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Normal variants - When to Refer

There are a number of common foot and lower limb deformities seen in children. Occasionally presenting symptoms are warning signs that there may be underlying pathology present.

Advice is given below on when and when not to refer for some of the common normal variants. 

Referral pathways will depend on local services available but often concerns regarding normal variants will be referred to paediatric orthopaedics, paediatric physiotherapy, community paediatrics or paediatric rheumatology.


Consider referral if: 

  • Toe-walking is persistent beyond 2 years.
  • There is associated developmental delay.
  • The child is unable to squat or stand with their heels on the floor (tightness of calf muscles).
  • The child is over 3 years and is unable to stand from floor sitting without using their hands.
  • The toe walking is asymmetrical.

Referral is not necessary if: 

  • The toe walking is intermittent or can be done intentionally by the child 'for fun'.
  • The child is able to squat to play on the floor and is able to keep their heels on the floor.


It is normal for babies and toddlers to have ‘flat feet’ due to the presence of fatty tissue on the insoles of their feet. This persists until approximately 4-6 years of age. Many children present with ‘flexible flat feet’ early in their walking development; most will 'grow out' of it as their walking matures and they develop a longitudinal arch. Walking in bare in feet is ideal for promoting foot development.

Consider referral if:

  • There are signs of abnormal pressure on the skin of the foot e.g. blistering or callosities.
  • The longitudinal arch does not form normally when the child stands on tip-toe.
  • The foot is stiff (i.e., the normal arch does not form when the child stands on tip-toe, or the big toe is passively extended) - example of stiff flat feet is shown below (due to tarsal coalition).

stiff flat feet

Referral is not necessary if: 

  • The child is under four years of age.
  • The longitudinal arch forms normally when the child stands on tip-toe or when the big toe is passively extended (i.e. flexible flat feet).


This is the opposite of flat feet and is when the arch is extremely pronounced. It is rarely seen as an isolated finding and is usually indicative of a neurological cause; therefore a referral to paediatric neurologist or paediatrician is the most appropriate action.

KNOCK KNEES (Genu Valgum)

This is when a child stands with their knees together and their ankles at least 2.5cm apart (intermalleolar distance). A gap of 6 – 7 cm between the ankles (intermalleolar distance) is normal between the ages of two and four years. Knock-knees usually resolve spontaneously approximately by the age of six years.

Consider referral if: 

  • The problem is associated with pain in the lower limbs.
  • The problem is asymmetrical.

Referral is not necessary if: 

  • The child is under the age of six and the problem does not result in any pain.

BOW LEGS (Genu Varum)

This is when there is a small gap between a child’s knees and the ankles when standing with the feet together. This is normally seen in children until the age of two years. Physiotherapy referral is generally not appropriate. Children are born bow-legged and it approaches normal by 2 years, typically as a result of the child beginning to walk.

Consider referral if: 

  • There is associated pain in the lower limbs.
  • The problem is persistent or asymmetrical.
  • The child has evidence of underlying metabolic disease (e.g. Rickets).


In-toeing is when a child walks with their feet turning inwards, and is commonly referred to as ‘pigeon toeing’. It is a variation of normal and is part of normal development for many toddlers when just learning to walk. It will usually resolve as the child grows and the musculo-skeletal system matures, normally by the age of ten years. During this period of in-toeing the child may tend to trip and fall a little more than their peer group. Insoles and exercises will not help. Surgery is reserved for children over ten years old, or with associated deformities not in keeping with normal variants. Physiotherapy referral is not usually appropriate. See the section on in-toeing for more details on etiology.


This is when a child’s feet point outwards. As with in-toeing, this condition will usually resolve spontaneously by the age of four and therefore referral to Physiotherapy is generally not necessary. Recent onset out-toeing in a teenager may be serious and an indication of Slipped Upper (Capital) Femoral Epiphysis. If the hips have normal range of motion and the child is pain free, referral is typically not necessary. If the child has abnormalities on examination, even if bilateral, referral should strongly be considered.

out toeing

Out-toeing in an adolescent - hips have normal range of movement and are pain free.

No action required other than reassurance.




Surgery is the only treatment and is usually done in those over 4 years of age. Physiotherapy and podiatry will not help.


There is considerable variation in the way normal gait patterns develop - such variation may be familial (e.g. ‘bottom-shufflers’ often walk later) and subject to racial variation (e.g. African black children tend to walk sooner and Asian children later than average).  

Consider referral if :

  • Walking is delayed beyond 18 months.
  • Delay in other milestones (e.g speech, communication, feeding).
  • Clumsiness or prone to falling.
  • Family history of delayed walking or muscle disease.
  • Muscles appear 'bulky' (e.g. calf pseudohypertrophy).
  • Difficulty getting up from the floor (Gower's sign).

Examples of Gower's sign, waddling gait and other features suggestive of muscle disease are available.

CLUBFOOT (Congenital talipes equinovarus - CTEV)

A true clubfoot, or congenital talipes equinovarus, is a structural deformity that presents in newborn babies.  It affects the bones, muscles and ligaments in the foot, and the foot usually adopts a fixed adducted, inverted and plantarflexed position. In 50 percent of cases both feet will be involved.

It is important to be able to distinguish between a CTEV, and a Positional talipes equinovarus, which is a flexible positional condition that is thought to occur due to the position of the foetus in utero. A positional talipes equinovarus does not involve a bony deformity, and usually responds well to physiotherapy.

Clubfoot is one of the most common birth defects, and affects 1 in every 800 births. There is variation in countries and across certain ethnic groups. The Ponseti method is the 'gold standard' treatment for children with this condition; this involves a series of casting (and in a minority, minor surgery is needed), to gradually improve the position of the foot.  The outcome is generally good for children identified and treated quickly. However unfortunately many children born with clubfoot in low or middle income countries have limited access to proper treatment.

All babies born with a talipes equinovarus should be examined by a paediatrician or paediatric physiotherapist, to distinguish whether the deformity is structural or positional in nature.  Those with a structural clubfoot should be referred to a specialist paediatric orthopaedic team, who can commence treatment as soon as possible.  If the foot position is found to be flexible, assessment should be sought from a paediatric physiotherapist, who can provide appropriate advice and stretches as necessary.

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