Children’s Therapy Services - Physiotherapy

What are curly toes?

Curly toes is a common condition in children and it is usually present from birth.

You might start to notice it more when your child starts walking.

Curly toes are usually seen in the 3rd, 4th and 5th toes on one foot or both feet.

The toes curl under because the tendons that flex them are too tight so they pull the toe under the next toe, curling them downwards.

Curly toes don't usually need any treatment and they don't affect walking or running.

In the past, strapping or taping for babies was used, but recent research shows this does not help.

What can I do to help?

• Stretching We always recommend stretching out the curly toes to keep them supple. This can be done every day as part of your child's bedtime or bath-time routine.
• Toe spacers Toe spacers may help to keep the toes apart and stop them from rubbing. You may find that your child might not like wearing them though, especially if they are very young. You can buy toe spacers from pharmacies or online.
• Supportive shoes Make sure your child wears supportive shoes that fit them well and allow room for the toes.

When to ask for more help

In a small number of cases, if the toes are causing a lot of trouble for a child (such as painful blisters that don't go away or painful rubbing) a small operation on the underside of the toe can release the tight tendon. Your GP might refer you to a specialist called an orthopaedic surgeon for this.

In very rare cases, if all the toes curl tightly and the arch of the foot is very high, this might be caused by a neurological (brain and nerve) problem. An MRI scan would be needed to investigate a problem like this.

More information

• Choosing Footwear for Children - Association of Paediatric Chartered Physiotherapists

What is intoeing?

Sometimes children's feet can turn in when they walk. This is known as 'intoeing gait' or 'pigeon toe'.

This is normal and common in children and they will usually outgrow it.

Intoeing will not affect your child's ability to walk, run, or jump - but some children might trip up over their feet more often. Intoeing might be more obvious when your child is tired or if they have flexible joints.

What causes intoeing? 

There are four main causes for intoeing in children:

• Femoral anteversion This happens when the femur (thigh bone) turns inwards, which causes the whole leg to turn in the same way. It is most common in children aged 2 to 4 years and will usually go away by the time the child is about 10 years old.
• Tibial torsion This happens when the tibia (shin bone) turns inwards, which causes the foot to turn in the same way. This will normally go away by the age of around 4 to 5 years.
• Metatarsus adductus This is when the foot curves inwards. It is mostly seen in young children and babies and it often goes away on its own. In more serious cases, where the foot is stiff, you might need to treat with stretches or get advice on footwear. Find out more about metatarsus adductus.
• Tight or weak muscles Sometimes the muscles around the hip joint that keep the leg in the correct position can be weak, which can make the legs turning inwards. Strengthening these muscles can help with this. Other tight muscles like hamstrings can cause intoeing, particularly after a growth spurt. Stretching exercises can help with this.

What can I do to help?

Discourage your child from sitting in the 'W' position, as shown in the image below.

Instead, encourage them to sit with crossed legs, if it is comfortable for them to do so, as shown in the image below. This helps to stretch their hips in the opposite direction.

Activities like swimming (especially breaststroke), martial arts, ballet dancing and horse-riding can help intoeing by making the hip muscles stronger.

Exercises like tandem walking (a balance exercise involving walking a straight line by putting the heel of one foot directly in front of the toes of the other foot) or out-toed walking (walking with toes pointed outwards like a penguin) can can help strengthen your child's hip muscles and encourage them to walk with their feet straighter.

When to ask for more help

Intoeing is a normal in children and will usually go away as they grow. Your child may need to be seen for more advice if they have:

• Asymmetry If only one foot is affected or there is a big difference between their legs
• A noticeable limp
• Severe pain that won't go away Especially if the pain gets worse when they are walking or being active

What are flat feet?

Flat feet (also known as 'pes planus') is a normal part of a child's development where the arch on the inside of their foot is flat. You might notice this when they are standing and sometimes when they are on tip-toes.

The arches on the inside of a child's foot usually form by the time they are 5 years old. This flexible flat foot shouldn't cause them any problems or prevent them from doing any activities or sports, and it's rarely a sign of anything serious.

