Intoeing and knock knees. Common issues in kids. Should you worry?

Parents often worry about the position of a child's feet or knees and don't realize that many of the issues are simply the normal progression during growth. Parents may know of a family member who needed special shoes or a splint to help with a similar condition, so assume a child will need the same. We now know that the special shoes and splints are usually not needed. Some of the treatments  parents try can be harmful because they interfere with normal play and movement, so discuss any treatment you want to try with your pediatrician first. Most kids outgrow the conditions on their own, so no time or money needs to be wasted on "cures." Most of the time these conditions do not cause permanent disfigurement or joint disease.

photo source: Shutterstock

Feet

Intoeing is commonly called being "pigeon toed." Intoeing does not cause pain and should not interfere with walking. If there is either pain or trouble walking, be sure to talk with your pediatrician. The most common causes of intoeing include:

• Metatarsus adductus is when the toes and part of the foot turn in. This is usually seen at birth. We often call this "positional foot deformity" because it is due to the position of the foot in the womb. We may ask parents to gently stretch the foot to help it straighten. If it is very stiff sometimes working with a physical therapist is helpful. Metatarsus adductus usually goes away on its own by 4-6 months of age. Occasionally casting of the foot is needed to straighten it by the time a child walks. 
• Internal tibial torsion is when the tibia (shin bone) rotates inward. It usually becomes noticed during the early walking years. The position of the tibia makes the feet turn inward when standing. As the tibia grows, it usually straightens on its own. If a child has problems with walking due to this or if it persists after 8 years of age, a consult with an orthopedist might be helpful.
• Femoral anteversion is similar to tibial torsion, but it involves the femur (thigh bone). It tends to occur in kids from preschool through elementary school. If the thigh bone turns in, it makes it appear that the knees and feet turn in. It is common in young school aged kids and usually resolves as the bones grow and straighten. If it causes significant problems walking or lasts past 10 years of age, a referral to an orthopedist might be considered.

 For great pictures and more information on in toeing visit OrthoInfo.

Club feet may look similar to metatarsus adductus, but more severe. The entire foot is typically involved and misshapen. It requires repeated casting and sometimes surgery to repair.

Flat feet are also common in kids. The foot often has a good arch when sitting, but when a child stands, the arch falls. Sometimes the ankle also rolls in. Flat foot is normal in infants and young children. The arch develops in your child's foot until at least age 5. You don't need special shoes, wedges, inserts or heels.

Knees

Between birth and 18 months, an outward-turning (varus) alignment from hip to knee to ankle is normal. This makes babies and toddlers look like cowboys with their bowed legs. Between about 18 and 24 months, this alignment normally becomes neutral. When the child is between 2 and 5 years old, an inward-turning (valgus) alignment is normal. This makes young children appear knock kneed. The alignment returns to neutral as the child grows. A wide range of knee alignment is normal. Just look around at people-- they come in all shapes, including their leg position. Special shoes and wedges don't help bowed legs or knock knees. Special exercises are not needed to straighten the legs. Again, most of the causes are simply a normal progression during growth, but if there is pain, difference from one leg to the other, or difficulty walking, it is not normal.

More on bowed legs:

• Physiologic bowed legs is the normal bowed leg appearance of toddlers. Both legs are affected equally for a symmetrical appearance to the knees. I always joke that they need the cowboy-style bowed legs to fit the diaper. This usually goes away by 3-4 years of age.
• Bowed legs can make a toddler's walk look funny, but it does not delay learning to walk and it does not cause them to fall more or be less coordinated. 
• Teens who have persistent bowed legs can have abnormal pressure placed on hips , ankles and knees, resulting in pain. If pain occurs, they should be evaluated by their doctor.
• Blount's disease is an abnormal bowing caused by an abnormal growth plate at the top of the shin bone. It might not be symmetrical from leg to leg. In young children it might look like physiologic bowed legs, but by 3 years of age it worsens. It can be diagnosed by x-ray. You can see a picture of this on OrthoInfo. This is an abnormal condition and requires treatment by an orthopedist.
• Rickets is an uncommon cause of bow legs in the US. It is due to insufficient calcium, phosphorus, and vitamin D, either due to nutritional deficiency or a metabolic problem. X-rays and labs can help diagnose this condition. It is an abnormal condition, and treatment varies depending on the cause.
• Overweight children can develop a bowed leg appearance. Losing weight can decrease the stress on the hips, knees, and ankles to decrease the associated pain. Work with your doctor for help.

