Lower Extremity Abnormalities in Children

Rotational and angular variations of the lower extremities in children are common conditions seen in primary care. These visits are often due to parental concerns about the appearance of their child's lower extremities. Common variations include intoeing (metatarsus adductus, internal tibial torsion, and femoral anteversion); out-toeing (external tibial torsion, femoral retroversion, and pes planus); and angular variations (genu varum and genu valgum). History, particularly age of onset; duration; progression; appearance and impact; prenatal and birth history; nutritional deficiencies; growth and development; medical and family history of related disorders, including rheumatologic, autoimmune, or neurologic conditions, can help differentiate normal variations from true deformities. In addition to a routine physical examination, a focused examination measuring a variety of parameters, such as foot progression angle, internal and external hip rotation, thigh-foot angle, joint laxity, and other condition-specific tests should be performed. If an underlying cause is identified, it should be treated; however, these conditions typically do not require further evaluation or treatment if measurements are within age-related normal ranges and patients are asymptomatic, and parents can be reassured that they are benign. There is minimal evidence to support the use of orthotics or braces. Referral to a pediatric orthopedist should be considered when measurements are more than 2 standard deviations outside of normal values, children have pain, or function is affected.