Normal Variants of the Lower Limbs in Pediatric Orthopedics

Normal variants of lower limb development such as in-toeing, out-toeing, flat feet, bow-legs and knock knees are a common cause for parental concern and also a common source of referral to pediatric clinics. A thorough history and clinical examination is usually all that is required to make the diagnosis of a normal variant. They also help to exclude pathological conditions that may present in a similar fashion. Radiological and other investigations are not routinely required in children with normal variants of the lower limb except to exclude pathological conditions. Shoe inserts, orthoses and physical therapy are not to be encouraged as they provide no benefit. In the majority of cases the natural history is one of spontaneous resolution of the deformity. Surgery may, however, be required in a small number of patients greater than eight years in whom severe in or out-toeing is present. Parental education and reassurance is an important part of the treatment and must be re-emphasized.