More on knock knees:

• Knock knees is a normal development in many kids. The knees seem to point inward. The knees can touch when the ankles are still apart. Knock knees usually straighten out by about 9 years of age, but in some families they persist into adulthood.

What to know about knock knees

• Knock knees are angular deformities at the knee, in which the head of the deformity points inward.
• A standing child whose knees touch but whose ankles do not is usually said to have knock knees.
• During childhood, knock knees are a stage in normal growth and development (physiologic valgus).*

* Between birth and 18 months, an outward-turning (varus) alignment from hip to knee to ankle is normal. Between about 18 and 24 months, this alignment normally becomes neutral. When the child is between 2 and 5 years old, an inward-turning (valgus) alignment is normal. The alignment returns to neutral as the child grows.

• The condition is slightly more common in girls, although boys can develop it, too.
• The condition usually becomes apparent when a child is 2 to 3 years old and may increase in severity until about age 4.
• Knock knees usually correct themselves by the time a child is 7 or 8 years old. Occasionally, the condition persists into adolescence.
• If the condition doesn’t appear until a child is 6 or older, she may have an underlying bone disease (pathologic valgus), and the condition may be more serious.
• Obesity can contribute to knock knees—or can cause gait (manner of walking) problems that resemble, but aren’t actually, knock knees.

How Boston Children's Hospital approaches knock knees
Doctors at Children's closely monitor your child’s leg development, to make sure that her legs straighten themselves naturally. In the unlikely event that the condition doesn’t self-correct, your child’s doctors may have her wear corrective leg braces. Only children with the most severe cases may need surgery.
Whatever observation or treatment your child needs, you can have peace of mind knowing that as a national and international orthopedics referral center, our Orthopedic Center has vast experience treating children with every kind of developmental condition, some of which few other pediatric hospitals have ever encountered. As a result, we can provide expert diagnosis, treatment and care for every severity level of knock knees.

- See more at: http://www.childrenshospital.org/health-topics/conditions/knock-knees#sthash.rE3S8TMp.dpuf

What to know about knock knees

• Knock knees are angular deformities at the knee, in which the head of the deformity points inward.
• A standing child whose knees touch but whose ankles do not is usually said to have knock knees.
• During childhood, knock knees are a stage in normal growth and development (physiologic valgus).*

* Between birth and 18 months, an outward-turning (varus) alignment from hip to knee to ankle is normal. Between about 18 and 24 months, this alignment normally becomes neutral. When the child is between 2 and 5 years old, an inward-turning (valgus) alignment is normal. The alignment returns to neutral as the child grows.

• The condition is slightly more common in girls, although boys can develop it, too.
• The condition usually becomes apparent when a child is 2 to 3 years old and may increase in severity until about age 4.
• Knock knees usually correct themselves by the time a child is 7 or 8 years old. Occasionally, the condition persists into adolescence.
• If the condition doesn’t appear until a child is 6 or older, she may have an underlying bone disease (pathologic valgus), and the condition may be more serious.
• Obesity can contribute to knock knees—or can cause gait (manner of walking) problems that resemble, but aren’t actually, knock knees.

How Boston Children's Hospital approaches knock knees
Doctors at Children's closely monitor your child’s leg development, to make sure that her legs straighten themselves naturally. In the unlikely event that the condition doesn’t self-correct, your child’s doctors may have her wear corrective leg braces. Only children with the most severe cases may need surgery.
Whatever observation or treatment your child needs, you can have peace of mind knowing that as a national and international orthopedics referral center, our Orthopedic Center has vast experience treating children with every kind of developmental condition, some of which few other pediatric hospitals have ever encountered. As a result, we can provide expert diagnosis, treatment and care for every severity level of knock knees.

- See more at: http://www.childrenshospital.org/health-topics/conditions/knock-knees#sthash.rE3S8TMp.dpuf