1. PIGEON TOES, KNOCK KNEES, AND FLAT FEET: WHEN TO SEE THE ORTHOPAEDIC SURGEON
I.M. Doctor, M.D.
My Office
My City, State
Good [morning/afternoon]. I’m Dr. [Name], an orthopaedic surgeon at [office]. Our focus today is on some of the toe and leg alignment problems commonly seen in children; what they are, how to treat them and what can be expected with growth.

2. Thank you to Members of the
The information in this presentation was provided to the presenter by the American Academy of Orthopaedic Surgeons and may be modified.
Endorsement of this presentation by the AAOS is not implied or inferred.
Thank you to Members of the
Pediatric Orthopaedic Society of North America
for contributions to the
content of this presentation.
The information in this presentation was provided to me by the American Academy of Orthopaedic Surgeons and may be modified. Endorsement of this presentation by the AAOS is not implied or inferred.

3. What is an orthopaedic surgeon?
MD who specializes in treatment and health maintenance of musculoskeletal system (bones, joints, ligaments, muscles, tendons, cartilage and spine)
First, I’d like to give you a little background on what orthopaedic surgeons do. An orthopaedic surgeon is a medical doctor with extensive training in helping to keep bones, joints, ligaments, muscles, tendons, cartilage and spine in good working order. Together, all of these parts of our bodies make up our musculoskeletal system

4. What is an orthopaedic surgeon?
The expert in treating the musculoskeletal system
The expert in maintaining musculoskeletal health
Orthopaedic surgeons have the greatest knowledge of and experience with the wide range of conditions and treatment options available in musculoskeletal care, many of which do not involve surgery. However, if surgery is the best recommendation for recovery, the orthopaedic surgeon is the best trained to provide that surgical treatment.

5. Educating an Orthopaedic Surgeon
College
Medical School
Internship
Orthopaedic Residency
Fellowship (optional)
2 Years Practice
TOTAL
4 1 (1) 2 16 years!
As this chart shows, it typically takes 16 years or more of formal education and training to become an orthopaedic surgeon. Beyond that, special certification and life-long learning is essential, as orthopaedics is a field that is continually growing and evolving.

6. What do orthopaedic surgeons do?
Diagnose
Treat
Medication
Physical Therapy
Exercise
Brace
Surgery
Prevent
Orthopaedic surgeons use the most effective and efficient diagnostic tools and experience in musculoskeletal treatment to determine the best course of treatment for our patients.

7. What is a pediatric orthopaedic surgeon?
Orthopaedic surgeons who have chosen to make the core of their practice the care of children and adolescents who have musculoskeletal conditions
Typically have completed additional subspecialty training (fellowship) in pediatric orthopaedics
Pediatric orthopaedic surgeons have chosen to focus their practice on children and adolescents who have musculoskeletal conditions. These surgeons typically have had additional training, such as a fellowship, to learn more about treating these young patients.

8. Why pediatric orthopaedics?
Children are not just small adults
Bodies are still growing
Responses to injuries and conditions are different
Communication skills, emotions and cooperation are different
Pediatric patients have special needs—they are not just small adults. Their bodies are still growing, so their muscles, bones, tendons, and ligaments require different types of treatment, and their bodies’ response to injuries and conditions are different that adults’. Also, as those of you with children know, their communication skills, emotions, and ability to cooperate are not the same.

9. When is a pediatric orthopaedic surgeon the best choice?
For uncommon conditions
When adult orthopaedic surgeons are not comfortable with evaluation or treatment
When you have concerns that pediatric-focused orthopaedic care is needed
While your pediatrician can handle many childhood ailments, a pediatric orthopaedic surgeon may be needed in some circumstances. These include uncommon conditions, when adult orthopaedic surgeons are not comfortable providing a child with evaluation or treatment, or when you have concerns that pediatric-focused orthopaedic care would be the best choice for your child.

