 

4. Talipes may be positional or congenital 

While positional talipes in infants can be easily corrected, congenital talipes needs careful management.

Talipes is a condition that may be present in one or both feet of an infant. 

There are two types of talipes: positional and congenital. 

Positional talipes is correctable by moving the infant’s foot; the muscles, ligaments and bones of the foot are normal. Treatment should begin as early as possible after birth. 

A paediatric physiotherapist will teach the parent how to gently move their infant’s foot to gain full movement and achieve early correction. 

A child with positional talipes will have normal gross motor development. 

Congenital talipes (club foot) is a fixed deformity of the foot. 

The muscles, ligaments and bones of the foot are abnormal and it cannot be moved into a normal position. 

Infants with congenital talipes should be referred to an orthopaedic surgeon to commence treatment within the first weeks of life. 

The gold standard treatment is the Ponseti method, involving a series of plaster casts and boots. 

Some infants may require ankle surgery. 

The Ponseti method has an excellent success rate but the child may always have a slightly smaller foot and leg. 

The child should be monitored during growth to ensure that they can engage in functional tasks and sport. 

Infants with talipes should undergo a full developmental assessment, including neck, spine and hips. 

5. Paediatric hypermobility exists on a spectrum

Paediatric hypermobility varies with age and gender.

Joint hypermobility in children exists on a spectrum and varies with age and gender (Williams et al 2024, Ituen et al 2025). 

Connective tissue disorders such as hypermobile Ehlers-Danlos syndrome should therefore not be diagnosed until skeletal maturity (Tofts et al 2023). 

While most children with generalised joint hypermobility remain asymptomatic and achieve typical motor milestones (Tofts et al 2023, Ituen et al 2025), monitoring is still recommended (Tofts et al 2023). 

Hypermobile children can develop symptomatic presentations that affect participation in school, play and daily physical activities (Tofts et al 2023). 

Strengthening, endurance conditioning, motor control training and graded activity are recommended interventions to address reduced stamina, fatigue and functional limitations (Tofts et al 2023). 

Physiotherapists should provide periodic reassessment to track changes in joint range, strength, endurance and symptom burden, especially during growth spurts (Tofts et al 2023). 

Studies are beginning to show an association between hypermobility and neurodevelopmental traits such as anxiety and depression as well as an increased association with attention deficit hyperactivity disorder and autism spectrum disorders (Moore et al 2023). 

While the research is inconclusive (Moore et al 2023), it is important that such children receive the assistance they need if these traits are impacting daily participation. 

>> Cynthia Lo APAM is a paediatric physiotherapist working across private and public sectors in New South Wales. She is passionate about neurological populations, infant development and neurodivergent children and actively advocates for the role of physiotherapists in early intervention. Cynthia is a member of the APA Paediatric national group. 

>> Alexandra Walton APAM has worked across the not-for-profit, private practice and public health sectors, both within cities and on rural outreach, and currently works at the Queensland Children’s Hospital. Alexandra is the chair of the Queensland branch of the Paediatric group. 

>> Emma Fletcher APAM trained in classical ballet, as both a performer and a teacher, before pursuing a career in physiotherapy. Emma’s work with dancers led to an interest in hypermobility and connective tissue disorders in adults and children. She is a member of the Paediatric group. 

>> Jessica Wilkes APAM moved to Broome after graduation to develop her physiotherapy skills, working with a diverse range of clients. Jessica enjoyed the challenge of diagnosing and treating paediatric clients in a resource-limited rural environment. Since relocating to Perth, Jessica has continued her work with paediatric clients. 

>> Tanmayi (Tammy) Patgaonkar APAM is the director and principal paediatric physiotherapist at First Step Therapy Services in Melbourne and a clinical supervisor for bachelor and master’s students at Monash University and the University of Melbourne. She is passionate about providing tailored play-based paediatric physiotherapy. She is a member of the Paediatric group. 

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