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W-Sitting: Why There Are Conflicting Opinions and Why Your Child’s Therapist Cares So Much

If you have a child who loves that “w” position while sitting on the ground, chances are you’ve either W-Sittingcorrected them yourself or heard someone else direct them to sit “criss-cross” or “fix their feet.” The challenge, however, is understanding why there are so many conflicting opinions on the matter. Is it really that bad? There was recently an article on Today.com titled “Why W-sitting is really not so bad for kids, after all.” Two orthopedic surgeons weigh-in on how w-sitting is a position that children sit in because their anatomy allows it, it feels comfortable, and when you should be concerned about it.

As a physical therapist, I felt it was important to address this article in a way other than pointing out our profession’s fears of w-sitting, which can be found in “What’s Wrong With W-Sitting?” and “W-Sitting and Your Child’s Growth.

I want to acknowledge that, to some extent, I agree with this article. The anatomy, angles, and alignment of a child’s leg bones changes extensively throughout young childhood. Children do have more flexibility which can make w-sitting often a preferred position. And most often, prolonged w-sitting will not progress to the point of being a surgical issue. If your child only sometimes sits in this position and can easily move into and out of it, it is probably not a big deal. (Please note: as with the article above, I am generalizing this blog post. I am just discussing w-sitting and am not going to address the impairments that often result in w-sitting: low muscle tone, decreased core strength, excessive femoral anteversion, etc. Please speak with your pediatrician or see a physical therapist if you have concerns with your child’s development. Sometimes w-sitting is the result of other things going on which can impact their gross motor success.)

So—why do people like myself lovingly attempt to annoy your child out of w-sitting? It is not that physical therapists do not acknowledge the natural development of their anatomy and what feels best. It is that we are bombarded throughout our schooling, clinical experiences, and our entire professional careers of what occurs when muscles are not aligned “within normal limits.” For pediatric therapists, we are given this unique and wonderful opportunity to work with bodies who are just beginning their development, moldable, and are constantly changing to assess and promote optimal alignment- a strong foundation for a strong life. For me, it does not matter if your child is coming to me for shoulder pain- I am going to correct how their legs are positioned while they are sitting; posture is like the “eat your vegetables” and “brush your teeth” of my profession. I want each child’s physical growth and development to occur on top of the best possible foundation. Just as pediatricians and dentists want to establish healthy habits, routines, and lifestyles for short and long term health, physical therapists want to encourage the best posture for your child so that they will not be limited or suffer from the painful conditions or injuries that result from poor alignment and muscle imbalances.

An easy example to compare w-sitting to is poor sitting or standing posture. Almost all adults can relate to the neck and back pain that can occur from poor posture. In addition, poor posture can contribute to nerve impingement, shoulder pain/injury, jaw pain, sciatica, etc. This pain did not happen as your parents/grandparents/teachers/caregivers encouraged you to “sit up straight” or “stop slouching”—it happened later as the bad movement patterns continued and the muscle imbalances grew worse. In my mind, w-sitting is the same. It may resolve and you may never develop pain, or these movement patterns and muscle imbalances may progress; when you look at the alignment and muscle activation that w-sitting encourages, physical therapists think of the following (to name a few): patellofemoral syndrome, hip pain from impingement, flat feet and foot pain, knee osteoarthritis, and increased risk of knee and ankle injuries.

As the parent, how you use information is up to you. As a physical therapist, I will continue to kindly request that each child sits “criss-cross applesauce” for their current AND future development.

NSPT offers services in Bucktown, Evanston, Highland Park, Lincolnwood, Glenview, Lake Bluff, Des Plaines, Hinsdale and Milwaukee. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates!

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w sitting

What’s Wrong With W-Sitting?

Parents bring their kids in for a physical therapy evaluation for many different reasons, from toe-walking to neuromuscular conditions to decreased ability to keep up with peers. Regardless of the diagnosis, about 25% of my clients under 5 also present with w-sitting. When brought to the attention of the parents, typical responses range from, “I’ve never noticed that before; is that bad?” to“I w-sat as a child, and I turned out fine.” Physical therapists will most always work to correct this sitting posture and some of the underlying impairments. Here are some of the reasons w-sitting is not healthy for children.

What’s wrong with w-sitting?