10. Pigeon Toes, Knock Knees, and Flat Feet
Common conditions that are often normal:
Feet turn out/in
Knock knees
Bow legs
Flat feet
Today I’m here to talk to you about some orthopaedic conditions common to children, known in layman’s terms as pigeon toes, knock knees, bow legs, or flat feet. Thankfully, many of these children who have these conditions will outgrow them over time.

11. What is normal? What is abnormal?
Understanding what can be normal and at what ages is most important. The range of “normal” changes with growth and development. So before saying something is normal, your orthopaedic surgeon will likely want to rule out potential abnormalities. There are conditions that children may not “grow out of” and may need treatment for improvement.

12. History What is the specific concern? When does it manifest? Duration?
Improving or worsening?
Patient’s medical history and family medical history
To evaluate orthopaedic problems in children, the physician will want to obtain a history from you. Before you visit the orthopaedic surgeon, take down notes about the child’s condition: What your specific concern is, when you see it most often, how long it has been going on, and whether you believe it’s improving or worsening. The patient’s own medical history as well as your family’s medical history will also be reviewed.

13. Who is concerned? Parents Grandparents Pediatrician Teachers Others
It can also be helpful for the orthopaedic surgeon to know who is concerned, and what those concerns and observations are.

14. In-toeing and Out-toeing
We’ll first consider two very common conditions that often concern parents: in-toeing and out-toeing.

15. In-toeing Common in babies and toddlers
Almost always resolves without treatment
In-toeing means that the feet turn inward instead of pointing straight ahead during walking or running. Children with this condition are sometimes said to be “pigeon-toed.” This condition is common in babies and toddlers, and almost always resolves itself as the child grows.

16. In-toeing Not painful in and of itself
Not associated with early arthritis
Can rarely be associated with knee pain and problems
In-toeing is typically not associated with pain or other symptoms. It is also not associated with early arthritis or other serious problems, although in rare cases, it can be associated with pain and other problems in the knee.

17. In fact, some studies have found that runners who have in-toeing tend to be faster.

18. In-toeing: Causes
Metatarsus adductus – atypical twisting or bending of the foot
Tibial torsion – twisting of the shin bone (tibia)
Femoral antetorsion – twisting of the thigh bone (femur)
In-toeing is usually caused by one of three common conditions:
Metatarsus adductus, which is an atypical twisting or bending of the foot;
Tibial torsion, a twisting of the shin bone, called the tibia; or
Femoral antetorsion, a twisting of the thigh bone, called the femur.
The orthopaedic surgeon will assess your child’s in-toeing to determine the source of the problem, because that will determine how the condition will be treated—if it requires treatment at all.

19. In-toeing: Metatarsus Adductus
Majority are flexible
Resolves by 3-4 years of age
10% stiff and may benefit from casting
Metatarsus adductus is also called “hooked foot.” In most cases, the feet are flexible and do not cause any developmental problems, and eventually straighten out on their own. For children whose feet are a little less flexible, the orthopaedist might recommend some exercises in which the parent helps the child stretch the feet. In about ten percent of cases, the feet are very stiff, and may need casts to help them straighten to within the normal range.

20. In-toeing: Tibial torsion
Common in infants
Usually resolves itself
May be treated with surgery in more serious cases
Many babies have some tibial torsion, due to the rotation of the legs as a baby grows in the womb. The condition usually resolves itself as the tibia grows longer and the child learns to walk. If the tibia remains turned once the child is out of toddlerhood, but doesn’t cause any difficulties in walking or running, the torsion is usually not treated; the orthopaedist may want to reassess the child periodically to ensure that the condition does not worsen. If the tibial torsion is creating some functional problems for the child, it may be treated with surgery.

21. In-toeing: Femoral antetorsion
This child has in-toeing related to femoral antetorsion, or an inward twist of the thigh bones. Such antetorsion may give the appearance of inward pointing knees and feet as well as an unusual gait. Thankfully, most children with this condition grow out of it, and it rarely causes any problems for them as they age.