Nearly all cases of flat feet (19 out of 20) will go away by themselves. In the other cases, children will still have flat feet but this is unlikely to give them any problems.

What can I do to help?

Flat feet do not need any treatment unless they are causing pain or stopping your child from moving properly.

When to ask for more help

Ask for more help if your child:

• Is over 5 years old and their flat feet are causing pain, affecting their balance or making them more tired
• Has painful, stiff or weak feet
• Has developed flat feet when they didn't have them before

If your child is having any of these problems, insoles from a footcare specialist (an orthotist or a podiatrist) may help to correct their foot position.

More information

• Flat feet in children - information for parents and carers

What is metatarsus adductus?

Metatarsus adductus is a common foot condition in babies and young children. It is usually seen at birth and can affect one foot or both feet.

Metatarsus adductus is believed to be linked to the position of the baby in the mother's uterus. Often babies can get stuck in this position for a long time, which makes the muscles on the outside of the leg and foot looser and weaker than and the muscles on the inside.

Normally, the outside edge of the foot is straight. In metatarsus adductus, the outside edge of the foot curves inwards, giving it a bean-shaped appearance, as shown in the image below.

There is nothing wrong with the structural of the feet so metatarsus adductus shouldn't cause any permanent problems for your child.

In most babies, the feet stay flexible and the condition goes away in the first 2 to 3 years without treatment. In 19 out of 20 cases, metatarsus adductus goes away without treatment by the age of 4.

What can I do to help? 

Gentle stretches can help correct the your child's foot position and you should do this as regularly as you can through the day. It's best to try to do this when your baby is settled and relaxed. The stretches should be easy to do and shouldn't cause any pain to your baby. They may get upset by their foot being held still, but they should quickly settle after the stretch.

Stretching helps to stimulate the weaker muscles so they become more active and stronger.

We recommend that you do the exercises about 5 times a day or with nappy changes or after day feeds. Each stretch should be held for 20 to 30 seconds.

Stretch 1 Gently stretch your baby's foot out towards the little toe. Make sure the movement is from the front of the foot (the forefoot) and not the ankle.

Stretch 2 Gently stroke or tickle the outside of your baby's foot to encourage them to actively move the foot outwards.

You should gradually notice your baby holding their foot in a more neutral position over a few weeks as you continue stretching.

It may be helpful to give your baby some time out of their clothes so they can kick and stretch their feet. When they are dressed, make sure their clothes are not too tight around their feet, so they have enough room to move.

When to ask for more help

You should ask for more help if you are worried that your baby's foot seems painful to stretch, it feels stiff, it is not fully flexible or their foot position has not got better after a few months of stretching.

In rare cases treatment may be needed. This might include the use of casts, special braces or shoe inserts.

More information

Metatarsus adductus factsheet - Steps

Metatarsus adductus - advice and guidance

Metatarsus adductus: signs, symptoms, causes and treatment

What is an elbow fracture?

An elbow fracture is a break in one or more of the bones that make up the elbow joint, often from a fall or a direct blow.

Common symptoms include severe pain and swelling around the elbow, bruising and tenderness around the injury site and difficulty moving the elbow.

Elbow fractures are diagnosed through an x-ray. They can be managed by allowing the bone(s) to heal in the right position or with surgery, as recommended by fracture specialists (orthopaedic team).

What can I do to help?

If you think your child has an elbow fracture, please go to your local urgent care centre for advice.

After an elbow fracture is diagnosed, you may be referred to your local physiotherapy service.

You can manage an elbow fracture with rest and using ice, wrapping the injured area with a bandage (compression) and keeping it raised (elbow) to help with swelling - but often your child will need to be in a cast at first.

After their cast has been removed, you can try these exercises at home to help rebuild strength and movement. Carrying shopping bags (or other weighted items) can also help with straightening the while press-ups against a wall can help with strength.

When to ask for more help

It is common for children to go back to their normal activities within 4 weeks after their cast has been removed. At first, they may find their elbow is stiff but this will get better with time.

