Intoeing, bow legs and knock knees

Clarify what the family sees: toes, patellae, knees or ankles, whether one side differs and whether appearance changes with fatigue. Ask when it began, progression, pain, falls, activity, birth position, developmental milestones, nutrition, vitamin-D risk, fracture, infection and family stature or deformity. Record growth chart rather than describing the child only as small. Cosmetic concern is legitimate, but surgery is justified by predicted persistence, function and joint mechanics rather than photographs alone.

Observe standing from front and behind, then gait barefoot at comfortable speed. Note foot progression and whether patellae face inward with the feet, which suggests femoral anteversion, or forward with inward feet, which favours tibial torsion. Inspect arches, heel position and lateral foot border. Measure intermalleolar distance with knees together for valgus and intercondylar distance with ankles together for varus using a reproducible position.

Complete the rotational profile prone and supine. Compare internal and external hip rotation; markedly increased internal rotation with reduced external rotation supports femoral anteversion. Measure thigh-foot angle with knees flexed to estimate tibial torsion. Use the heel-bisector line and forefoot flexibility for metatarsus adductus. Assess leg length, knee stability, patellar tracking, joint range, spine, tone, power and reflexes. Never infer the level from shoe direction alone.

Typical symmetrical variants within the expected age course need no imaging. Obtain standing AP long-leg radiographs with patellae forward when deformity is persistent, asymmetric, progressive, painful or outside age expectations. Draw the mechanical axis and localise joint-orientation abnormality rather than measuring only knee gap. For suspected Blount disease assess proximal tibial metaphysis and metaphyseal-diaphyseal angle. CT torsion studies are reserved for operative planning because of radiation.

Investigate systemic clues selectively. In a child with bowing, pain, growth failure or dietary or renal risk, measure adjusted calcium, phosphate, ALP, PTH, vitamin D and renal profile and radiograph wrists or knees for metaphyseal change. Dysplasia assessment uses skeletal-survey and genetic pathways, not indiscriminate images. MRI or CT maps a suspected physeal bar after injury. A normal blood panel does not make a progressive unilateral deformity physiological.

Reassure clearly when development is typical. Metatarsus adductus that is flexible often corrects spontaneously; stretching is optional only if taught gently, and rigid progressive feet need referral. Internal tibial torsion and femoral anteversion commonly remodel with growth. Ordinary play should continue. Special shoes, braces and sitting restrictions do not change bony version and can create cost, stigma and reduced activity.

Pathological coronal deformity is treated according to cause and growth. Correct rickets or endocrine disease first. In early Blount disease, selected bracing may be considered within specialist practice, while progressive disease can need guided growth or osteotomy. Temporary hemiepiphysiodesis tethers one side of an open physis to correct valgus or varus gradually; timing must allow enough growth without overshoot. Mature or severe multiplanar deformity needs planned osteotomy.

Derotation osteotomy is reserved for persistent severe torsion causing functional limitation, patellar instability or major psychosocial impact after spontaneous-remodelling age. The surgeon selects femoral or tibial level from the rotational profile and gait, not from intoeing alone. Follow alignment and limb length after guided growth and remove implants at the intended correction. Explain rebound and overcorrection, especially in younger children with substantial growth remaining.