22. However, symptoms that occur or continue for an older child can be associated with a risk for future joint problems. In such a case, braces or special shoes are not effective for treatment. Surgical care is the only effective treatment, but these cases are rare.

23. In-toeing: Treatment No treatment necessary in most cases
Ongoing observation may be recommended
Surgery in some severe cases
Whatever the cause of in-toeing, the treatment is usually just allowing mother nature to work her magic. In the past, children with in-toeing often had to wear special braces or shoes, which were uncomfortable for the child and expensive for the parents, but we know now that these do not help in-toeing resolve itself any more quickly than it would without treatment.
Your orthopaedic surgeon may offer checkups until it is certain that your child’s condition isn’t getting any worse. Surgery is only recommended in severe cases where the condition isn’t improving on its own and is preventing the child from walking or running properly.

24. Out-toeing Toes pointing outward Less common than in-toeing
Caused by twisting of hip, thigh, shin, or foot
Unlikely to improve over time, unless a result of flat feet
Out-toeing is the opposite of in-toeing, where the feet point out more than is typical. As with in-toeing, the out-toeing may be caused by a twisting of the hip, thigh, shin, or foot. It can also result from having flat feet. Usually, this condition will not improve over time, unless it is a result of flat feet.

25. Out-toeing Usually in normal range Usually causes no problems
Rarely requires special care
However, studies have found that most cases of out-toeing fall within the broad range of normal, and therefore cause no problems for the patient and require no special care.

26. Angular Problems Knock-knees (genu valgum) Bow legs (genu varum)
Next, we’ll discuss angular problems of the legs, usually known as knock-knees and bowlegs. The medical terms for these conditions are genu valgum and genu varum.

27. Angular Problems
As with rotational problems like in-toeing and out-toeing, it is important to recognize that angular problems can have normal patterns of variation. Frequently toddlers can be bowlegged, then turn a bit knock-kneed around kindergarten age, then end up pretty straight by age eight or so. A pediatric orthopaedic surgeon can determine whether your child’s angular problem is within this normal range.

28. Angular Problems Physiologic Pathologic Trauma or injury Rickets
Tibia vara (Blount’s disease)
Skeletal dysplasia
When the angular problem is part of the normal growth pattern, it is said to be physiologic, and is not treated. However, when it is caused by another condition, it is said to be pathologic, and will require medical treatment. Pathologic bowing can be due to a trauma or other injury. It can also be due to:
Rickets, which is caused by a severe vitamin D deficiency
Tibia vara, or Blount’s disease, a condition which alters the tibia growth center; or Skeletal dysplasia, a group of genetic conditions in which the bones do not form properly.
Skeletal dysplasia, a group of genetic conditions in which the bones do not form properly.

29. Angular Problems
Often times the visual impression is worse than the reality of the condition.

30. These x-rays of a child at age two show dramatic bowing that corrected on its own some two years later.
Age Age 4

31. When medical treatment was required for angular problems in growing children, braces were often used in the past.

32. 2+ 4 2
For some conditions, they may still be effective, but for other conditions, surgical care is the best option.

33. In growing children, sometimes that surgery may involve altering the remaining growth and be relatively minor.

34. Others may require more dramatic procedures to make their outlook better.

35. More than 15% of adults have it
Flatfoot
All infants have it
Most children have it
More than 15% of adults have it
A third common condition in children is flatfoot. People with flatfoot do not appear to have an arch in the bottom of their feet—the whole sole of the foot is flat on the floor when they stand. To some degree, most infants and children have it, but most have grown out it by adulthood. Fifteen percent of adults still have flat feet.

