BMJ 2015;351:h3394 doi: 10.1136/bmj.
h3394 (Published 7 July 2015)
Clinical Review
Normal lower limb variants in children
Andrea Yeo fellow in paediatric orthopaedics, Kyle James consultant paediatric orthopaedic surgeon,
Manoj Ramachandran lead consultant paediatric orthopaedic surgeon
The Royal London & Barts and The London Children’s Hospitals, Barts Health NHS Trust, London E1 1BB, UK
Bow legs, knock knees, flat feet, intoeing, and out-toeing gaits
in children are common but often cause undue parental anxiety,
prompting frequent visits to general practice.1-5 A substantial
proportion of referrals to paediatric orthopaedic clinics consist
of normal physiological variants in growing children. Careful
history, examination, and knowledge of the clinical course of
rotational and angular deformities allow accurate assessment
of children and provide reassurance to parents. Our review aims
to assist general clinicians in recognising normal physiological
variants in the lower limbs of children and to identify abnormal
features that require specialist attention.
Why are normal limb variants important?
Musculoskeletal symptoms are one of the leading causes of
visits to primary care doctors and such visits are on the increase.1
One in eight children each year visits a doctor for a
musculoskeletal disorder.2 Normal variants form an important
proportion of secondary care referrals. Two similar studies,
conducted in Canada and the Republic of Ireland, identified
25-50% of all new referrals to paediatric orthopaedic outpatients
to be related to physiological variants, with intoeing and flexible
flat feet the most common.3 4 Many parents seek medical
attention for the appearance of their child’s lower limbs, or with
concerns that their child’s condition may lead to degenerative
musculoskeletal problems or a reduction in their sporting
ability.5 In most cases the problem is a variation of normal
development, which follows a benign and predictable course.6-8
Rarely does the problem persist into adolescence or require
treatment.
In a retrospective review of all intoeing referrals to a Scottish
paediatric orthopaedic unit, no children required surgery for
their condition, with over 85% being discharged on their first
visit.5 Similarly, in a large American series reviewing 720
intoeing referrals in a year, only one child required surgery.9
These figures highlight that orthopaedic intervention is seldom
required in these children, these and the number of referrals
stretch limited paediatric orthopaedic resources, potentially
delaying care for children who do need more specialist input.3-5
The same Scottish group5 also identified that general
practitioners face a difficult task of reassuring families, as nearly
85% of parents who sought medical attention expected their
child to be referred to a specialist despite only 22% thinking
Correspondence to: A Yeo andreayeo@doctors.org.uk
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 1 of 11
CLINICAL REVIEW
there was something major wrong with their child’s gait. There
is concern that training and confidence of doctors and medical
students in diagnosing and managing musculoskeletal disorders,
particularly in children, is inadequate.3-12 A study assessing the
competence of UK foundation doctors showed that less than
9% passed a basic musculoskeletal cognitive examination.12
Additionally, a survey found that primary and secondary care
clinicians from various specialties have the lowest confidence
in paediatric musculoskeletal assessment.11
A Cochrane review of interventions to improve outpatient
referrals from primary to secondary care suggested that passive
dissemination of referral guidelines was ineffective.13 An
effective strategy may be to combine educational activities
championed by consultant specialists (in this case, paediatric
orthopaedic surgeons or rheumatologists) in combination with
structured referral guidelines.13
How are normal variants assessed?
Careful history and examination are mandatory in the evaluation
of lower limb problems in children. It is crucial to elucidate the
reason for consultation and identify parental concerns—for
example, pain, long term disability, cosmesis, awkward walking
or running, frequent trips or falls. Occasionally, rotational or
angular malalignment are the presenting symptoms of underlying
disorders (table⇓); for example, children with mild spastic
hemiparesis (cerebral palsy) may present with unilateral
intoeing.
To manage the problem effectively, it is essential to determine
the level of the deformity, as it may occur anywhere between
the foot and the hip. Two or more deformities may be additive
or compensate for each other. Examination of children’s
rotational and angular profiles should therefore proceed in a
sequential fashion (box 1).
What are the different normal variants
seen in clinical practice?
Lower limb variants can be broadly divided into rotational
(intoeing and out-toeing gait) and angular (genu valgum and
genu varum) deformities.
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 2 of 11

