R E S E A R C H R E P O R T

Genu Valgum and Flat Feet in

Children With Healthy and
Excessive Body Weight
Agnieszka Jankowicz-Szymanska, PhD; Edyta Mikolajczyk, PhD
Section of Physical Education (Dr Jankowicz-Szymanska), Institute of Health Sciences, State Higher Vocational School,
Tarnow, Poland; and Section of Kinesitherapy (Dr Mikolajczyk), Department of Physiotherapy, University School of
Physical Education, Krakow, Poland.

Purpose: To examine the relationship between obesity, genu valgum, and flat feet in children, and find
practical implications for therapeutic interventions. Methods: A total of 1364 children aged 37 years took
part in the research. Their body mass index was calculated and their weight status described. Participants
knee alignment was assessed by measuring the intermalleolar distance in the standing position with the
knees in contact. The height of the longitudinal arch of each foot was measured using Clarkes angle.
Results: The prevalence of overweight and obesity increased with age. Reduction of intermalleolar distance
and increased longitudinal arch of the foot, characteristic of typical growth and development, were observed.
Genu valgum was more common in children who were overweight. Significant correlations among body mass
index, intermalleolar distance, and Clarkes angle (P < .05) were also discovered. Conclusion: Children who
are overweight or demonstrate obesity are more likely to develop genu valgum and flat feet. (Pediatr Phys
Ther 2016;28:200206) Key words: child, flat feet, genu valgum, obesity, overweight, Poland

INTRODUCTION valgum,1317 but also between lowered arches of the

Children are born with genu varum (bow legs) that
remains until approximately the second year of age and
evolves into physiological genu valgum (knock knees).1,2
In 7-year-old children, the alignment of the knees is usu-
ally neutral, as in adults.3 The arches of the feet also change
with age. The medial longitudinal arch develops between
the second and third years of age and systematically in-
creases in height until school age.1 However, the collapse
of the natural arches of the feet and genu valgum often
persist in ontogenesis and can negatively affect the quality
of gait,4,5 the risk of injuries,6 and prevalence of mus-
culoskeletal conditions (eg, dislocation of the patella,7,8
osteoarthritis, 9 pain10 ).
Some interdependencies are thought to exist not
only between excessive weight, flat feet,1,11,12 and genu
0898-5669/110/2802-0200
Pediatric Physical Therapy
Copyright  C 2016 Wolters Kluwer Health, Inc. and Section on
feet and genu valgum.4 Pediatric care, understood as
the medical treatment of the physical and psychological
development of children, attaches great significance
to preventing obesity. Corrective exercises to improve
posture are commonly introduced into kindergartens and
schools in Poland. However, overweight, obesity, and
postural defects are treated as separate problems. The
purpose of this study was to examine the relationships
between flat feet, genu valgum, and excessive body weight
in children aged 3 to 7 years. This age range seemed to
the authors the most suitable, because during that period
significant developmental changes are seen in the medial
longitudinal arch and in knee alignment. The authors
wanted to draw attention to the need for a comprehensive
look at the prevention of musculoskeletal defects, which
requires a simultaneous implementation of specialist
exercises correcting body posture and encouragement of
a more physically active lifestyle.

Pediatrics of the American Physical Therapy Association

METHODS
Correspondence: Agnieszka Jankowicz-Szymanska, PhD, Instytut
Ochrony Zdrowia PWSZ, ul. A. Mickiewicza 8, 33-100 Tarnow, Poland Participants
(jankowiczszymanska@gmail.com).
The authors declare no conflicts of interest. A total of 1377 children aged 3 to 7 years, attending
DOI: 10.1097/PEP.0000000000000246
12 public kindergartens and the first 4 grades of a
randomly selected primary school in the south of Poland,
200 Jankowicz-Szymanska and Mikolajczyk Pediatric Physical Therapy
Copyright 2016 Wolters Kluwer Health, Inc. and the Section on Pediatrics of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
took part in the research. All participants were divided into
5 age groups on the basis of their calendar age, that is, a
child was considered to be a 3-year-old if his or her age fell
between 2.51 and 3.5 years.
Seven children had genu varum (intercondylar dis-
tance measured with the medial malleoli in contact in the
standing position equaled more than 2.5 cm): one 5-year-
old girl, one 4-year-old boy, three 5-year-old boys, one
6-year-old boy, and one 7-year-old boy. They all had
healthy weight. Six of them developed appropriate arches
of the feet and 1 boy had flat feet (pes planus). Their mean
body height was 111.8 cm. One child with Perthes dis-
ease, 1 who had congenital fragility of the bones, 1 with
displacement of the hip at birth, and 3 children with a
diagnosed intellectual disability were excluded from the
study. The final sample included a total of 1364 children:
654 girls (48%) and 710 boys (52%).
The height of the arches of the feet was assessed by
means of a podoscope (CQ Elektronik System, Wisniowa,
Poland) equipped with computer software. During the
measurements, all participants stood with both feet on the
podoscope platform in their habitual positions. The height
of the longitudinal arch of the foot was given in Clarkes
angles (Figure 1). Points used to calculate Clarkes angle
were determined by the first author. Smaller Clarkes an-
gles indicated lower arches of the feet. All measurements
were taken once and the examination of each participant
lasted for approximately 5 minutes. The person in charge
of the examination described the position, which should be
assumed by the participant, and helped the children place
their feet properly on the podoscope. Participants did not
find it difficult to maintain a motionless position during
the measurement.