If your child still finds it hard to move their elbow after doing the exercises above or they have pain that won't go away, please contact your GP practice or your orthopaedic consultant.

What is hypermobility?

Hypermobility means having very flexible joints. It is where the ligaments (which attach to bones make joints stable) are looser making the joints more flexible.

Hypermobility is not an illness or a disease - it is just the way someone is put together. It is considered normal by medical professionals and many children with hypermobility do not have any problems. Most children will become less flexible as they get older, but a small number will stay very flexible.

Children who experience symptoms from hypermobility often complain of pain, tiredness after long walks, tripping and falling more often, flat feet, clicking joints, difficulty with handwriting, difficulty holding a knife and fork, and dressing.

Pain is often caused by the muscles working hard to protect the extra joint movement, rather than pain in the joints themselves.

What can I do to help? 

Managing pain

A warm bath or a hot water bottle can help with pain, especially at the end of the day or after activity.

You can also try to distract your child from any pain with something they enjoy, like books or toys.

Encourage positive thinking, such as focusing on all the healthy activity they have done which is making their legs feel tired and sore.

Exercise

Being active will help to your child have a healthy, strong body that protects their hypermobile joints. Strengthening the muscles around a joint can improve your child's control over their movement and help to reduce pain and tiredness.

Pacing

If your child has pain after exercising, they should not stop being active. Instead, it can be helpful to pace - or spread out - their activity so they are not doing too much in a short time. 

After a very active day they should try to have a rest day afterwards. More challenging activities or contact sports (like rugby) can have more of an impact on them so think about how you could change this.

Supportive footwear

Give your child supportive footwear, especially if they have flat feet.

Supportive footwear is stiff around the heel and has a sturdy sole to act as a shock absorber. Soft uppers (at the back and sides) with laces or buckles, or boots that fasten with laces can be very effective.

Other shoes can still be worn for short periods of time or special occasions.

When to ask for more help

• Speak to your GP practice if your child is having frequent or severe pain
• They may refer to a physiotherapist who can assess and give advice and exercises to ease your child's symptoms
• A physiotherapist can refer your child on to other specialists (e.g. occupational therapy or orthotics) if they need more help with things like daily tasks or foot position

More information

• The Hypermobility Syndromes Association
• Ehlers-Danlos Support UK

What is toe walking? 

Toe walking is where the heel of the foot makes little or no contact with the floor when standing or walking.

It can happen all the time when your child is walking or just some of the time. Toe walking can happen for lots of different reasons and is common in children.

It is common for children under the age of 3 years old to walk on tiptoes as they learn to walk and balance. Some children will continue to do this up to the age of 6 or 7, when it usually goes away naturally - but others may continue to walk like this as they get older.

Toe-walking is more common in boys and is often seen in members of the same family.

What can I do to help? 

Calf muscles can get tight from toe-walking. These stretching exercises can help to loosen them. 

Heel hangs

• Stand with your toes on the edge of a step, holding onto a sturdy surface for support
• Gently drop both heels down so that they are lower than the step until your feel a stretch in your calf muscles
• Hold for 30 seconds and repeat 2 to 3 times

Calf stretch

• Stand facing a wall or a table for support
• Step one foot back, make sure both feet are facing towards the wall and not out to the side
• Keep the knee of your back leg straight and your heel on the floor
• Gently lean forwards until you can feel a stretch in your calf muscle
• Hold for 30 seconds and repeat 2 to 3 times with each leg

Walking on heels

• Practise walking on your heels, keeping your toes off the floor the whole time

When to ask for more help

If your child is having frequent or severe pain, please contact your GP practice. They may refer you to physiotherapy referral for the following problems:

• If your child cannot put their heels on the floor when standing because of tightness in their calf muscles
• If your child's walking pattern is uneven (e.g. they are only toe walking on one side)

What is posture?

Posture is the way we position and hold ourselves when lying, sitting and standing.

