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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.


YES – please refer 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.

NO – referral not necessary if: -

  • the toe walking is intermittent.
  • 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 four - six years of age. Many children present with ‘flexible flat feet’, early in their walking development and may well grow out if it as their walking matures, and they develop a longitudinal arch. Walking in bare in feet is ideal for promoting foot development.

YES – please refer if: -

  • there are signs of pressure on 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 shown below (due to tarsal coalition).

stiff flat feet

NO – referral 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.


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.


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.

YES – please refer if: -

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

NO – referral not necessary if: -

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


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.

YES – please refer if: -

  • there is associated pain in the lower limbs
  • the problem is persistent or asymmetrical


In-toeing is when a child walks with their feet turning inwards, and is commonly referred to as ‘pigeon toed’. 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. Physiotherapy referral is not usually appropriate.


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. Check the hips for a Slipped Upper (Capital) Femoral Epiphysis.

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).  

YES - please refer if :- 

  • walking delayed (18 months) and especially in boys
  • 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'
  • 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.

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