Procedure
The examination was conducted in the kindergartens
and the primary school (in the case of the 7-year-old
children) attended by the children. The measurements
were performed by an experienced physiotherapist (not
the author) in a well-lit and warm room (gymnastics hall
or a classroom), between 8:30 AM and 12:00 PM. Writ-
ten informed consent of participants parents and/or legal
guardians was obtained prior to the study and they were
informed about the date of the examination, so that they
could observe the sessions. Consent of the local Bioethics
Committee was also obtained.
All participants were measured undressed down to
their underwear. Body weight was measured on Tanita
scales (body composition analyzer bf-350; Tanita Corpo-
ration of America, Inc, Arlington Heights, Illinois) to an
accuracy of 0.1 kg, and body height by means of a cali-
brated anthropometer (ZPH Alumet No 010208, Warsaw,
Poland) in the standing position with the feet placed to-
gether and the line of sight directed horizontally straight
ahead with an upright head. The results were recorded in
centimeters (within 5 mm), which corresponded to a dis-
tance between the base and the highest point on the head
(vertex). The body mass index (BMI) (kg/m2 ) was calcu-
lated on the basis of the results obtained. Participants were
classified as healthy weight, overweight, or obese on the
basis of the standards from Cole et al.18
Genu valgum was assessed in the standing position
with the knees fully extended. The intermalleolar distance
(IMD) was measured to the nearest 0.5 cm with the medial
side of the knees in light contact using a spreading caliper
(ZPH Alumet No 030208, Warsaw, Poland). The method
described earlier was selected as it is an easy and reliable
way of gathering measures that did not require exposure
to any harmful radiation.1921 If the IMD was less than or
equal to 2 cm, the knee alignment was considered to be
correct. An IMD between 2.5 cm and 5 cm denoted slightly
valgus knees and above 5 cm referred to an increased valgus
knee alignment. Fig. 1. Clarkes angle (Cl) and gamma angle ( ).

Pediatric Physical Therapy Genu Valgum, Flat Feet, and Weight in Children 201
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Data Analysis
The results of the tests were entered into the database
and analyzed by means of Statistica v10 software. Means
and standard deviations were calculated. The normality of
the distribution was tested by the Shapiro-Wilk test. Dif-
ferences between groups were determined by means of the
factorial analysis of variance and Tukeys post hoc test (ad-
justed for unequal sample sizes, if needed). Correlations
between the variables were analyzed by means of Pearsons
correlation and the level of significance was established at
= .05.
RESULTS
The following differences between boys and girls were
found: boys in all age groups were slightly taller and heavier
than girls, and mean BMI values did not significantly differ
in girls and boys at the same age (Table 1). The height of
the longitudinal arch of the foot increased with age (greater
Clarkes angles), with the exception of 6-year-old girls who
had lower arches of the feet than 5-year-old girls. Girls in
all age groups had higher arches of the feet than boys of the
same age. In the case of 4- and 5-year-old children, those
differences were of statistical significance. Knee valgus was
greatest in the 3-year-old group and lowest in the 7-year-
old participants. No gender differences were found in any
age group.
According to the classification into 3 groups by weight
status (healthy weight, overweight, obesity), excessive
body weight (overweight or obesity) was most frequently
observed in the 6-year-old children (above 24% of the
age group) and in the 5-year-old children (17%), and it
was the least prevalent in the 3-year-old participants (5%)
(Table 2). Children with healthy and excessive weight var-
ied in terms of knee alignment in all age groups. The IMD
in each age group was the smallest in participants with
healthy weight, and IMD was greater in children with over-
weight and the greatest in boys and girls with obesity (the
greatest in 7-year-old children who were obese). Signifi-
cant differences in IMD were observed between children
with healthy weight and overweight in the case of 3-, 5-,
6-, and 7-year-old participants, and between children with
healthy weight and obesity in the case of 4-, 5-, 6-, and
7-year-old participants.
The arch of the foot expressed by Clarkes angle was
the highest in children with healthy weight, except for
the left foot in the 5-year-old children. In that age group,
Clarkes angles were greater by 0.29 in obese children than
in those with a healthy weight. Significant differences in
the longitudinal arch of the foot were discovered between

