Intoeing, bow legs and knock knees — Rapid

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.
First-line assessment is history, growth and a bilateral standing and walking examination; typical symmetrical age-appropriate variants need no radiographs.
Obtain standing full-length alignment films for asymmetric, severe, painful or progressive deformity and targeted mineral bloods when rickets is plausible.
Shoes, insoles, twister cables, splints and stopping W-sitting do not accelerate normal femoral or tibial derotation.
First-line management of a typical painless variant is explanation, unrestricted activity and planned review only when age, severity or parental concern warrants it.
Use guided growth for selected pathological coronal deformity with sufficient growth remaining and rotational osteotomy only for persistent severe functional torsion.

Key red flags

Marked asymmetry, rapid progression or deformity confined to one limb is not a typical physiological developmental pattern.

Varus that worsens after age two, especially in a heavier early walker, raises infantile Blount disease and needs standing imaging.

Short stature, widened wrists, bone pain, delayed milestones or poor diet with bowed legs suggests rickets or skeletal dysplasia.

Persistent severe knock knees beyond about seven years, intermalleolar gap progression or patellar instability warrants specialist measurement.

Pain, limp, joint swelling, night waking or loss of function requires a diagnosis beyond parental cosmetic concern.

Weakness, abnormal tone, unequal reflexes or regression suggests neuromuscular rotation rather than benign developmental intoeing.

Investigation priorities

First-line rotational and coronal profileFirst stepFirst line

Localise deformity to foot, tibia, femur or knee and compare severity with age and function.

Management branches

Typical developmentExplain and observe safely

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.
Provide return advice for asymmetry, progression, pain, limp or functional loss.
Use a planned review only when the child is near an age boundary or family concern remains high.

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.Check calcium, phosphate, renal disease, malabsorption and duplicate supplements; severe or atypical rickets needs specialist management and monitoring.

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.Verify weight and all combination products; increasing pain can indicate compartment pressure, infection or fixation problem and requires examination.

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