CLINICAL REVIEW

The bottom line

• Musculoskeletal symptoms are one of the leading reasons for visits to general practitioners, with over 10% of children presenting for
medical attention each year
• Common reasons for referral include intoeing, flat feet, knock knees, and bow legs—all normal variants in growing children
• Additionally, vitamin D deficiency and obesity in children are on the increase, with well documented associations with musculoskeletal
disorders ranging from chronic conditions such as rickets with resultant bow legs or knock knees, to more acute conditions such as
slipped capital femoral epiphysis
• Recognising developmental norms and differentiating them from disease may help allay parental anxiety, ease referrals to primary
and secondary care, and prompt appropriate timely referrals for abnormal conditions

Sources and selection criteria

We searched PubMed and Google Scholar using the terms “p(a)ediatric”, “lower limb variants”, “intoeing”, “out-toeing”, “pes planus”, “flat
foot”, “genu varum”, “genu valgum”, “vitamin D deficiency”, “obesity”, and “sporting activity”. The search was conducted from inception of
databases to March 2015. Wherever possible we used evidence from randomised controlled trials, systematic reviews (including Cochrane
reviews), and expert review articles published in the past 10 years. Current relevant Department of Health policies were also included.

Box 1 Musculoskeletal examination of a typical child

• Weight
• Height

Rotational profile (especially if a child has an intoeing or out-toeing gait)

• Observe gait and foot-progression angle (angle the axis of the child’s foot makes with the direction in which he or she is walking)
• Observe child standing (squinting patella of femoral anteversion; flat foot), sitting (“W” position), running (running accentuates the
problem), and lying down
• Shape of foot (heel bisector line—normal between second and third toes)
• Tibial rotation (thigh-foot angle)—prone position with knees flexed to 90° and measure the angle the foot makes with the thigh
• Femoral rotation—prone position with knees flexed to 90°; hip rotation is generally symmetrical in internal and external rotation
• Hypermobility (Beighton score)

Angular profile (especially in the presence of knocked knees or bow legs)

• Distance between knees while standing and lying with the ankles together (normal intercondylar distance <6 cm)
• Distance between ankles while standing and lying with the knees together (normal intermalleolar distance <8 cm)