TABLE 1
Levels of Variables in Girls and Boys of Different Age Groups (Mean and Standard Deviation, Factorial ANOVA)

Age; Number of Observations Variable Girls Boys P

3-year-old children Body weight, kg 15.78 2.51 16.40 2.35 .99

n = 102; 7.5% of sample Body height, cm 100 6.81 102.71 6.24 .73
Girls, n = 57 BMI, kg/m2 15.51 1.40 15.49 1.15 .99
Boys, n = 45 Intermalleolar distance, cm 3.68 2.06 4.00 2.49 .99
Clarkes angleright foot, 34.36 12.72 28.97 13.59 .50
Clarkes angleleft foot, 34.40 12.72 27.60 13.13 .20
4-year-old children Body weight, kg 17.79 2.87 18.09 2.95 .99
n = 314; 23% of sample Body height, cm 107.14 6.04 108.05 6.03 .90
Girls, n = 159 BMI, kg/m2 15.44 1.54 15.44 1.66 .99
Boys, n = 155 Intermalleolar distance, cm 3.30 1.97 2.99 2.13 .95
Clarkes angleright foot, 36.35 11.77 29.97 13.67 .0004 a
Clarkes angleleft foot, 36.45 12.11 30.18 12.67 .0001a
5-year-old children Body weight, kg 19.16 3.01 19.66 2.52 .87
n = 403; 29.5% of sample Body height, cm 110.58 4.68 111.88 4.73 .33
Girls, n = 203 BMI, kg/m2 15.63 1.87 15.70 1.69 .99
Boys, n = 200 Intermalleolar distance, cm 2.72 1.97 2.83 2.04 .99
Clarkes angleright foot, 39.23 12.19 31.65 13.43 .00001a
Clarkes angleleft foot, 38.39 12.46 30.80 13.71 .00001a
6-year-old children Body weight, kg 22.42 3.64 22.91 3.95 .84
n = 468; 34% of sample Body height, cm 116.97 5.44 118.20 5.48 .32
Girls, n = 200 BMI, kg/m2 16.34 2.09 16.34 2.13 .00
Boys, n = 268 Intermalleolar distance, cm 3.06 2.24 2.92 2.38 .99
Clarkes angleright foot, 37.90 12.24 35.83 13.08 .77
Clarkes angleleft foot, 36.96 12.71 35.64 13.27 .98
7-year-old children Body weight, kg 23.54 3.40 25.50 5.11 .21
n = 77; 6% of sample Body height, cm 122.91 4.25 124.54 5.11 .95
Girls, n = 35 BMI, kg/m2 15.55 1.95 16.34 2.40 .71
Boys, n = 42 Intermalleolar distance, cm 2.45 1.88 2.60 2.67 .99
Clarkes angleright foot, 41.87 8.47 37.43 12.96 .88
Clarkes angleleft foot, 40.13 10.47 37.70 12.03 .63

Abbreviations: ANOVA, analysis of variance; BMI, body mass index.

a Statistically significant difference at P < .05.

