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Knocked knees / Bow legs Care Pathway Overview

Knocked knees and Bow legs in children are a normal part of a child's development and do not require referral into Orthopaedics. Please manage in Primary Care with advice, encouragement and self-management.

Practice Point

The advice in this pathway applies to patients up to musculoskeletal maturity at approximately 18 years of age

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Red Flags
  • Persistent pain, redness, heat, swelling, raised body temperature
  • History of trauma/injury/fracture
  • Inability to weight bear
  • Multiple joint pain/swelling
If fracture suspected, follow the Fracture pathway
If infection suspected, treat accordingly
If multiple joint pain/swelling consider Rheumatology referral
For persistent foot or ankle pain, weakness, limping swelling or stiffness, encourage patient to self-refer into Core Podiatry
Presentation

Knocked knees and bow legs are common in children up to eight years old and are part of the process of normal development.

Symptoms

  • A standing child of average weight whose knees touch, but whose ankles do not, is usually considered to have knock knees
  • An abnormal walking gait can also be a sign of the condition
  • Usually becomes apparent when a child is 2 to 3 years old and may increase in severity until about age 4
Differential Diagnosis
  • Rickets/lVitamin D insufficiency
  • Blounts disease
  • Inflamatory arthropathy
  • Inherited bone growth disorders - e.g. epiphyseal dysplasia
  • Fracture (follow the Fracture pathway)
  • Infection (treat accordingly)
Initial Primary Care Assessment

Examination may include:

  • measurements of child’s length and height 
  • measurements of weight and body mass index (BMI) 
  • measurements taken of knee extensions and rotations 
  • assessment of leg-lengths and leg symmetry 
  • observation and assessment of gait
Primary Care Management

Knocked knees and Bow legs in children are a normal part of a child's development and do not require referral into Orthopaedics. Please manage in Primary Care with advice, encouragement and self-management.

Provide advice/encouragement:

  • In normal childhood development both legs will look the same
  • The presentation can persist in children who are overweight
  • Children with bowed legs or knocked knees do not benefit from physiotherapy
  • Bowed legs and knocked knees will not affect a child’s normal mobility
  • No podiatry treatment is required
  • Provide Parent/Carers/Patient with the Knocked knees and Bow legs Information leaflet
  • Correct footwear is important for any child to ensure support during periods of growth and development – provide Parent/Carers/Patient with the 'First shoes' Patient Information Leaflet if appropriate

Practice Point

The advice in this pathway applies to patients up to musculoskeletal maturity at approximately 18 years of age

When to Refer

If additional support is required to manage the problem, Gloucestershire Care Services (GCS) provides foot and ankle services in Gloucestershire.

The main entry point for foot and ankle services is via Core services, accessed via the online self-referral form, (click here for printable link), which the patient can complete themselves if able to and willing.

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