Common childhood foot and leg conditions

A child’s lower limbs (legs and feet) are constantly developing and changing shape during the first decade of their life. During this musculoskeletal development, some children’s lower limbs differ in appearance to their peers. Often this is considered as a normal physiological process called Normal Variant. This means there is an acceptable range of variation amongst children and even as the child develops the variations in their own lower limb appearance changes, as shown in the picture below.

Infographic showing stages of normal foot development in children, highlighting common foot conditions.

Normal Development

As the child grows, something that appears to look unusual will often correct itself as the development continues, without the need for any intervention or further assessment.

This is not to say that all variation is acceptable. Sometimes it can be that there is something more going on that needs to be addressed. The quick rule of thumb of when a child should seek further assessment is:

– If a child is limping or moving one lower limb quite differently to the other
– If a child is complaining of pain in the lower limb or back
– If a child is tripping or falling more than their peers
– If a younger child or toddler is slower than their peers to achieve their motor milestones, such as rolling/crawling/sitting/standing/walking
– If a child is not able to keep up with their peers in activities, such as running or playing sports

Normal Variants

So, what are the different Normal Variants we commonly see?
In-toeing (pigeon toes) or out-toeing are rotational variations within a child’s lower limbs.

In-toeing is more common than out-toeing, and it occurs in 2 per 1000 children.

In-toeing is more common than out-toeing, and it occurs in 2 per 1000 children. It usually occurs in both legs and affects boys and girls equally. It is often seen in sprinters! There are 3 common reasons for in-toeing.
1. In toddlers under the age of one, a condition causing a curve in the foot, which is known as Metatarsus Adductus. **This is not the same as positional talipes (which does require intervention).
2. In younger children, under the age of 4, a condition called Tibial Torsion, which is a slight twist in the shin bone
3. In older children, between the age of 4-10, a condition called Femoral Anteversion, which is a turning in of the thigh bone at the hip joint
** In the younger child excessive turning inwards of the foot, coming from the hip joint, can sometimes be indicative of a hip condition, called hip dysplasia. This warrants further assessement.

Knock Knees or Bow legs

Knock Knees (Genu valgum) or Bow legs (Genu Varum) are types of angular variations.
In the younger toddler, age 10-14 months, bow legs are a normal presentation when the child starts standing. This is thought to be due to the positioning of the baby in the womb. It can look more prounounced if the child has started standing and walking at an earlier age than their peers. If it continues past the age of 3 years, or it is progressing as the child gets older, is painful or occurs in only 1 side, it warrants further assessment.

Knock knees usually occurs at the age of 3-4 years and resolves at age 7-8 years

Knock Knees

Knock knees usually occurs at the age of 3-4 years and resolves at age 7-8 years. If can be familial so if the adults in the family have knock knees, the children may also continue to have a degree of knock knees past the age of 7-8 years. It can be accentuated by obesity, hypermobility or ligament laxity, flat feet and if the child also has femoral anteversion (intoeing coming from the hip). If it is progressing, is painful, the knees are stiff, it is more obvious on one side, or following an injury, it is worth seeking further assessment.

Flat Feet

Flat feet are one of the greatest concerns for parents for their child, accounting for over 90% of referrals to specialist paediatric orthopaedics and physiotherapy. We all want to ensure we prevent any current issues for our child, but also for their future. However, just like the rest of the lower leg, the foot is also developing over the 1st ten years of a child’s life, so the foot will at times appear quite flat, especially when the child is younger. This is a normal occurrence and does not necessarily warrant treatment, such as orthotics.

When a baby is not yet walking there is a large fat pad on the sole of the foot and no arch is visible. By the age of 2-3 an arch will start to develop and by the age of 4-8 if the child is going to develop an arch, it will do so. It is good to remember our children inherit our feet though, so if you or your partner have a flat foot, most likely your child will also have a degree of flat foot. Flat feet can be accentuated in a child with hypermobility or ligament laxity; obesity or in certain conditions also, such as Down Syndrome, a child may have a flatter foot.

Flat feet are one of the greatest concerns for parents for their child

Flexible Flat Foot

When a child has a normal developing foot, but at some point, it appears flat, we call this a flexible flat foot. A flexible flat foot means your child’s feet are flat but when they stand up on to their tiptoes an arch appears.

If a child has a flat foot that is not part of normal development, no arch will form as they go up onto their tiptoes. We call this a rigid flat foot. A rigid flat foot requires further assessment usually with an paediatric orthopaedic surgeon.
If a child is limping, complaining of pain, has one foot shaped differently to the other, has a flat foot in all positions, both weightbearing and non-weightbearing; and/or is not able to keep up with their peers, this indicates further assessment is required.

There are times when even a flexible “flat” foot can cause a child issues, and at this point, help with an orthotic, could be beneficial. This does not mean that the child always needs an orthotic. If the foot develops and the issue resolves, it is highly likely for most children that extra help is no longer needed.

PMC Physio Recommendation

If you have any concerns regarding your child’s lower limb development, please contact us here in PMC Physiotherapy clinic, where Caitriona, our specialist Paediatric Physiotherapist, is more than happy to fully assess your child, and ensure that it is normal development, as opposed to a condition that requires further investigation and treatment. We here also provide and fit for orthotics if that is deemed suitable for your child.


PMC Physiotherapy Clinic, Unit 36, Dunboyne Business Park, Dunboyne, Co Meath

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