202 Jankowicz-Szymanska and Mikolajczyk Pediatric Physical Therapy

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 TABLE 2
Comparison of Variables in Children Classified by Weight Status (Normal, Overweight, Obese) (Factorial ANOVA and Tukeys Post Hoc Test)

Age Variable Normal Weight Overweight Obese P

3-year-old children
Healthy, n = 97 Intermalleolar distance, cm 3.84 2.27 3.4 2.19 ... Healthy and overweight, P < .02a
Overweight, n = 5 Clarkes angleright foot, 32.17 13.36 28.26 13.28 ... Healthy and overweight, P = .99
Obese, n = 0 Clarkes angleleft foot, 31.34 13.48 23.64 9.84 ... Healthy and overweight, P = .98
4-year-old children
Healthy, n = 279 Intermalleolar distance, cm 2.99 1.96 3.94 2.04 6.21 2.73 Healthy and overweight, P = .49
Healthy and obese, P < .0002a
Overweight and obese, P = .31
Overweight, n = 28 Clarkes angleright foot, 33.61 13.18 29.53 12.42 31.61 12.79 Healthy and overweight, P = .94
Healthy and obese, P = .99
Overweight and obese, P = .99
Obese, n = 7 Clarkes angleleft foot, 33.76 12.78 30.78 12.88 27.48 10.14 Healthy and overweight, P = .99
Healthy and obese, P = .99
Overweight and obese, P = .99
5-year-old children
Healthy, n = 333 Intermalleolar distance, cm 2.46 1.82 4.02 1.98 5.0 2.5 Healthy and overweight, P < .00004a
Healthy and obese, P < .00004a
Overweight and obese, P = .89
Overweight, n = 52 Clarkes angleright foot, 36.50 12.82 29.78 15.23 32.94 13.65 Healthy and overweight, P < .03a
Healthy and obese, P = .99
Overweight and obese, P = .99
Obese, n = 18 Clarkes angleleft foot, 35.46 13.17 28.88 15.45 35.75 12.74 Healthy and overweight, P < .04a
Healthy and obese, P = .99
Overweight and obese, P = .81
6-year-old children
Healthy, n = 353 Intermalleolar distance, cm 2.51 2.03 4.0 2.32 5.5 2.83 Healthy and overweight, P < .00002a
Healthy and obese, P < .00002a
Overweight and obese, P < .02a
Overweight, n = 82 Clarkes angleright foot, 37.37 12.85 36.14 13.11 31.08 9.31 Healthy and overweight, P = .99
Healthy and obese, P = .29
Overweight and obese, P = .82
Obese, n = 33 Clarkes angleleft foot, 36.64 13.10 35.87 12.89 32.4 12.4 Healthy and overweight, P = .99
Healthy and obese, P = .88
Overweight and obese, P = .99
7-year-old children
Healthy, n = 67 Intermalleolar distance, cm 1.93 1.60 5.6 2.5 7.6 2.19 Healthy and overweight, P < .007a
Healthy and obese, P < .00002a
Overweight and obese, P = .95
Overweight, n = 5 Clarkes angleright foot, 39.74 11.18 44.14 7.93 30.94 13.43 Healthy and overweight, P = .99
Healthy and obese, P = .97
Overweight and obese, P = .94
Obese, n = 5 Clarkes angleleft foot, 38.91 11.93 43.06 6.13 33.14 10.62 Healthy and overweight, P = .99
Healthy and obese, P = .99
Overweight and obese, P = .99

Abbreviation: ANOVA, analysis of variance.

a Statistically significant difference P .05.

children with healthy weight and overweight in the 5-year- The correlation analysis showed significant relation-
old children (right and left feet). ships between BMI and IMD in the whole sample (all ages)
In each group, 3 knee alignment subgroups were dis- and in separate age groups, except for the 3-year-old chil-
tinguished (neutral knee, slightly valgus knee, and valgus dren (Table 4). A significant negative correlation was found
knee). In each age group, the BMI value increased as the between the arch of the right foot and the BMI in the 5-,
IMD increased. The highest IMD was in 7-year-old chil- 6-, and 7-year-old children, and also between the arch of
dren who were obese. Significant BMI differences were the left foot and BMI in the whole sample and in the 4- and
found between children with neutral versus slightly and 5-year-old children. Some correlations between IMD and
considerably valgus knees in the 5-, 6-, and 7-year-old the height of the arches of the feet were also noted in the
children (Table 3). whole sample and in the 5- and 6-year-old children.
Differences between Clarkes angles in children with
neutral, slight, and considerable genu valgum were not
present in 3- and 7-year-old children. In the 4-, 5-, and DISCUSSION
6-year-old children, Clarkes angles decreased as IMD The study revealed that the incidence of overweight
increased. and obesity in young children increased with age. The
Pediatric Physical Therapy Genu Valgum, Flat Feet, and Weight in Children 203
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 TABLE 3
Comparison of Variables in Children With Neutral, Slightly Valgus, and Valgus Knee Alignment (Factorial ANOVA and Tukeys Post Hoc Test)

