Hyperextension is a fairly common fault, usually associated with lack of firm ligamentous support. It tends to disappear as the ligaments tighten, but if it persists as a postural habit, a corrective effort should be made by postural training. (See page 81.)
A degree of knock-knee is common in children and usually first observed when the child begins to stand.
The height and build of the child must be taken into consideration when judging whether the deviation is a fault, but in general, it may be said that a fault exists if the ankles are more than 2 inches apart when the knees are touching. (See p. 81.) The knock-knee condition should show definite improvement and be nonexistent by the age of 6 or 7 years. (See Figure A, p. 100.)
In some cases, knock-kneed children may stand with one knee slightly flexed and the other slightly hyperex-tended so that the knees overlap to keep the feet together. Knock-knees may persist, and in adults, it is more prevalent among women than among men.
Records of the change in the degree of knock-knee can be kept by drawing an outline of the legs on paper while the child is standing with the knees touching each other. Mild to moderate knock-knee conditions are usually treated by shoe corrections, but bracing or even surgery may be required for the more severe cases.
Bowlegs is an alignment fault in which the knees are separated when the feet are together. It may be a postural or a structural fault. Postural bowing is a deviation associated with knee hyperextension and hip medial rotation. (See p. 82.) As the posterior ligaments tighten and hyperextension decreases, this type of fault tends to become less pronounced. If it persists as a postural habit, the child should be given instruction to correct the alignment faults. This fault is less easy to correct as the individual approaches maturity, although some degree of correction may be obtained in young adults who are very flexible.
Postural bowlegs may be compensatory for knock-knees. If a knock-kneed child stands with the legs thrust back into hyperextension, the resultant postural bowing of the legs will let the feet be brought together without having the knees overlap. In this position, the knock-knee fault may be obscured, but it will become obvious if the legs are brought into a neutral position of knee extension. (See p. 83.)
Postural bowing usually disappears when an individual is recumbent, whereas structural bowing does not. Structural bowing requires early treatment; in later stages, it may require surgery.
Drawings to record the change in structural bowlegs can be made while the child is in a back-lying position with the feet together. Because postural bowing shows up only in standing, the drawing must be made in standing. This can be done by placing the paper on a wall behind the standing child. (See p. 81.)
Figure A shows the posture of an 18-month-old child. The flexed hips and wide stance suggest the uncertain balance associated with this age. Although it is not very evident in the picture, the subject had a mild degree of knock-knees. (This deviation gradually decreased without any corrective measures, and by the age of 6 years, the child's legs were in good alignment.) The development of the longitudinal arch is very good for a child of this age.
Figure B shows a 7-year-old child who has very good posture for his age.
Figure C shows poor posture in a 6-year-old child. There is forward head, kyphosis, depressed chest and a tendency toward sway-back posture. Prominence of the scapulae is evident in side view.
Figure D shows marked lordosis in an 8-year-old child. A corset to hold the back in good alignment and to support the abdomen is needed, along with therapeutic exercises when alignment is this faulty.
Beginning in infancy, there is a persistent imbalance between the strength of the anterior and posterior muscles of the trunk and neck. The greater strength of the posterior muscles permits the child to raise the head and trunk backward long before being able to raise either one forward without assistance. Although the abdominal and neck flexor muscles never match the strength of their opponents, their relative strength is much greater in the adult than in the child. Thus, in this regard, individuals should not be expected to conform to the adult standard until they are approaching maturity.
It is characteristic of small children to have a protruding abdomen. For the most part, the contour of the abdominal wall changes gradually, but a noticeable change occurs at approximately 10 to 12 years of age, when the waistline becomes relatively smaller and the abdomen no longer protrudes.
The posture of the back varies somewhat with the age of the child. A small child may stand bent slightly-forward at the hips and with the feet apart for better balance (see Figure A). Children of early school age appear to have a typical deviation of the upper back in which the shoulder blades are quite prominent. Beginning at approximately 9 years of age, there seems to be a tendency for increased forward curve or lordosis of the low back. The deviations should become less pronounced as the child grows older (19,22).
Normal range of motion for lumbar flexion and extension has been shown to decrease with increasing age in both children and adults (23-2 5).
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