Rotational deformities Internal tibial torsion

The child’s rotational profile is a composite of measurements
of the lower limbs—that is, rotational range of the hips and
rotational alignment of the tibia and foot. The most obvious
manifestation is the position of the feet—commonly referred
to as “intoeing” or “out-toeing.” Figure 1⇓ shows the normal
range of rotational motion.
Overall, only 0.1% of rotational deformities persist and may
necessitate surgery if severe and produce functional disability
in older children.14
Intoeing gait (“pigeon-toed” gait)
There are three main causes of an intoeing gait: metatarsus
adductus, internal tibial torsion, and increased femoral
anteversion.
Metatarsus adductus
Metatarsus adductus is the most common congenital foot
deformity, occurring in 1 in 1000 births.14 It is defined as an
internal angulation of the forefoot (or metatarsals) on a neutral
or flexible hindfoot. Clinically, the foot has a curved border and
an abnormal heel bisector line (fig 2⇓).15 In a study of 379
children with metatarsus adductus, nearly 90% required no
treatment.16 No study has proved the effectiveness of passive
stretching or corrective shoes for the flexible, benign forms;
therefore, these may be allowed to resolve naturally.15 16 For the
rigid type, and cases that do not resolve by age 6-9 months,
serial casting may be of value.14
For personal use only: See rights and reprints http://www.bmj.com/permissions
Internal tibial torsion is the most common cause of intoeing.14
It is defined by the angular difference between the transmalleolar
axis of the ankle and the bicondylar axis of the knee. Clinically,
the feet are internally rotated while the patella remains in neutral
position (fig 3⇓). Internal tibial torsion is most apparent when
infants first begin to walk, and parents may mention that their
child trips frequently and appears clumsy. The condition affects
both sexes equally, is bilateral in two thirds of affected infants,
and is associated with metatarsus adductus in about one third.14
Varus at the knee, either physiological or disease related (such
as in Blount’s disease), is often associated with internal tibial
torsion.
The clinical course is of spontaneous resolution—the
transmalleolar axis rotates laterally from 2-4° at birth to 10-20°
in adulthood.7 Resolution is most rapid in infancy. Three per
cent of adults show persistence of major internal tibial torsion,
although disability is rare.17 In fact, sprinters have been shown
to have an intoeing gait, and this is thought to be beneficial.18
Treatment with orthotic devices is unnecessary and ineffective.14
In severe cases that cause functional disability, such as frequent
trips and falls, tibial rotational osteotomy may be considered in
older children (>10 years).14
Femoral anteversion
Femoral anteversion is defined as the angular difference between
the axis of the femoral neck and the transcondylar axis of the
knee. The natural femoral anteversion has been well documented
in a 20 year follow-up study of 1148 hips.19 On average, femoral
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015)
anteversion is 40° at birth, decreasing throughout growth to 16°
in adulthood.19
Femoral anteversion is most pronounced between 4 and 6 years
of age. It is twice as common in girls and is nearly always
symmetrical. It is also often familial. Children sit with their
limbs in the “W” position (fig 4⇓), walk with an intoeing gait
with the patella pointing inwards (“squinting patella”), and run
in an awkward pattern (“eggbeater” pattern, with inward rotation
of the thighs and outward rotation of the legs and feet). Intoeing
typically becomes more pronounced when children are tired.
Tripping as a result of crossing feet may occur.
Femoral anteversion spontaneously resolves in more than 80%
of affected children by late childhood.9 14
Femoral anteversion was once speculated to cause osteoarthritis
of the hip or knee and to impair physical performance; however,
this has been disproved by several studies.19-21 Various orthotics
have been used in the past but none have shown efficacy.19 In
the rare adolescent who has major cosmetic deformity secondary
to anteversion, rotational osteotomy of the femur may be
considered, although the rate of complications is high (15%
overall risk of non-union, malunion, delayed union, or
infection).22
Out-toeing gait
In early infancy out-toeing is normal and usually resolves by
18-24 months of age.14 Out-toeing in older children is usually
due to external tibial torsion and occasionally femoral
retroversion; the latter is more commonly seen in obese
adolescents. However, more serious conditions such as Perthes’
disease and slipped capital femoral epiphysis should always be
considered in older children, especially if unilateral.
At birth, calcaneovalgus may present as out-toeing, with the
foot being able to dorsiflex nearly to the shin. This condition
may be confused with congenital vertical talus, and a lateral
radiograph of the plantar flexed foot usually differentiates the
two conditions (fig 5⇓). Calcaneovalgus generally responds
quickly to passive plantar flexion stretching exercises, whereas
congenital vertical talus typically requires serial casting or
surgical correction.
External tibial torsion can cause disability—for example,
increased prevalence of patellofemoral instability and
patellofemoral pain.14 It is also thought to develop in
compensation for femoral anteversion, which may lead to the
“miserable malalignment syndrome.” Presentation is usually in
adolescent girls, with symptoms of anterior knee pain or patellar
instability. A comprehensive review on this vast topic is
available elsewhere.23
Flexible pes planus (flat feet)
The foot is the most common region prompting medical attention
for musculoskeletal problems in children,24 with 90% of concerns
related to flat feet.25 The prevalence of flat feet inversely
correlates with age—about 45% in children aged 3-6 years,26
decreasing to 2-16% in older children.26 27
Neonates and toddlers universally have “flat feet” owing to the
presence of a fat pad beneath the medial longitudinal arch.
Additionally, intrinsic laxity and the lack of neuromuscular
control in children starting to mobilise result in flattening of the
foot when weight bearing.6 26 This typically resolves between
the ages of 4 and 8 years.25 26
Clinically, the heel is in valgus, with sagging of the medial arch
(fig 6⇓). A careful assessment should be made to differentiate
a flexible flat foot from a rigid one, with the latter encompassing
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 3 of 11
CLINICAL REVIEW
<1% of children,28 which is usually painful and caused either
by tarsal coalitions (presentation is typically in adolescence),
congenital vertical talus, or inflammatory disorders (pes planus
is a common feature of juvenile idiopathic arthritis).29 The
medial arch of a flexible flat foot reconstitutes on tiptoeing (fig
6) or when the foot is dependent. Children rarely have
symptoms, with parental concern mainly related to cosmesis or
the misconstrued belief that the condition could lead to pain or
functional problems in later life.29 Risk factors include
hyperlaxity, obesity, and a positive family history. Examination
may reveal the flat foot to be severe and causing the shoe to
become deformed.
Most flexible flat feet are physiological, asymptomatic, and
require no treatment, although other neurological (cerebral
palsy), muscular (muscular dystrophy), syndromic (trisomy 21),
or connective tissue (Marfan’s and Ehlers-Danlos syndromes)
disorders should be actively sought. Some cases of flexible flat
feet may be painful, with more specific problems after activity.
The treatment of paediatric flat foot has been controversial and
debate is still ongoing with no current ideal intervention.23
Historically, various devices (for example, high top shoes) were
used to correct and prevent such deformities.14 The consensus
now is that the asymptomatic flexible flat foot is benign.
Treatment is mainly directed towards symptoms of pain and
severity of the deformity. A Cochrane review of non-surgical
treatment for paediatric flat feet showed a general lack of good
quality trials but suggested that bespoke orthoses may improve
pain and function in children with juvenile idiopathic arthritis
and flat feet; however, in otherwise normal, asymptomatic
children, there is no evidence for the efficacy of foot orthoses
or any other non-surgical intervention.24 In children with
symptoms, expert opinion favours the use of a well moulded
insole, which does not correct the flat foot but alleviates pain
and prevents shoe deformation.24 30
Angular deformities
Angular alignment refers to the tibiofemoral angle, which can
be clinically assessed by the intermalleolar and intercondylar
distances (fig 7⇓). Angular deformities (for example, genu
varum and genu valgum) tend to be symmetrical and cause no
pain. Clinical examination should focus on excluding rotational
abnormalities and ligamentous laxity as these can exaggerate
the appearance of angular deformities.31
In the landmark study of tibiofemoral angles in 1500 normal
children, Salenius and Vankka showed that up to the age of 18
months, children often present with genu varum (bow legs;
mean of 15°).32 Thereafter, a genu valgum (knock knees; mean
of 12°) deformity ensues, which subsequently corrects itself to
the normal value in adults (7-8° valgus) by the age of 7 years.15
This study has been replicated in a modern radiological study
with more stringent methodology.33
Disease should be considered in cases where the deformity is
unilateral, asymmetrical, severe, progressive, or accompanied
by short stature. Genu varum in children aged more than 3 years
or genu valgum in children aged less than 2 years should also
raise concern and warrant specialist referral for further
investigation, where typically long leg alignment radiographs
are taken (fig 8⇓). Box 2 lists the possible causes of both
conditions.
Genu varum (bow legs)
Physiological genu varum is thought to relate to intrauterine
positioning, which leads to the contracture of the medial knee
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 4 of 11

