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Hip rotation degrees, intoeing problem, and sitting habits in nursery school children: an analysis of 1,134 cases.
Altınel L, Köse KC, Aksoy Y, Işık C, Erğan V, Ozdemir A. Acta Orthop Traumatol Turc. 2007;41(3):190-194.
Quote:
OBJECTIVES: We investigated hip rotation degrees, frequency of intoeing problems, and sitting habits in nursery school children and the relationship between these parameters.
METHODS: The study included 1,134 children (612 boys, 522 girls), aged between three to six years, attending 26 nursery schools in the central area of Afyon. First, informed consent was obtained from the parents and a questionnaire was administered about demographic data and sitting habits of the children. Then, the children were examined in lower underwear. Foot progression angles were determined and progression to midline during walking was evaluated as intoeing. Internal and external rotation degrees of the hips were measured using a goniometer in prone and supine positions.
RESULTS: In girls, internal rotation of the hip was nearly 13 degrees greater in the prone position, and 9 degrees greater in the supine position compared to those of the boys. Intoeing was detected in 67 children (5.9%), 76.1% being bilateral. The girl-to-boy ratio was 2.4/1. Intoeing problem originated from the femur in 74.6%, and from the tibia in 25.4%. Compared to normal children, intoeing was associated with a greater internal rotation and a smaller external rotation of the hip. Overall, 36.7% had a crossed-leg sitting habit, and 63.3% had a television sitting habit. The latter was more frequent in intoeing children (p=0.001).
CONCLUSION: Although hip rotation degrees in our study were similar to those reported in the literature, higher hip internal rotation degrees were found especially in girls. Television sitting which is a frequently preferred position among nursery school children was significantly prevalent in intoeing children.
This is definitely something I have noticed with children who intoe when walking. When speaking to parents about sitting posture the children always tend to W sit which is a big no no.
I have used gait plates with mixed results in some of the older children who intoe. I would be intersted to hear other peoples experiences with gait plates.
This is definitely something I have noticed with children who intoe when walking. When speaking to parents about sitting posture the children always tend to W sit which is a big no no.
BUT, is sitting in the W position part of the pathomechanical aetiology of this or do they just sit that way as its easier for them to sit that way?
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I have used gait plates with mixed results in some of the older children who intoe. I would be intersted to hear other peoples experiences with gait plates.
BUT, is sitting in the W position part of the pathomechanical aetiology of this or do they just sit that way as its easier for them to sit that way?
Ronald Valmassy, DPM, who taught our courses at CCPM on podopediatrics, and who was the Chairman of the Biomechanics Department at CCPM during my student and biomechanics fellowship years, taught us that the child with an intoeing problem that sat with the feet and legs positioned along the lateral border of their thighs ("W" style or "television sitting"??) did so because it was a more comfortable way to sit due to their restricted external range of motion in their hips. He also encouraged teaching the parents to have the child sit "Indian style" or "cross-legged" which would tend to gradually increase the external range of motion of the hip in the child whereas sitting "W" style would tend to reinforce the internal femoral position. In additon, I tell the parents to encourage roller skating and/or in-line skating in their intoed children which will force them to externally rotate their hips and hopefully also stretch out some of the the soft tissues elements that cross the hip and that may be partially responsible for their intoed position during gait.
__________________
Sincerely,
Kevin
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
About 29 years ago, when I was a clinician in the Podopediatric clinic at OCPM (where we had 40 patient visits/day), I put together the pieces of the puzzle of internal femoral position.
Children at about 6 months of age have a sitting phase that is between scooting and crawling which lasts for about 2 weeks. Some children miss this phase, so they do not learn to sit. Instead they kneel exclusively which eventually results in the W position. (The first article on the sitting positions was by Fitzhugh in the early 1900's). This position results in the internal rotation of the femur.
More importantly, during the sitting position, certain reflexes are developed using the hips as a focal point for balance. So when the child starts to walk, and they feel like they are going to fall, they stick out their bun and land on it. Children that miss this, will develop balance reflexes around the knee, so when they become unstable they bend their knee and land forwards on their knees or backwards on their heads. This is the clumsiness that we see with these patients.
In addition to gait plates, and stretching exercises, balance exercises help with the clumsiness. The balance exercise is to have the child sit on the floor, and roll a ball to him, and then have him roll it back. Make sure that the ball is rolled to one side and then the other.
There is also the situation where the child takes an excessively long time to learn to walk, for some reason they spend a greater percentage of time kneeling rather than sitting. These children will usually self resolve.
I have seen children with significant joint laxity problems who do find this the most comfortable way to sit. I have even come across a child recently who sleeps with the legs in a W position. The parents are normally unaware about the difficulties that this creates and the effect it has on gait.
The chicken or egg situation, I would imagine that the hip joint may be set in an excessively internaly rotated position at birth. The child may find W sitting more comfortable and stable and it is possibly from this position that the internal rotation worsens.
OK, I am a dummy, but I cannot help thinking that the significance of this research will emerge when the children are aged greater than 6 years. My hypothesis is the "cause and effect" of sitting, internal rotation and in-toeing will deminish as children assume normal activity with age and growth (current lifestyle issues of the young being an important parameter).
Sitting habits in children
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