36. Flexible flatfoot Often resolves with growth
Not correlated with disability in military populations
Not affected by special shoes, inserts, or braces
A flatfoot that is flexible is less likely to be problematic. It often resolves as the child grows, but if it does not, studies have found that it usually doesn’t lead to a disability. It also cannot be corrected with special shoes, inserts or braces—and in fact, these devices can be very painful for people with flatfoot.

37. Stiff flatfoot
An older child with a rigid flatfoot that does not correct on toe standing warrants investigation, and may need treatment. This can be due to a bone deformities within the foot, and may need to be treated surgically.
Stiff flatfoot on the right – does not correct on toe standing

38. More foot pathologies to consider
Clubfoot
Calcaneovalgus foot
Certain other foot conditions may require investigation and care. These include clubfoot and calcaneovalgus foot.

39. Clubfoot Incidence 1:1000 Boys > girls
One or both feet turned inward
May sometimes be genetic
Parents can observe immediately if their newborn has a clubfoot. Some will even know before the child is born, if an ultrasound was done during the pregnancy. The appearance is unmistakable: the foot is turned to the side and it may even appear that the top of the foot is where the bottom should be.
A clubfoot occurs in approximately one in every 1,000 births, with boys slightly outnumbering girls. One or both feet may be affected. We still aren't certain why it happens, though it can occur in some families with previous clubfeet. In fact, your baby's chance of having a clubfoot is twice as likely if you, your spouse, or your other children also have it.

40. Clubfoot treatment Serial manipulations and casting
Begin first week of life, if possible
Perform weekly
90% of routine clubfoot respond
Clubfeet aren’t painful for babies, but if the condition isn’t treated, it can cause pain and disability later in life. This is why a clubfoot must be treated very early in life—in fact, many babies begin treatment before they are one week old. This allows the feet to be improved in time for the child to walk.
The common form of treatment today involves casting the feet and legs, and changing the casts each week to slowly stretch the feet and legs into the correct position. Once the feet are corrected, the child wears braces at night for about two years to maintain the correction. About ninety percent of clubfoot cases respond to this treatment. In the other cases, the clubfoot can be treated surgically.

41. Calcaneovalgus foot Most common foot deformity at birth Foot points up
Resolves spontaneously
Associated with hip dysplasia
Some babies are born with their feet pointing upwards, toward the leg—and sometimes even touching the leg. While the appearance of calcaneovalgus foot can be alarming at first, it is also a very common condition in newborns.
This condition is due to positioning inside the uterus, and resolves itself as the baby grows. It is sometimes associated with hip dysplasia, which is also common in newborns. A pediatric orthopaedic surgeon may recommend some stretching exercises, but further treatment is rarely needed.

42. When do you need to see a pediatric orthopaedic surgeon?
Over three years of age with documented progression of deformity
Stiff metatarsus adductus
These are some general guidelines for variations that are outside of the normal ranges. For example, if your child is over the age of three and the deformity is not improving or is getting worse or if your child has a stiff, hooked foot, you should see a pediatric orthopaedic surgeon.

43. When do you need to see a pediatric orthopaedic surgeon?
Bowing
below the 5th percentile for height
marked asymmetry
Marked knock-knees or in- toeing in patients over 8 years of age
You should also see a pediatric orthopaedic surgeon if your child has bow legs that are asymmetrical and is below the fifth percentile for height or if your child is over the age of eight and has noticeable knock-knees or in-toeing. Your pediatrician can help you find an appropriate orthopaedic surgeon.

44. American Academy of Orthopaedic Surgeons
Resources
American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
For more information about musculoskeletal conditions, visit the website of the AAOS, or their patient information site at

45. What are your questions and concerns?
Pigeon Toes, Knock Knees, and Flat Feet
What are your questions and concerns?
What questions or concerns do you have that we have not addressed yet?

46. Pigeon Toes, Knock Knees, and Flat Feet
Thank you for participating today
Remember, your orthopaedic surgeon can help get you back in the game
Thank you for participating today. Remember, your orthopaedic surgeon can help get you or your child back in the game.