Synopsis
Separate normal rotational and coronal development from progressive unilateral, metabolic or growth-plate deformity and avoid ineffective bracing while identifying the small group needing guided growth or osteotomy.
- Common intoeing sources change with age: metatarsus adductus in infancy, internal tibial torsion in toddlers and femoral anteversion in preschool or school years.
- Use the rotational profile: foot progression angle, patellar direction, hip rotation, thigh-foot angle and heel-bisector line localise the level.
- Physiological coronal alignment progresses from infant bowing to neutral near two years, peak knock knees around three to four and gradual mature alignment by about seven.
Key red flags
Marked asymmetry, rapid progression or deformity confined to one limb is not a typical physiological developmental pattern.
Investigation priorities
Localise deformity to foot, tibia, femur or knee and compare severity with age and function.
Management branches
Alignment is symmetrical, painless, age-appropriate and the child grows and functions normally.
- Document the rotational profile or coronal measure and explain the expected age trajectory.
- Encourage unrestricted play and advise that shoes, insoles, braces and sitting changes do not accelerate remodelling.
Key medicines
Colecalciferol only for confirmed vitamin-D needUse the age-specific prevention or deficiency-treatment regimen from current BNFC and local paediatric metabolic guidance after measuring or establishing need; do not prescribe a universal dose for every bowed child.
Paracetamol after corrective surgeryPrescribe the current BNFC age- and weight-based dose with exact milligrams, formulation, interval and daily maximum as part of multimodal postoperative analgesia.