CLINICAL REVIEW

Box 2 Causes of genu varum and genu valgum

Genu varum
• Blount’s disease
• Metabolic (for example, rickets, renal osteodystrophy)
• Post-traumatic
• Post-infection (for example, osteomyelitis)
• Skeletal dysplasias (for example, achondroplasia, osteogenesis imperfecta, metaphyseal chondrodysplasia)
• Tumours

Genu valgum
• Idiopathic
• Metabolic (for example, rickets, renal osteodystrophy)
• Obesity
• Post-traumatic (for example, proximal tibial metaphyseal fracture)
• Post-infection
• Neuromuscular
• Congenital (for example, fibular dysplasia)
• Skeletal dysplasias (for example, pseudoachondroplasia, multiple epiphyseal dysplasia)
• Tumours

joint capsule.31 This, in addition to the internal tibial torsion
common in this age group, accentuates the deformity when
children weight bear. Therefore, referrals for bow legs are
common for children aged between 10 and 14 months, the
average age at which children start to stand and ambulate. The
intercondylar distance is measured with the medial malleoli in
contact and should be less than 6 cm.34
Some studies suggest that participation in high impact sport
may predispose to knee varus.35-38 Knee varus has been shown
to occur more frequently in adult football players than in the
general population.35 This, in addition to external tibial torsion,
has been similarly shown in several large cross-sectional studies
of adolescents participating in a variety of high impact sport
compared with non-sporting boys.36-38 It is, however, not clear
if the demands for intensive practice on the growing skeleton
lead to the varus axis, or that knee varus confers some advantage
resulting in natural selection of such individuals.36 This has
important clinical implications as such angular deformities of
the knee are associated with an increased risk of injury37 and
osteoarthritis in later life.35 Further studies are required to find
preventive solutions to this relation. There is currently no
specific advice that can be given to such high performance
adolescents who present with knee varus. However, those who
present with concurrent knee pain should be investigated for
alternative injuries—for example, meniscal injury,
osteochondritis dessicans, or ligamental injury.
Genu valgum (knock knees)
Referrals for knock knees are common in children aged between
3 and 4 years. Knock knees can be accentuated by obesity,
ligamentous laxity, and flat feet. In addition, torsional
deformities such as femoral anteversion with compensatory
external tibial torsion may make a physiological genu valgum
appear more severe. The intermalleolar distance is measured
with the knees in contact and should be less than 8 cm.34
Treatment of physiological genu varum and valgum involves
reassurance and observation.
What else should be considered?
children in Europe and Australasia.39-41 Lower limb deformities
have been attributed to vitamin D or calcium deficiency, or both.
Genu varum is typical of rickets, but genu valgum can also
occur.
Vitamin D insufficiency has been a recent focus of the UK
Department of Health (the “Healthy Start” supplements and
National Institute of Health and Care Excellence guidelines).42 43
A comprehensive review on the diagnosis and management of
vitamin D deficiency can be found elsewhere.44
Obesity
Globally, the prevalence of obesity is increasing.45-47 Current
evidence points to a negative effect of obesity on the
musculoskeletal health of children.48-51 An increased body mass
index in children has been identified as a predictor for
musculoskeletal problems, with knee and foot pain the most
commonly reported symptoms.50-53 Children who are overweight
or obese show alterations in standing balance, postural
adjustment, and movement efficiency, which has been proposed
to contribute to the development of lower limb angular
deformities and premature osteoarthritis.48-53 Several studies
have found a positive relation between body mass index and
genu valgum51 53 and flat feet.27-55 Similarly, there are positive
associations between childhood obesity and conditions such as
Blount’s disease (fig 9⇓) and slipped capital femoral
epiphysis.51-57 Blount’s disease is a growth disturbance of the
medial portion of the proximal tibial growth plate. It can occur
at any age from birth to skeletal maturity. Slipped capital
femoral epiphysis, on the other hand, typically occurs during
adolescence. It is a disorder of the proximal femoral growth
plate (physis), leading to displacement of the femoral neck from
the femoral head.
Contributors: All authors contributed equally to the writing and reviewing
of all versions of the manuscript. MR is the guarantor.
Competing interests: We have read and understood BMJ policy on
declaration of interests and declare the following: none.
Provenance and peer review: Not commissioned; externally peer
reviewed.