Slightly Valgus
Age/Knee Alignment Variable Correct Knee Knee Valgus Knee P

3-year-old children
Neutral, n = 29 BMI, kg/m2 15.02 1.25 15.57 1.35 15.87 1.1 Neutral and slightly valgus, P = .99
Neutral and valgus, P = .86
Slightly valgus and valgus, P = .99
Slightly valgus, n = 45 Clarkes angle right foot, 32.76 13.0 32.41 13.8 30.49 13.22 Neutral and slightly valgus, P = .99
Neutral and valgus, P = .99
Slightly valgus and valgus, P = .99
Valgus, n = 28 Clarkes angle left foot, 31.19 14.5 31.38 13.73 31.46 12.13 Neutral and slightly valgus, P = .99a
Neutral and valgus, P = .99
Slightly valgus and valgus, P = .99
4-year-old children
Neutral, n = 130 BMI, kg/m2 14.88 1.31 15.65 1.56 16.45 1.85 Neutral and slightly valgus, P < .01a
Neutral and valgus, P < .00003a
Slightly valgus and valgus, P = .28
Slightly valgus, n = 139 Clarkes angle right foot, 34.35 13.15 33.17 12.87 29.87 13.54 Neutral and slightly valgus, P = .99
Neutral and valgus, P = .79
Slightly valgus and valgus, P = .97
Valgus, n = 44 Clarkes angle left foot, 34.89 12.23 32.65 13.29 30.98 12.33 Neutral and slightly valgus, P = .99
Neutral and valgus, P = .99
Slightly valgus and valgus, P = .98
5-year-old children
Neutral, n = 209 BMI, kg/m2 15.07 1.55 15.86 1.36 17.43 2.24 Neutral and slightly valgus, P < .02a
Neutral and valgus, P < .00002a
Slightly valgus and valgus, P < .00002a
Slightly valgus n = 138 Clarkes angle right foot, 38.47 12.56 33.75 13.19 28.32 13.48 Neutral and slightly valgus, P < .05
Neutral and valgus, P < .00004a
Slightly valgus and valgus, P = .33
Valgus n = 55 Clarkes angle left foot, 37.38 12.43 32.48 14.42 29.47 13.65 Neutral and slightly valgus, P < .04a
Neutral and valgus, P < .005a
Slightly valgus and valgus, 0.98
6-year-old children
Neutral n = 235 BMI, kg/m2 15.66 1.56 16.6 2.04 17.92 2.74 Neutral and slightly valgus, P < .00003a
Neutral and valgus, P < .00002a
Slightly valgus and valgus, P < .00003a
Slightly valgus n = 159 Clarkes angle right foot, 37.90 12.74 35.8 12.71 34.91 12.75 Neutral and slightly valgus, P = .96
Neutral and valgus, P = .91
Slightly valgus and valgus, P = .99
Valgus n = 74 Clarkes angle left foot, 37.37 13.22 35.32 12.15 34.41 14.05 Neutral and slightly valgus, P = .97
Neutral and valgus, P = .93
Slightly valgus and valgus, P = .99
7-year-old children
Neutral n = 44 BMI, kg/m2 15.27 1.26 15.61 1.4 18.52 3.32 Neutral and slightly valgus, P = .99
Neutral and valgus, P < .00002a
Slightly valgus and valgus, P < .00001a
Slightly valgus n = 18 Clarkes angle right foot, 39.65 12.01 39.2 9.68 39.18 11.62 Neutral and slightly valgus, P = .99
Neutral and valgus, P = .99
Slightly valgus and valgus, P = .99
Valgus n = 15 Clarkes angle left foot, 39.32 11.53 37.88 11.61 38.42 11.14 Neutral and slightly valgus, P = .99
Neutral and valgus, P = .99
Slightly valgus and valgus, P = .99

Abbreviation: ANOVA, analysis of variance; BMI, body mass index.

a Statistically significant difference P .05.

proportion of children who were overweight went up from
5% in the 3-year-old children to 24.5% in the 6-year-old
participants. In the 4-, 5-, and 7-year-old participants, the
proportions who were overweight were 11%, 17%, and
12%, respectively. The examination of knee alignment re-
vealed that IMD decreased with age, which was especially
noticeable in children with a healthy weight. This con-
firmed the findings of Kaspiris et al,22 in which, in a group
of 316 children aged 3 to 9 years, slight or considerable
genu valgum was discovered in more than 48% of all par-
ticipants. In our study, genu valgum was seen in 52% of
participants. That difference may be due to the younger
median age of the sample. The incidence of genu valgum
increased with BMI across all ages.
The effect of weight status on the height of the longi-
tudinal arch of the foot expressed by Clarkes angles was

