W-sitting: problem or solution?

When a child w-sits he spreads his hips with his bottom on the floor, his knees bent, and his feet behind him, making a "W" shape with his legs.

When a child w-sits he spreads his hips with his bottom on the floor, his knees bent, and his feet behind him, making a “W” shape with his legs.

I’m going to come right out and say it.

I’m a pediatric physical therapist, and I think W-sitting is OK.

Like most physical therapists, I learned in school that W-sitting is bad.  Very bad.  The worst.  When I talk to other physical therapists, even those who don’t treat children, they remember the same thing.  In a recent conversation, one colleague recalled the time she came home from PT school in a panic because her then-5-year-old sister was a W-sitter.  It is a single, pervasive, clear message taught to physical therapy students everywhere.  W-sitting must always be corrected.  But why?

The reasons given usually fall into 3 categories:

  1. W-sitting will cause orthopedic issues such as twisted bones and hip dislocation.
  2. W-sitting will cause muscle tightness, especially in the hips.
  3. W-sitting will aggravate neurological issues such as low muscle tone.

For the first several years of my practice as a PT, I taught families about the dangers of W-sitting, reciting the 3 reasons over and over again.  For the first couple of years I taught pediatric PT, I passed these beliefs onto my students.

Then I became a mother.  And my son was a W-sitter.

And for the first year or so of his life, as he played, I chirped “Fix your feet!” and moved him, over and over again, into other sitting positions.  At first, it wasn’t a big deal. But then he started to get frustrated with me.  And I started to get frustrated with him.  And I noticed that, when I moved him to a new position (or forced him to do so himself), he often wasn’t able to play as well or effectively as he was before my “intervention.”  He was a happy, bright, social kid.  He was developing normally, hitting all his milestones on time, and had no orthopedic or muscular problems that I could identify.  So I stopped worrying about it.  I stopped correcting him.  I started to wonder why I had been correcting W-sitting just for the sake of correcting W-sitting.  And I started to think really carefully about what I was really doing when teaching families to discourage W-sitting.

The truth is, as common as it is for therapists to teach children to “fix your feet,” there is really no evidence to support this practice.  A quick Google search for “W-sitting” reveals hundreds of posts about W-sitting, most written by physical and occupational therapists.  Almost without exception, they caution against W-sitting.  Almost without exception, they give the 3 reasons that W-sitting is bad.  But, in reviewing all 10 posts on the first page of search results on W-sitting, not a single one provides any references for those claims.  Searches for W-sitting on Google Scholar and PubMed come up empty.

“Fix your feet!”  For a practice with such a high level of adoption, there sure is a low level of evidence.

Now, I don’t dispute the fact that children with low muscle tone often choose W-sitting as a preferred position.  It gives them a wide base of support which makes them really stable.  But you know what that means?  They are functional in that position!  They can use their hands better and manipulate toys better because they aren’t using all their energy just trying not to fall down.

I also understand that often, children who W-sit often have orthopedic issues and muscle tightness.  But I don’t think that we can confidently say that W-sitting CAUSES those issues.  Perhaps it’s the other way around – unstable hips and tight hamstrings lead to W-sitting.  Or maybe there’s a third variable that’s causing both problems.  The truth is we don’t know.

And many might argue, “What’s the harm?  It won’t hurt to take them out of W-sitting.  Why wouldn’t we correct it?”  My response would be that correcting it might actually be harmful.  Perhaps not for the child’s physical development.  But what about their interactions with their parents?  Is constantly having a parent telling their child to “fix their feet” promoting good parent-child interactions?  What about parents who worry constantly about their child’s W-sitting?  How much stress and worry are we therapists causing over something we really can’t even prove causes harm? And finally, what about function?  What are we taking away from the child when we correct W-sitting?

So perhaps we therapists should soften a bit on W-sitting.  Not that we should NEVER correct it – sometimes it is clearly problematic for a child.  But we should recognize that W-sitting isn’t an all or nothing proposition.  It can be normal and is not always be dangerous or bad.  It doesn’t always need to be corrected.  Let’s look at children as individuals, address their real impairments, and always keep our eye on enhancing participation rather than reinforcing “normal.”  If low tone and core strength are the issues, let’s address those.  Let’s provide opportunities for a variety of movements and help children explore different sitting positions.

