Lower Extremity Abnormalities in Children

Caitlyn M. Rerucha; Caleb Dickison; Drew Baird

Aug 15, 2017 Issue

Lower Extremity Abnormalities in Children

CAITLYN M. RERUCHA, MD; CALEB DICKISON, DO; and DREW C. BAIRD, MD, Carl R. Darnall Army Medical Center, Fort Hood, Texas

Am Fam Physician. 2017 Aug 15;96(4):226-233.

Patient Information: Handouts on this topic are available at https://familydoctor.org/condition/intoeing/ and https://familydoctor.org/condition/flat-feet/.

Author disclosure: No relevant financial affiliations.

Leg and foot problems in childhood are common causes of parental concern. Rotational problems include intoeing and out-toeing. Intoeing is most common in infants and young children. Intoeing is caused by metatarsus adductus, internal tibial torsion, and femoral anteversion. Out-toeing is less common than intoeing and occurs more often in older children. Out-toeing is caused by external tibial torsion and femoral retroversion. Angular problems include genu varum (bowleg) and genu valgum (knock knee). With pes planus (flatfoot), the arch of the foot is usually flexible rather than rigid. A history and physical examination that include torsional profile tests and angular measurements are usually sufficient to evaluate patients with lower extremity abnormalities. Most children who present with lower extremity problems have normal rotational and angular findings (i.e., within two standard deviations of the mean). Lower extremity abnormalities that are within normal measurements resolve spontaneously as the child grows. Radiologic studies are not routinely required, except to exclude pathologic conditions. Orthotics are not beneficial. Orthopedic referral is often not necessary. Rarely, surgery is required in patients older than eight years who have severe deformities that cause dysfunction.

Parents commonly seek medical advice because of concerns about the appearance of their child's lower extremities, feet, or gait.1,2 Most concerns are normal variations of growth and development and are best managed with parental reassurance.1 Common normal variants of the lower extremities in children include rotational problems such as intoeing and out-toeing, angular problems such as genu varum (bowleg) and genu valgum (knock knee), and pes planus (flatfoot).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Radiography is not needed in the initial evaluation to differentiate normal variations in childhood limb development from pathologic lower extremity abnormalities.	C	2–7, 9, 12
The physical examination for lower extremity abnormalities should include measurements of height and weight with growth percentiles; inspection of the face, skin, and neurologic system; and focused musculoskeletal examination, including torsional profile and angular measurements.	C	3–6
Discussions with parents should focus on the natural course of lower extremity abnormalities and include reassurance; most rotational and angular concerns resolve spontaneously if measurements are within two standard deviations of the mean.	C	1–5, 12, 18–21, 25–28, 30, 31
Lower extremity rotational and angular abnormalities that are two standard deviations outside the mean or that persist beyond the expected age of resolution should be referred to an orthopedic surgeon.	C	3, 5, 11, 21, 25–28
Orthotics are not effective in the treatment of lower extremity rotational and angular abnormalities.	C	3–5, 20
Adjustable shoes are effective for the treatment of metatarsus adductus in prewalking infants with motivated parents and are less expensive than serial casting.	B	10, 14, 16, 17
Adolescents with rigid or symptomatic flexible pes planus should receive imaging of the feet and referral to a podiatrist or orthopedist.	C	6, 22–24

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Radiography is not needed in the initial evaluation to differentiate normal variations in childhood limb development from pathologic lower extremity abnormalities.	C	2–7, 9, 12
The physical examination for lower extremity abnormalities should include measurements of height and weight with growth percentiles; inspection of the face, skin, and neurologic system; and focused musculoskeletal examination, including torsional profile and angular measurements.	C	3–6
Discussions with parents should focus on the natural course of lower extremity abnormalities and include reassurance; most rotational and angular concerns resolve spontaneously if measurements are within two standard deviations of the mean.	C	1–5, 12, 18–21, 25–28, 30, 31
Lower extremity rotational and angular abnormalities that are two standard deviations outside the mean or that persist beyond the expected age of resolution should be referred to an orthopedic surgeon.	C	3, 5, 11, 21, 25–28
Orthotics are not effective in the treatment of lower extremity rotational and angular abnormalities.	C	3–5, 20
Adjustable shoes are effective for the treatment of metatarsus adductus in prewalking infants with motivated parents and are less expensive than serial casting.	B	10, 14, 16,

The Authors

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CAITLYN M. RERUCHA, MD, is a faculty physician at the Carl R. Darnall Army Medical Center Family Medicine Residency, Fort Hood, Tex....

CALEB DICKISON, DO, is a faculty physician at the Carl R. Darnall Army Medical Center Family Medicine Residency.

DREW C. BAIRD, MD, is program director of the Carl R. Darnall Army Medical Center Family Medicine Residency.

Address correspondence to Caitlyn M. Rerucha, MD, Carl R. Darnall Army Medical Center, 36000 Darnall Loop, Fort Hood, TX 76544 (e-mail: cmreruchamd@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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