When looking at someone's back from the side it has two natural curves. These curves start from the base of the neck to the middle of the back, then out again at the base of the spine.

Good posture is where your child holds their position correctly with their spine being straight.

It is important to keep a good posture as this puts less strain on your child's joints and muscles. This lowers the risk of back pain or stiffness.

Poor posture is where your child does not position and hold themselves correctly. This can put extra strain on their bodies and lead to pain and stiffness. If your child is able to change their position, their posture can be corrected. If they can't change their posture it can affect how they move.

What do good and poor posture look like?

Good posture - standing

• Chin is not poking out
• Shoulders are back and down
• Back is straight with weight evenly distributed
• Knees are 'soft' - they have a slight bend
• Bottom is tucked in

Poor posture - standing

• Chin is poking out
• Shoulders are rounded
• Back is rounded with weight coming forward
• Knees are 'hyperextended' - they are straighter beyond normal limit
• Bottom is sticking out

Good posture - sitting

• Chin is not poking out
• Shoulders are back and down
• Back is straight with weight evenly distributed
• Hips and knees are bent at 90 degrees
• Feet are flat on the floor 

Poor posture - sitting

• Chin is poking out
• Shoulders are rounded
• Back is rounded and not straight
• Legs are crossed
• Hips and knees are not bent at 90 degrees
• Feet are not flat on the floor 

What can I do to help? 

Carrying a school bag

• Never allow your child to carry a bag on one shoulder as it can make them tilt to one side
• We recommend a rucksack instead of a satchel. Using the straps of the rucksack can help evenly distribute the weight across your child's back and help them keep good posture. Make sure that straps are adjusted so the bag is in contact with your child's back and the top strap is in line with their shoulders
• Make sure the bag is not overfilled and too heavy to carry

Technology and screen time

Technology and screens are becoming more of a part of children's daily lives across all ages.

When using devices like computers, tablets, mobile phones and television, it is important for your child to be aware of their posture and not spend too much time in front of a screen.

Using screens for a long time can increase your child's risk of developing poor posture and potentially develop stiffness and pain.

Encourage your child to take regular rest breaks to avoid sitting with poor posture for too long.

General exercise like going outside to play, having a walk and doing something different helps to break the cycle of developing poor posture.

Good posture for using devices

Poor posture for using devices

Sitting at a desk

• Make sure the computer screen, desk and chair are at the right height for a good sitting posture
• Make sure your child's bottom is back against the chair and the chair is supporting the natural curves of their spine
• Encourage your child to change their position regularly and take rest breaks away from the computer screen

Everyday tasks

Be aware of your child's posture during everyday tasks such as brushing their teeth or reading a book. The more your child is aware of their posture, the more likely they are to make good posture a habit.

Here are some useful links to support your child's health and wellbeing in North Northamptonshire, county-wide and nationally. For health and wellbeing opportunities in West Northamptonshire, please visit the West Northamptonshire Council website.

North Northamptonshire parks

Northamptonshire Sport

Kids' sports and activities - NHS Healthier Families

North Northamptonshire swimming pools

Kidz Clubs - children's sports in Corby

Cerebral Palsy Sport

WheelPower wheelchair sport

LimbPower - living life without limbs: children's resources

Advice and support about children and young people - Mencap

What is good posture and why is it important?

Posture is the term used to describe the way someone holds their body in relation to gravity, movements include standing, sitting, moving or playing.

Key features of posture include:

• Head should be in a neutral position with eyes forward
• Shoulders should be relaxed and back
• Chest should be open
• Back should be in a natural position
• Core muscles should be engaged to support your back
• Hips should be even and held in a neutral position
• Knees should be straight but not locked
• Weight should be evenly distributed across both feet

Good posture will support a child's growth and development (bones, muscles, tendons, ligaments), breathing and circulation, reduce the risk of developing back and neck pain and will support a child's learning in the school environment.

What causes poor posture?

There are many causes for poor posture in children. These include:

• Sedentary behaviours and poor exercise tolerance
• Being overweight and low self confidence
• Carrying heavy school bags during the school day
• Inadequate seating in school or at home
• Too much screen time

What can I do to help?