Kids are smart.  They usually know what they need.  And the body has a way of finding the most effective and efficient way to move.  For many kids, W-sitting isn’t a problem, it’s their solution.

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9 responses to “W-sitting: problem or solution?”

  1. Shelley Mannell says :

    Thanks for this Kendra. I had 2 children who preferred to W sit when they were young. And in my professional practice, I prefer to look at W-sitting as a red flag that points to the need to delve further into the reasons why a child prefers a wide base of support.

    • kendrapedpt says :

      I could not agree more, Shelley! Often (not always) W-sitting is the result of another underlying impairment. As you said, we need to focus our attention on figuring out WHY the child is W-sitting.

  2. lej1123 says :

    This is my first time checking out your blog, and I found this post through the AbbyPediatricOT blog (http://www.abbypediatricot.blogspot.com/). I’m a soon-to-be OT student who is currently volunteering at a pediatric facility and I have heard several therapists and parents correct or chide a child for W-sitting.

    I never really thought to ask why it was such a bad thing, and it happens infrequently so I haven’t yet been “indoctrinated” with the anti-W mindset! However, I think it is very wise of you to take a step back and consider WHY it might be such a bad thing. Your comment that “…I don’t think we can confidently say that W-sitting CAUSES those issues. Perhaps it’s the other way around – unstable hips and tight hamstrings lead to W-sitting. Or maybe there’s a third variable that’s causing both problems” took me back to my days in statistics and research classes where I was made to consider all the possible reasons for an outcome! And you’re right, the correction of the position may ultimately be doing more collateral damage to relationships and functionality than the position is for any physical structures.

    This post was a great reminder for me that critical, questioning thinking and the desire to be evidence-based is always important.

    • kendrapedpt says :

      I’m so glad the blog made you think. Whether you ultimately agree or disagree that W-sitting needs to be corrected, I think we all need to acknowledge that “fix your feet” has become a dogma that few of us question. Thanks for your comment and the re-blog!

  3. lej1123 says :

    Reblogged this on Gotta Be OT and commented:
    As I continue to volunteer and learn more about pediatric occupational therapy, I am finding out so much about things children do that I had never thought might be harmful. One of these things is “W-sitting.” This happens when a child “spreads his hips with his bottom on the floor, his knees bent, and his feet behind him, making a “W” shape with his legs.” (Kendra Ped PT Blog)

    I did not know what the big deal was about W-sitting before I started volunteering, but in my time at the clinic I’ve heard several therapists correct a child who was seated in this position. I wondered why it was such a big and even if it was such a big deal, and Kendra’s post about W-sitting provides great discussion about making sure that therapeutic recommendations are actually evidence-based, backed up by fact and ultimately beneficial to all parties involved.

  4. Sarah says :

    My daughter has increased femoral anteversion diagnosed by pediatric orthopedist at Mass General Hospital. Here is a link to a handout received regarding femoral anteversion and how w-sitting “should not be discouraged or avoided” in this case. No research is cited but perhaps it is based on some. http://www.massgeneral.org/ortho/services/pediatrics/intoeing.aspx
    Thoughts?

  5. Sharon says :

    I was and still am a w-sitter. I am 41 years old. So far, no problems. I played sports when younger and am still physically active. I was born with displaced hips so I figured that’s why I did it. But now my 3 year old does it and she has no hip problems. She sits in other positions but prefers w-sitting. I never knew this was even a problem until I read an article from pediatric physical therapists. My motherly-intuition tells me she’s fine sitting how she wants but I now have this in the back of my head. Thanks for the post, I’m glad to hear another opinion as I’ve not found any real research to support the negative claims. I’ll keep an eye on her posture and coordination though.

  6. Mansi says :

    I think we have a lot of anecdotal evidence regarding W-sitting. We really need some evidence as to how W-sitting affects children with special needs. Since your child is a neurotypical child, can we really apply your observations to children with special needs? Can we really generalize based on the experience of one mom? Although I agree that W-sitting may not cause orthopedic problems, it may aggravate them. W-sitting is usually seen in children with low tone who are unable to maintain an upright posture while sitting on the floor. The knees are in extreme varus and hips internally rotated. Maybe these children develop hip/knee arthritis down the line. But we don’t know it, because there isn’t enough evidence. So, as a pediatric OT, I prefer to err on the side of caution and correct W-sitting. I am only talking from the POV of special needs kids,.

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