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.

Share and Cite:

S. Jones, S. Khandekar and E. Tolessa, "Normal Variants of the Lower Limbs in Pediatric Orthopedics," International Journal of Clinical Medicine, Vol. 4 No. 7B, 2013, pp. 12-17. doi: 10.4236/ijcm.2013.47A2004.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] D. Molony, G. Hefferman, et al., “Normal Variants in the Pediatric Orthopedic Population,” Irish Medical Journal, Vol. 99, No. 1, 2006, pp. 13-14.
[2] T. L. Lincoln and P. W. Suen, “Common Rotational Variations in Children,” Journal of the American Academy of Orthopaedic Surgeons, Vol. 11, No. 5, 2003, pp. 312-320.
[3] L. T. Staheli, “Lower Limb-Fundamentals of Pediatric Orthopedics,” 4th Edition, Lippincott Williams and Wilkins, Philadelphia, 2008.
[4] D. H. Jones and R. A. Hill, “Children’s Orthopedics: Normal Development and Developmental Disorders,” R. C. G. Russell, C. J. K. Bulstrode and N. S. Willams, Eds., Bailey and Love’s Short Practice of Surgery, 23rd Edition, Hodder Arnold, London, 2000, p. 421.
[5] D. R. Wenger, D. Mauldin, G. Speck, et al., “Corrective Shoes and Inserts as Treatment for Flexible Flatfoot in Infants and Children,” The Journal of Bone and Joint Surgery, Vol. 71, No. 6, 1989, pp. 800-810.
[6] A. Dietz, “Intoeing: Fact, Fiction and Opinion,” American Family Physician, Vol. 50, No. 6, 1994, pp. 1249-1259, 1262-1264.
[7] L. A. Karol, “Rotational Deformities in the Lower Extremities,” Current Opinion in Pediatrics, Vol. 9, No. 1, 1997, pp. 77-80. doi:10.1097/00008480-199702000-00016
[8] L. T. Staheli and G. M. Engel, “Tibial Torsion: A Method of Assessment and a Survey of Normal Children,” Clinical Orthopaedics, Vol. 86, 1972, pp. 183-186. doi:10.1097/00003086-197207000-00028
[9] S. B. Murphy, S. R. Simon and P. K. Kejewski, “Femoral Anteversion,” The Journal of Bone and Joint Surgery, Vol. 69, No. 8, 1987, pp. 1169-1176.
[10] L. T. Staheli, “Rotational Problems in Children,” The Journal of Bone and Joint Surgery, Vol. 75, No. 6, 1993, pp. 939-949.
[11] L. T. Staheli, M. Corbett, C. Wyss, et al., “Lower Extremity Rotational Problems in Children: Normal Values to Guide Management,” The Journal of Bone and Joint Surgery, Vol. 67, No. 1, 1985, pp. 39-47.
[12] J. A. Herring, “Tachdjians Pediatric Orthopedics,” 3rd Edition, Vol. 2, WB Saunders, Philadelphia, 2002.
[13] U. A. Hunziker, R. H. Largo, et al., “Neonatal Metatarsus Adductus, Joint Mobility, Axis and Rotation of the Lower Extremity in Preterm and Term Children 0 5 Years of Age,” European Journal of Pediatrics, Vol. 148, No.1, 1988, pp. 19-23. doi:10.1007/BF00441806
[14] E. E. Bleck, “Metatarsus Adductus: Classification and Relationship to Outcomes of Treatment,” Journal of Pediatric Orthopaedics, Vol. 3, No. 1, 1983, pp. 2-9. doi:10.1097/01241398-198302000-00002
[15] K. Katz, R. David and M. Soudry, “Below-Knee Plaster Cast for the Treatment of Metatarsus Adductus,” Journal of Pediatric Orthopaedics, Vol. 19, No. 1, 1999, pp. 4950. doi:10.1097/01241398-199901000-00011
[16] D. R. Wenger and J. Leach, “Foot Deformities in Infants and Children,” Pediatric Clinics of North America, Vol. 33, No. 6, 1986, pp. 1411-1427.
[17] E. J. Wall, “Practical Primary Pediatric Orthopaedics,” Nursing Clinics of North America, Vol. 35, No. 1, 2000, pp. 95-113.
[18] L. T. Staheli and L. Giffin, “Corrective Shoes for Children: A Survey of Current Practice,” Pediatrics, Vol. 65, No. 1, 1980, pp. 13-17.
[19] P. Salinius and E. Vankka, “The Development of the Tibiofemoral Angle in Children,” The Journal of Bone and Joint Surgery, Vol. 57, No. 2, 1975, pp. 259-261.
[20] C. H. Heath and L. T. Staheli, “Normal Limits of Knee Angle in White Children: Genu Varum and Genu Valgum,” Journal of Pediatric Orthopaedics, Vol. 13, No. 2, 1993, pp. 259-262.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.