Vitamin D deficiency 1 Brooks PM. The burden of musculoskeletal disease—a global perspective. Clin Rheumatol
There is a resurgence of nutritional rickets secondary to vitamin 2006;25:778-81.

D deficiency in children from ethnic minority groups and white

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 5 of 11

CLINICAL REVIEW

Tips for non-specialists

• Take the concerns of the family seriously, providing parents with information about the clinical course of normal variants and emphasising
that they tend to resolve spontaneously
• Consider risk factors and treat or advise accordingly (for example, vitamin D deficiency, obesity, sporting activity)
• Features that raise concern and warrant specialist referral:
Genu valgum in child aged less than 2 years
Genu varum in child aged more than 3 years
Asymmetrical findings (symmetrical findings in both limbs are usually not related to disease, unless severe and associated with short
stature)
Genu varum at any age with an acute deformity centred at the proximal tibia (possible Blount’s disease)
Unilateral or bilateral knee, hip, or thigh pain, or progressive out-toeing in an adolescent, especially if overweight or obese (possible
slipped capital femoral epiphysis, this warrants radiography with or without onward referral)
Unilateral or bilateral knee, hip, or thigh pain in a school age child (possible Perthes’ disease, this warrants radiography with or without
onward referral)
Painful, rigid flat feet especially in adolescents (possible tarsal coalition, this warrants referral to a paediatric orthopaedic surgeon)

Additional educational resources

Resources for healthcare professionals
Examination of the paediatric musculoskeletal system58 (http://onlinelibrary.wiley.com/doi/10.1002/acr.20569/suppinfo)—a thorough
description of how to examine the paediatric musculoskeletal system, which would be useful for all clinicians
World Health Organization collaborative cross-national survey. Health Behaviour in School-Aged Children (www.hbsc.org/)—an
international research network involving 44 countries that collaborate on the cross-national survey of school children’s health and
wellbeing, social environment, and health behaviour. It is an extensive databank that can be utilised by clinicians globally to support
research interests, inform policy and practice, and monitor trends.
Public Health England Obesity (www.noo.org.uk)—provides a single point of contact for the clinician to access authoritative information
on data, evaluation, evidence, and research related to obesity and related issues
National child measurement programme (www.hscic.gov.uk/ncmp)—This UK national programme measures the height and weight of
primary school children and provides yearly data on overweight and obese children. This can be a vehicle for assisting the clinician in
engaging families about healthy lifestyles and weight problems. There is also a link to assist clinicians in calculating a child’s body mass
index

Resources for parents

American Academy of Orthopaedic Surgeons. OrthoInfo (www.orthoinfo.aaos.org)—an open access, extensive patient friendly website
that provides information and useful treatment advice on orthopaedic conditions. A whole section is devoted to children’s conditions,
including normal variants (for example, bow legs, flexible flat feet) and disease or abnormal conditions (for example, Blount’s disease,
adolescent anterior knee pain, Perthes’ disease, slipped capital femoral epiphysis)
Healthy Start Scheme (www.healthystart.nhs.uk)—a UK-wide government public health scheme that provides nutritional support for
pregnant women, new mothers, and young children in very low income families. This also includes the Healthy Start Vitamins. This vast
resource provides information for patients and healthcare professionals