1. School bags

Encourage children to follow this advice when carrying a school bag:

Backpacks

• Use both straps on the backpack so weight is even over both sides of the body, keeping the body symmetrical
• Adjust both straps to they are equal in length
• Ensure both straps are adjusted so the top of the backpack is in line with the shoulders
• Pack the bag with the heaviest items at the bottom of the bag first
• Try not to overload the bag with too much weight - for example, make use of lockers or only take the books that are needed for that day and leave the rest at home
• Try to keep water bottles stored in the main compartment of the bag rather than the side pocket as this can create an uneven weight

Single-strap bags

• Encourage children to carry a single strap bag across the body, not over one shoulder
• Children should regularly swap sides

2. Technology

• Try to reduce screen time as much as possible
• Encourage children to change positions regularly by having movement breaks
• Try to encourage children to take part in active hobbies which will improve strength resulting in improved posture when spending time on screens

3. Sitting at a desk

• When sitting in a chair children's feet should touch the floor or be raised on a step
• Ensure chairs have a back rest and ask children to sit with their bottom as far back in the chair as they are able
• Elbows should be at 90 degree angles when sitting at a desk and knees should be able to fit under the desk comfortably
• If using a screen the top of the screen should be at eye level

Exercises for good posture

To improve children's posture encourage them to complete the following exercises on a daily basis.

1. Bridge

[IMAGE FROM DCD SECTION]

This exercise will strengthen the core (tummy) and glutes (bottom), which are essential for good posture.

• Lie on your back with knees bent and feet flat on floor
• Feet should be hip-width apart
• Keep your arms by your sides on the floor or cross them over your chest
• Keep your tummy muscles tight
• Lift your hips up off the floor to form a straight line from knees to shoulders
• Hold this position for 3 to 5 seconds
• Lower and repeat 10 times

2. Cat/Cow  

This exercise will help build flexibility in the upper body and spine, improving posture.

• Start on your hands and knees
• Ensure your hands are under your shoulders and your knees are under your hips in a table position
• Relax your tummy down, lifting your chest and tailbone up
• Look up with your head (Cow position)
• Change from this position into the Cat position
• Bring in your chin to your chest, round your spine up and pull your tailbone under
• Alternate between the two positions, holding for 5 to 10 seconds each

3. Superman

This exercise will improve lower back strength, reducing the risk of developing lower back pain. It will also strengthen the back of the legs (hamstrings), bottom (glutes) and tummy (core) muscles.

• Lie face down on the floor with legs out together and kept straight and arms above your head
• Lift your arms, chest and legs up off the floor together
• Maintain a neutral neck position by looking down at the floor
• Hold for 3 to 5 seconds
• Keep the movement smooth and lift up to a comfortable position
• Repeat 10 times

4. Wall press-ups

A wall press-up will strengthen your chest, shoulders, arms and tummy muscles - all of which support good posture.

• Facing a wall, place both hands flat against the wall at shoulder height and width apart
• Stand with both feet hip width apart
• Bend your elbow, moving your chest towards the wall and keeping your body straight
• Push back through your hands away from the wall to return to the starting position
• Repeat 10 times

More information

• Managing posture - information for parents and carers
• Posture Exercises for Kids - The OT Toolbox
• Healthy Working: MOVE - free online posture resources
• Choosing the right school bag - information for parents and carers
• Choosing footwear for children - information for parents and carers

For information about referrals to the Children's Physiotherapy Service in North Northamptonshire, please contact our Referral Management Centre

Referral Management Centre

Referrals can be made by any healthcare or educational professional including health visitors, GPs, paediatricians, consultants, therapists, special educational needs co-ordinators (SENCO), teachers.

Please note: We only see primary school aged children with musculoskeletal problems in North Northamptonshire. Secondary school aged children are seen by the Adult Physiotherapy team. Primary school aged children with musculoskeletal problems in West Northamptonshire are seen by Northampton General Hospital.