Children’s Physiotherapy Referral Criteria (Warwickshire)

We accept referrals for Children and Young People aged 0-18 (19 if in special education), with a Warwickshire GP who have a physical need that physiotherapy can help with, including a:

• Movement disorder including altered gait, development, or co-ordination difficulties
• Neurological impairment due to abnormal muscle tone
• Neuro-muscular condition
• Musculoskeletal condition (0-10 year olds)

A child can be referred to us if any of the above conditions have an impact on their development, functional ability or causes pain

Exclusion criteria:

• Respiratory conditions as a primary diagnosis
• Primary school age children requiring an assessment for DCD who have not completed a motor skills programme in school
• Normal variants (unless indicated – see below)

NORMAL VARIANTS – WHEN TO REFER

Young children often present with the following as “normal sequences” of development

They should always be symmetrical, non-restrictive and pain free

These are all normal variants and will resolve naturally as the child grows

Children with these presentations need to develop their movement skills through everyday play activities

Bow legs

This is when there is a small gap between the child’s knees when standing with their feet together

Children are born bow legged and this should be improving by around 2 years of age

Consider referral if:

There is associated pain in the lower limbs

The problem is persistent or asymmetrical

The child has evidence of underlying metabolic disease (e.g. Rickets)

Referral is not necessary if:

• The child is under 2 with no other symptoms
• The measurement is less than 6cm between the inner aspect of the knees

Knock knees

In young children a small gap between the child’s ankles when standing with their knees together is normal

Between the ages of 2-4 a gap between the ankles is normal and this should resolve by the age of 6

Consider referral if:

• The problem is associated with pain in the lower limbs
• The problem is asymmetrical

Referral is not necessary if:

• The child is under the age of six and the problem does not result in any pain
• The measurement between the ankles is less than 8cm

Curly toes

Physiotherapy or orthotics (insoles) will not help to correct this

Surgery may be indicated but not until children are over 4 years old

In-Toeing

In-toeing can also be referred to as “pigeon toe’d” and is when a child walks with their feet turning inwards

It is a part of normal development for many toddlers when just learning to walk and may become more noticeable between 2-5 years old, resolving by around the age of 10 years

During this period of in-toeing the child may tend to trip and fall more than their peer group, it is unlikely to cause long term problems

Physiotherapy or insoles will not help to speed up the natural correction

Consider referral if:

• There is pain, a limp or evidence of joint swelling
• The tripping and falling is significant and not improving with age
• There are neurological concerns
• The problem is asymmetrical

*Link to APCP in-toeing leaflet

Out-Toeing

This is when a child’s feet are turned outwards when the child is standing, walking and running

This usually resolves spontaneously by 4 years of age and referral to physiotherapy is not indicated

Consider referral if:

• Recent onset out-toeing in a teenager – this may be serious and an indication of Slipped Upper Femoral Epiphysis
• If the child has abnormalities on examination in terms of pain and range of movement, even if bilateral

Flat feet

It is normal for children to have flat feet due to the presence of fatty tissue on the soles of their feet

The arches in feet may not develop until 6 years old

Consider referral if:

• The child is having significant functional difficulties
• There are signs of abnormal pressure on the skin of the foot
• The arch is not seen when the child stands on tip-toe or when the big toe is passively extended
• The foot feels stiff
• If the child is getting pain in their legs or feet

Referral is not necessary if:

• The child is under 4 years of age, with no other symptoms

*Link to APCP flat feet leaflet

Joint Laxity/ Hypermobility

2 Joint Laxity is a common feature of normal development in healthy children

Children with increased flexibility need to improve their motor skills through daily participation in age appropriate physical activities

Consider referral if:

• The child has any pain or functional difficulties
• Suspicion of inherited collagen syndromes
• Asymmetrical joint involvement
• Inflammatory joint or muscle disease is suspected
• Recurrent dislocations

*Link to APCP leaflet on symptomatic hypermobility

Tip-toe walking

Toe walking is common in young children when they are learning to stand and walk

Consider referral if:

• Toe-walking is persistent beyond 2 years
• There is associated developmental delay
• The child is unable to squat or stand with their heels on the floor
• The child is over 3 years and is unable to get up from the floor without using their hands
• The toe walking is asymmetrical

Referral is not necessary if:

• The toe walking is intermittent
• The child is able to squat to play whilst keeping their heels on the floor

SIGNPOSTING TO OTHER SERVICES

Referrals for children and young people with needs that cannot be met by the Children’s Community Physiotherapy Service should be sent to the services detailed below:

• Referrals for children aged 11 and over with a musculoskeletal condition should be sent directly to the local Adult Out-Patient Physiotherapy Department
• Referral enquires for orthotic footwear/helmet assessment should be made to the local Appliance Department
• Referrals for Wheelchairs – should be sent directly to Warwickshire Wheelchair Services
• Referrals for upper limb splints and fine motor skills only should be sent to the local Occupational Therapy Service

WHO CAN REFER?

• GP’s
• Consultants and Community Paediatricians
• Healthcare Professionals
• SEND Co-Educational Psychologists ONLY if related to motor skills

HOW CAN I REFER?

The Physiotherapy service accepts referrals by:

• Post / email referral details using referral form to:

South: southchildrensphysiotherapy@swft.nhs.uk

North: northchildrensphysiotherapy@swft.nhs.uk

East: eastchildrensphysiotherapy@swft.nhs.uk