2 Gunz A, Canizares M, MacKay C, Bradley E. Magnitude of impact and healthcare use 21 Eckhoff DG, Kramer RC, Alongi CA, Van Gerven DP. Femoral anteversion and arthritis
for musculoskeletal disorders in the pediatric population: a population-based study. BMC of the knee. J Pediatr Orthop 1994;14:608-10.
Musculoskelet Disord 2012;13:98. 22 Staheli LT, Clawson DK, Hubbard DD. Medial femoral torsion: experience with operative
3 Carli A, Saran N, Krujit J, Alam N, Hamdy R. Physiological referrals for paediatric treatment. Clin Orthop Relat Res 1980;146:222-5.
musculoskeletal complaints: a costly problem that needs to be addressed. Paediatr Child 23 Jackson AM. Anterior knee pain. J Bone Joint Surg Br 2001;83:937-48.
Health 2012;17:e93-7. 24 Rome K, Ashford RL, Evans A. Non-surgical interventions for paediatric pes planus.
4 Molony D, Hefferman G, Dodds M, McCormack D. Normal variants in the paediatric Cochrane Database Syst Rev 2010;7:CD006311.
orthopaedic population. Ir Med J 2006;99:13-4. 25 Fabry G. Clinical practice. Static, axial, and rotational deformities of the lower extremities
5 Blackmur JP, Murray AW. Do children who in-toe need to be referred to an orthopaedic in children. Eur J Pediatr 2010;169:529-34.
clinic? J Pediatr Orthop B 2010;19:415-7. 26 Volpon JB. Footprint analysis during the growth period. J Pediatr Orthop 1994;14:83-5.
6 Sass P, Hassan G. Lower extremity abnormalities in children. Am Fam Physician 27 Bordin D, De Giorgi G, Mazzocco G, Rigon F. Flat and cavus foot, indexes of obesity and
2003:68:461-8. overweight in a population of primary-school children. Minerva Pediatr 2001;53:7-13.
7 Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. 28 Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Prevalence of flat foot in preschool-aged
Normal values to guide management. J Bone Joint Surg Am 1985:67:39-47. children. Pediatrics 2006;118:634-9.
8 Talley W, Goodemote P, Henry SL. Managing intoeing in children. Am Fam Physician 29 Hendry G, Gardner-Medwin J, Watt GF, Woodburn J. A survey of foot problems in juvenile
2011;84:942-4. idiopathic arthritis. Musculoskelet Care 2008;6:221-32.
9 Karol LA. Rotational deformities in the lower extremities. Curr Opin Pediatr 1997;9:77-80. 30 Evans AM. The flat-footed child—to treat or not to treat—what is the clinician to do? J Am
10 Foster H, Kay L, May C, Rapley T. Pediatric regional examination of the musculoskeletal Podiatr Med Assoc 2008;98:386-93.
system: A practice- and consensus-based approach. Arthritis Care Res (Hoboken) 31 Wilkins KE. Bowlegs. Pediatr Clin North Am 1986;33:1429-38.
2011;63:1503-10. 32 Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint
11 Jandial S, Myers A, Wise E, Foster HE. Doctors likely to encounter children with Surg Am 1975;57:259-61.
musculoskeletal complaints have low confidence in their clinical skills. J Pediatr 33 Sabharwal S, Zhao C, Edgar M. Lower limb alignment in children. J Pediatr Orthop
2009;154:267-71. 2008;28:740-6.
12 Al-Nammari SS, James BK, Ramachandran M. The inadequacy of musculoskeletal 34 Heath CH, Staheli LT. Normal limits of knee angle in white children:genu varum and genu
knowledge after foundation training in the United Kingdom. J Bone Joint Surg Br valgum. J Pediatr Orthop 1993;13:259-62.
2009;91:1413-8. 35 Chantraine A. Knee joint in soccer players: osteoarthritis and axis deviation. Med Sci
13 Akbari A, Mayhew A, Al-Alawi MA, et al. Interventions to improve outpatient referrals from Sports Exerc 1985;17:434-39.
primary care to secondary care. Cochrane Database Syst Rev 2008;4:CD005471. 36 Yaniv M, Becker T, Goldwirt M, et al. Prevalence of bowlegs among child and adolescent
14 Staheli LT. Rotational problems in children. J Bone Joint Surg Am 1993;75:939-49. soccer players. Clin J Sport Med 2006;16:392-6.
15 Bleck EE. Metatarsus adductus: classification and relationship to outcomes of treatment. 37 Witvrouw E, Danneels L, Thijs Y, Cambier D, Bellemans J. Does soccer participation lead
J Pediatr Orthop 1983;3:2-9. to genu varum? Knee Surg Sports Tramatol Arthrosc 2009;17:422-7.
16 Ponseti IV, Becker JR. Congenital metatarsus adductus: the results of treatment. J Bone 38 Thijs Y, Bellemans J, Rombaut L, et al. Is high-impact sports participation associated with
Joint Surg Am 1966;48:702-11. bowlegs in adolescent boys? Med Sci Sports Exerc 2012;44:993-8.
17 Hutter CG Jr, Scott W. Tibial torsion. J Bone Joint Surg Am 1949;31:511-8. 39 Prentice A. Vitamin D deficiency: a global perspective. Nutr Rev 2008;66(10 Suppl
18 Fuchs R, Staheli LT. Sprinting and intoeing. J Pediatr Orthop 1996;16:489-91. 2):S153-64.
19 Fabry G, MacEwen GD, Shands AR Jr. Torsion of the femur: a follow-up study in normal 40 Beck-Nielsen SS, Jensen TK, Gram J, Brixen K, Brock-Jacobsen B. Nutritional rickets in
and abnormal conditions. J Bone Joint Surg Am 1973;55:1726-38. Denmark: a retrospective review of children’s medical records from 1985 to 2005. Eur J
20 Hubbard DD, Staheli LT, Chew DE, Mosca VS. Medial femoral torsion and osteoarthritis. Pediatr 2009;168:941-9.
J Pediatr Orthop 1988;8:540-2.