204 Jankowicz-Szymanska and Mikolajczyk Pediatric Physical Therapy

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 TABLE 4
Relationships Between Variables (Pearsons Linear Correlation); Correlations Are Significant at P < .05

Correlated Variables

Intermalleolar Intermalleolar
BMI and Distance, cm, and Distance, cm, and
Intermalleolar BMI and Clarkes BMI and Clarkes Clarkes AngleRight Clarkes Angleleft
Distance, cm AngleRight Foot,o AngleLeft Foot,o Foot,o Foot,o

Group r P r P r P r P r P

All 0.38 .001a 0.13 .0001a 0.10 .0001a 0.17 .0001a 0.14 .0001a
3-years-old 0.10 .29 0.008 .93 0.08 .41 0.11 .27 0.029 .76
4-years-old 0.34 .0001a 0.10 .61 0.15 .0005a 0.07 .18 0.07 .18
5-years-old 0.44 .001a 0.25 .0001a 0.19 .0001a 0.31 .0001a 0.24 .0001a
6-years-old 0.39 .0001a 0.13 .005a 0.08 .07 0.12 .005a 0.13 .0005a
7-years-old 0.67 .0001a 0.26 .01a 0.18 .10 0.10 .36 0.06 .59

Abbreviation: BMI, body mass index.

a Statistically significant correlation P < .05.

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cance was possibly a low number of children with obesity
in the study. The data corresponded to previous reports
concerning the increased prevalence of knee and foot de-
formities in preschool-aged children.23
The examination of body posture and weight status in
children should constitute an integral whole. Correction
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The calculation of Clarkes angles required the author
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The prevalence of overweight and obesity increased
with age in children. Genu valgum was more common in
children with excessive weight. Correlations were found
between the longitudinal arch height and weight status and
between the arch height and genu valgum. Physical thera-
pists working with children who are overweight or obese
should incorporate interventions to address their poten-
tial lower extremity malalignments to help these children
achieve a more healthy weight status.
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CLINICAL BOTTOM LINE

Commentary on Genu Valgum and Flat Feet in Children With Healthy and Excessive Body Weight

How could I apply this information?

According to estimates from the Centers for Disease Control and Prevention, obesity has more than doubled
over the last 30 years in children aged 6 to 11 years. One of many long-term health risks associated with obesity
is a greater incidence of bone and joint problems, particularly in distal weight-bearing joints such as the knees
and feet.1 This article lends support to both premises. The changes in lower extremity alignment that develop
concurrently with increasing body mass index heighten the importance of prevention programs for childhood
obesity. Clearly, the efforts of public health and population-based pediatric physical therapy need to focus early if
obesity is on the rise by 5 years of age. With the combined effects of rapid growth, musculoskeletal development,
and emerging health behaviors, the early years between 3 and 5 may form a critical window for reprogramming a
childs physical activity habits and healthy weight trajectory.
What should I be mindful about when applying this information?
Age and body mass index are important to consider when clinicians explore interventions for children with
flat or pronated feet. Overall activity level, though not explored in this article, is another crucial factor to assess.
Musculoskeletal impairments and obesity are intimately linked. So it is inadvisable for a health professional to
address one without the other. Because this is a correlational study, we cannot assume that obesity causes the
identified musculoskeletal problems. Instead, perhaps a separate factor or combination thereof contributes to both
obesity and musculoskeletal malalignment. Possibilities include low muscle tone, low activity level, poor diet, and
age at which the weight gain commences.

REFERENCE
1. McPhail SM. Age, physical activity, obesity, health conditions, and health related quality of life among patients receiving conservative
management for musculoskeletal disorders. Clin Interventions Aging. 2014;9:1069-1080.

Sandra L. Willett, PT, MS, PCS

Munroe Meyer Institute, University of Nebraska Medical Center
Omaha, Nebraska
Regina T. Harbourne, PT, PhD, PCS
Rangos School of Health Sciences, Duquesne University
Pittsburgh, Pennsylvania
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000232

206 Jankowicz-Szymanska and Mikolajczyk Pediatric Physical Therapy

Copyright 2016 Wolters Kluwer Health, Inc. and the Section on Pediatrics of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.