  • Decreased Core Activation – Due to the wide base of support afforded with w-sitting, less coreWhat's Wrong With W-Sitting? muscle (trunk extensors and abdominals) activation is required to maintain position. This wide base of support also limits the child’s need to weight shift from side to side during play, resulting in decreased use of lateral and posterior balance reactions.
  • Poor Posture – “W”-sitting encourages excessive posterior pelvic tilt, which can result in slouching. Excessive hunching over results in minimal trunk extensor activation. This creates a cycle of poor sitting posture due to muscle weakness, resulting in poor sitting posture.
  • Pigeon-Toed (In-Toeing) Walking Pattern – Increased hip internal range of motion, decreased hip external range of motion, and hip abductor weakness can contribute to an in-toeing gait pattern. It should be noted, however, that some in-toeing gait can be attributed to femoral anteversion.
  • Decreased Trunk Rotation – Poor trunk extension due to posterior pelvic tilt can limit ability to turn trunk from side to side. This is important because decreased trunk rotation during play can impair the body’s ability to integrate left and right sides of the body, leading to decreased coordination
  • Delayed or Impaired Fine Motor Development – This delay is usually due to a combination of the impairments already mentioned above, such as decreased trunk rotation and poor core strength. These impairments can lead to decreased play involving midline crossing and poor development of bilateral coordination. High level fine motor tasks, such as fastening a button, requires a coordinated effort between left and right hands.

Click here to read more about w-sitting and the young child.

To help your child who ”w”-sits, please contact one of our physical therapists at North Shore Pediatric Therapy for a free screen.

NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates today!

signs a child may need PT at school

Signs at School a Child May Need Physical Therapy

Teachers can be wonderful allies to the healthcare field. They spend up to 8 hours a day observing and helping children. Often times, they are the first to notice concerning signs, and when given the right tools, can direct parents where to go to get their children the help they need. Here a few signs teachers can look out for that would warrant a physical therapy screen.

5 Signs at School a Child May Need Physical Therapy:

  1. Unable to keep up with peers during recess or P.E – This may present as a child whosigns a child may need PT at school doesn’t follow friends onto the jungle gym or pulls themselves out of games of tag. A child would benefit from a physical therapy screen if they are unable to perform a jumping jack or skip forward.
  2. “W”-sits or props onto arm when sitting criss-cross – A child who sits in a “w” position or props onto their arm when sitting on the floor may present with weak core muscles. Weak core muscles result in a poor foundation for other fine motor skills, and may present in sloppy or slow handwriting, poor cutting skills, or decreased independence in self care tasks.
  3. Places both feet onto step when going up and down stairs – A child should be able to go up and down a set of stairs, without holding onto a handrail, by the age of 4. A child who presents difficulty, or immature form, during a stair task, may have lower extremity weakness, impaired balance, or developmental coordination disorder.
  4. Toe-Walking Toe-walking or early heel rise during gait (which may looking like bouncing while walking) can arise from a multitude of impairments including muscle tightness, core weakness, impaired balance, etc. Prolonged toe-walking may also result in any of the above, excessive falls, or muscle contractures.
  5. Poor sitting posture at desk – Poor posture may be a sign of decreased endurance of trunk muscles. Trunk weakness may also result in a poor foundation for fine motor skills, resulting in poor handwriting, decreased grasping ability, or decreased independence in self care tasks.

Click here to view our gross motor milestones infographic!

NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates today!

boy with truck

W-sitting and the Young Child

Chances are, if you know what W-sitting is, you or someone you know sits just like that. Occupational, physical, and developmental therapists often express their disapproval whenever they see a child sit in this position. More and more parents are catching on to the fact that this is a posture to keep their children out of. The most common questions they have are 1) why is it so bad? and 2) what is there to do to help change this habit?

What is W-sitting?

Many children with low muscle tone, decreased core strength, increased joint laxity, or hip instability, will sit and play with their knees together, bottom on the floor, and feet out to both sides.

Why do some children like to sit this way?

Simply put, a young child’s joint and bone structures will allow them to sit in this position. Certain medical diagnoses, such as Down syndrome and femoral anteversion, are often associated with this preferred sitting posture. In this position, children are more comfortable and don’t have to work as hard to hold their trunks upright. Instead, they are spreading their lower limbs out over a wider base of support, thus relying on their joint structures and not their muscles, to hold them up to play.

Why do therapists recommend against it?

While the knees together and feet out position is fine as a transitional position, our hips are not designed to be in the W-sitting position for a long period of time. Prolonged sitting in this position places significant stress on inner hip muscles and joint structures. The young musculoskeletal system will then develop in such a way that just creates more and more instability of the hips. If a child gets used to sitting and playing in this position, weaknesses and orthopedic misalignments will only travel up and down the musculoskeletal chain. Children who W-sit well into their preschool to school years often experience decreased trunk strength, poor attention, in-toeing, poor posture, clumsy coordination, and frequent loss of balance.

How to help a child out of the position?

Many parents would tell me that they are at their wits’ end, constantly instructing their child out of the W-sit position.  While repetition and consistency are key, habits are difficult to change, especially with verbal reprimands alone. Change things up and give your child other sitting postures as options:

1) The most common alternate position is with feet crossed and knees apart. “Criss-cross applesauce” is what we usually tell children when we see them W-sitting. They respond well to this simple cue.

2) Side-sitting is a great alternative if sitting with knees out is too difficult. In side-sitting, both knees are bent, weight is shifted to one hip, and both feet are out to the same side. This takes away stress from the hip joint structures, allowing for easy transitions in and out of sitting.

3) Long sitting with feet forward and back supported is a great way to stretch out those hamstrings and keep hip/knee joints in neutral.

4) If a child has a hard time sitting and playing, I let them kneel with their feet tucked together under their bottom. As long as they don’t slowly shift back into the W-shape, kneeling is a great position to strength their hip and core muscles.

5) Half-kneeling with one foot tucked and the other foot flat on the ground will keep the hips in neutral alignment. In this position, muscles will be active and hip joint structures will not be put under damaging stress.

6) Finally, squatting or sitting on a low chair will also help keep a child out of W-sit during play.

If you are still looking for ways to keep your child out of this injurious habit, talk to a therapist. Physical therapists will come up with ideas and exercises tailored to each individual child and find the best ways to improve his or her posture and alignment.




10 Signs at School Suggesting a Student May Benefit from Physical Therapy

Children develop and improve their gross motor skills significantly during their early school years, between three and ten years of age. A lot of gross motor development occurs at school while playing at recess or doing activities in gym class. School offers the opportunity to recognize if a child needs extra assistance from a physical therapist in expanding or improving their gross motor skills.

Physical therapist treats child

Here are some tips for teachers that will help determine if a child would benefit from physical therapy:

  1. The child prefers to sit and play instead of run or participate in gross motor activities during recess or gym class.
  2. The child has difficulty jumping, skipping, or galloping when compared to their peers.
  3. The child has an atypical gait pattern (for example, they walk on their toes or they are “knock-kneed”)
  4. The child prefers to w-sit (with their knees bent, feet by their bottom, and bottom on the floor) instead of crossed-legged on the floor.
  5. The child frequently trips, falls, or bumps into objects.
  6. When walking up and down the stairs, the child does not alternate their feet, instead placing both feet on each step.
  7. The child is unable to kick a soccer ball.
  8. The child is unable to catch or throw a playground ball.
  9. The child runs significantly slower than his peers or has difficulty running for more than one minute.
  10. The child complains of pain or tightness in their ankles, knees, hips, or back.

If you see any of these characteristics in children at school, they may benefit from a physical therapy evaluation. Without fully developed gross motor skills, a child is going to have difficulties keeping up with their peers during recess or gym class. It will also affect their ability to participate in gross motor games and sports. Also, it is important to note that many children will exhibit the above behaviors and may or may not require physical therapy (PT) intervention therefore it is important to consult with a PT first.

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Low Muscle Tone Revealed

Muscle tone refers to the muscle’s ability to sustain a contraction. It is different than muscle strength, which refers the muscles’ power. A child with low muscle tone is often observed to sit with a slouched posture, may have difficulty holding their head upright when sitting at a desk and may be observed to prop their head up with their hand. Mother and child with balance ballOther observations include having difficulty sitting for extended periods of time, particularly without back support or w-sitting, where the legs are splayed out to the side in the shape of a ‘w’ when sitting on the ground.

Muscle tone cannot actually be changed, though through occupational or physical therapy, muscles will become stronger and compensate for the low muscle tone to help support your child through his/her daily tasks.

Here are five activities to help address strength, endurance and low muscle tone at home and in the community:

  1. At the park, have your child lie on his belly on the slide and pull himself up the slide using only his arms.
  2. Complete yoga poses that work on balance and core strength, like down dog or plank.
  3. Using a weighted ball or BOSU ball, have your child lift the ball overhead with both arms, lower it to the floor and balance his hands on the ball while he jumps his feet backwards into a plank position. Repeat these steps 10 times.
  4. Have your child lie on his back on the floor. With his legs raised off the floor and knees bent, have him weave a ball between his legs.
  5. Encourage your child to use the monkey bars or hang from the zip-line when at the park.

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