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 6 of 11

CLINICAL REVIEW

41 Voloc A, Esterle L, Nguyen TM, et al. High prevalence of genu varum/valgum in European 50 Paulis WD, Silva S, Koes BW, van Middelkoop M. Overweight and obesity are associated
children with low vitamin D status and insufficient dairy products/calcium intakes. Eur J with musculoskeletal complaints as early as childhood: a systematic review. Obes Rev
Endocrinol 2010;163:811-7. 2014;15:52-67.
42 Department of Health, UK. Vitamin D—advice on supplements for at risk groups. 2012. 51 Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children
www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups. and adolescents. Pediatrics 2006;117:2167-74.
43 National Institute of Health and Care Excellence guideline [PH56]. Vitamin D: increasing 52 Bell LM, Curran JA, Byrne S, et al. High incidence of obesity co-morbidities in young
supplement use among at-risk groups. (Public health guideline ph56.) 2014. www.nice. children: a cross-sectional study. J Pediatr Child Health 2011;47:911-7.
org.uk/guidance/ph56. 53 O’Malley G, Hussey J, Roche E. A pilot study to profile the lower limb musculoskeletal
44 Pearce SH, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ health in children with obesity. Pediatr Phys Ther 2012;24:292-8.
2010;340:b5664. 54 Riddiford-Harland DL, Steele JR, Storlien LH. Does obesity influence foot structure in
45 Lobstein T, Jackson-Leach R, Moodie ML, et al. Child and adolescent obesity: part of a prepubescent children? Int J Obes Relat Metab Disord 2000;24:541-4.
bigger picture. Lancet 2015 published online 18 Feb. 55 Mauch M, Grau S, Krauss I, et al. Foot morphology of normal, underweight, and overweight
46 Department of Health, UK. Healthy lives, healthy people: a call to action on obesity in children. Int J Obes (Lond) 2008;32:1068-75.
England. 2011. www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 56 Dietz WH Jr, Gross WL, Kirkpatrick JA Jr. Blount disease (tibia vara): another skeletal
213720/dh_130487.pdf. disorder associated with childhood obesity. J Pediatr 1982;101:735-7.
47 Department of Health. Physical activity, health improvement and protection. Start active, 57 Murray AM, Wilson NI. Changing incidence of slipped capital femoral epiphysis: a
stay active: a report on physical activity from the four home countries’ Chief Medical relationship with obesity? J Bone Joint Surg Br 2008;90:92-4.
Officers. 2011. www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 58 Foster HE, Kay LJ, Friswell M, et al. Musculoskeletal screening examination (pGALS) for
216370/dh_128210.pdf. school-age children based on the adult GALS screen. Arthritis Rheum 2006;55:709-16.
48 Shultz SP, Anner J, Hills AP. Paediatric obesity, physical activity and the musculoskeletal
system. Obes Rev 2009;10:576-82.
49 Gettys FK, Jackson JB, Frick SL. Obesity in pediatric orthopaedics. Orthop Clin North Cite this as: BMJ 2015;351:h3394
Am 2011;42:95-105.
© BMJ Publishing Group Ltd 2015

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 7 of 11

CLINICAL REVIEW

Table

Table 1| Normal variants and abnormal conditions according to age

Normal variants Conditions

Newborn to toddler:
Out-toeing Developmental dysplasia of the hip; neuromuscular (for example, myelodysplasia,
poliomyelitis)
Intoeing—metatarsus adductus with or without internal tibial torsion Congenital talipes equinovarus (clubfoot); neuromuscular (for example, cerebral
palsy)
Flexible flat foot Rigid flat foot—congenital vertical talus
Genu varum (bow legs) Infantile Blount’s disease
Preschool age (2-4 years):
Intoeing—internal tibial torsion with or without metatarsus adductus
Genu valgum Fracture (for example, consequence of proximal tibia metaphyseal fracture, also
known as Cozen’s fracture); genu varum—infantile Blount’s disease
School age (4-10 years):
Intoeing—femoral anteversion with or without internal tibial torsion Perthes’ disease (can present as intoeing or out-toeing)
Genu valgum Cozen’s fracture
Intoeing—residual femoral anteversion with or without internal tibial torsion
Out-toeing—lateral tibial torsion; femoral retroversion Slipped capital femoral epiphysis; genu varum—adolescent Blount’s disease
Flexible flat foot Rigid flat foot: tarsal coalition

In all age groups, other differential causes should be considered, such as vitamin D deficiency (rickets) and obesity, which can cause both genu valgum and genu
varum.

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 8 of 11

CLINICAL REVIEW

Figures

Fig 1 Typical normal values (mean and 2 standard deviations) for musculoskeletal measurements in children. Adapted
from Staheli et al 19857

Fig 2 Vertical line (heel bisector line) drawn through centre of heel. The severity of deformity is determined by where this
line meets the forefoot. (Left) Normal foot morphology in child, with heel bisector line crossing second webspace (between
second and third toes; red line) and straight lateral border of foot (blue line). (Right) Child with moderate metatarsus adductus,
with heel bisector line crossing third webspace (between third and fourth toes; red line), and a curved lateral border of foot
(blue line)

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 9 of 11

CLINICAL REVIEW

Fig 3 (Left) Both patellas point forwards (neutral position), but left foot turns inwards suggesting internal tibial torsion. Right
foot rests in normal slightly externally rotated position. Left leg is smaller overall as a result of congenital talipes equinovarus
(clubfoot), which was successfully treated in infancy. (Right) Toddler in prone position with knees at 90°, axes drawn through
thigh and foot show an increased thigh-foot angle on left, indicating internal tibial torsion; compare this with parallel axes
on right

Fig 4 Two year old sitting in “W” position, typical of femoral anteversion

Fig 5 Congenital vertical talus may be clinically confused with calcaneovalgus deformity or severe flat feet. (Upper left)
Rockerbottom deformity of sole of left foot (curved red outline); whereas right foot (upper right) is normal, with straight
outline of sole. Radiograph of child’s left foot (bottom) shows talus (blue line) to be in vertical position when it typically
should be in line with first metatarsal/big toe (yellow line)—angle formed between these two lines is known as Meary’s
angle. Note curved soft tissue outline of sole of foot as a result (red line). This condition warrants specialist referral

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 10 of 11

CLINICAL REVIEW

Fig 6 Child with bilateral flexible flat feet and fallen medial arches, hyperpronation of foot (left) and valgus heels (middle,
red line showing outward tilting of both heels) with “too many toes” sign. However, on tiptoe, the medial arch reforms (right)

Fig 7 (Left) Infant with bilateral physiological genu varum (bow legs)—gap between the knees (intercondylar distance, blue
line, normal <6 cm) is wider than gap between the ankles (intermalleolar distance, red line). (Right) Older child with genu
valgum (knock knees)—there is an appreciable gap between the ankles (red line, normal intermalleolar distance <8 cm)
when the knees are together

Fig 8 Long leg radiograph of a child with rickets. Both femora bow and there is unilateral overall genu varum of the left
leg—the mechanical axis (green line) of the left limb passes medial to the centre of the knee compared with the normal
alignment of the right leg

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;351:h3394 doi: 10.1136/bmj.h3394 (Published 7 July 2015) Page 11 of 11

CLINICAL REVIEW

Fig 9 Long leg radiographs of child with bilateral Blount’s disease of proximal tibia. Both legs box (worse on left) and space
between the knees (intercondylar distance) is wide when the ankles are together

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe