East Coast Podiatry
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Last Updated: 07 Oct 2021

Knock Knees

Knock Knees in Children

Knock-knees, or genu valgum, is an angular deformity that can be seen when a child stands with their back and legs straight; their knees touch, but the feet do not.

Mild knock knees can be a physiological variant of growth. However medical attention is warranted in children who develop symptoms, who present with asymmetrical knee position, or those with pronounced severity. In rare cases, knock knees may be caused by underlying bone disease, particularly if the condition first presents at the age of 6 or above. Surgery may be needed for such cases. Podiatrists with experience in paediatric development can help correct knock knees conditions in short amounts of time, taking into consideration the secondary effects of knock knees on the feet, hips and spine. During a child’s growth and development, it is important to protect the immature skeleton from abnormal stresses and to prevent it from settling into an abnormal position.

When do children usually present with knock knees?

While children can outgrow mild knock knees as their legs strengthen and develop, many cases can persist into adulthood and cause permanent changes to the child’s gait and posture. It is crucial to understand the usual development of a child to enable early identification of any issues.

  • Infants: It is rare for infants to present with knock knees; they usually have bowlegs (outward curving of both legs) until about the age of 2.
  • Toddlers: Mild knock knees usually start to develop between the age of 3 to 4 years old. If you notice that the feet are pronated and the inward tilt of the knees continue to persist after the age of 4, you should consult with a healthcare professional.
  • Young children: By the age of 7, most children’s legs become properly aligned.

Symptoms of knock knees

Knock knees are easily detected when a child stands upright. Signs and symptoms to look out for include:

  • Knees bend inwards while ankles are far apart
  • Unusual gait pattern
  • Outward rotation of feet

Causes of knock knees

Knock knees usually develop in young children as the stance can provide more balance when they first start walking. In rare cases, knock knees may be caused by disorders, such as:

  • Genetic conditions, e.g. skeletal dysplasia and osteogenesis imperfecta
  • Abnormal bone development, e.g. rickets
  • Obesity
  • An injury to the knees or leg bones (such as the tibia or femur)
  • Leg length difference
  • Malalignment syndrome
  • Hypermobility

Should I be concerned about my child’s knock knees?

You should consult a podiatrist about your child’s knock knees if they present any of the following symptoms:

  • Apparent knock knees before 2 years old
  • Knock knees become progressively worse
  • Asymmetry of the legs
  • Unusual walking pattern, i.e. limping
  • Knee or hip pain
  • Short stature

How can podiatrists treat knock knees?

At East Coast Podiatry, we see many paediatric cases of knock knees. After completing a thorough assessment to check for the severity of the condition and rule out any other worrying conditions, our podiatrists will be able to recommend an appropriate treatment plan.

Treatment is dependent on the age of the patient, the severity, and the impact on the patient’s daily life. For infants below the age of 2, immediate serial casting of the knees is recommended to correct abnormal bone development. This is best carried out before the child is walking. If the child is walking already, then knee braces may be a suitable alternative for guiding the bone development into correct alignment.

For children with mild knock knees, the best time to treat the condition is after the age of 4. Treatment may include custom foot orthotics, custom ankle orthotics, knee braces and therapy, such as SIS, to strengthen the muscles. From age 7, knock knees becomes increasingly difficult to treat conservatively as the child attains skeletal maturity. In such cases, knee braces may be used in a final attempt at conservative treatment. Some cases may become permanent and may require surgical intervention if conservative measures are not taken.

Frequently Asked Questions

Many parents are concerned when their child is ‘walking funny’. Your child may be walking in a different manner due to several reasons such as flat feet, toe walking or knock knees. An assessment by a professional is required to highlight the exact cause of what parents are seeing. The different walking patterns may be due to foot or bone position, muscle or ligament tightness or congenital problems with the lower limbs.

X-shape legs is a colloquial term used to describe the genu valgum knee position, known as knock knees. Mild knock knees are a variable during childhood growth and development, but moderate to severe knock knees are a concern that requires non-delayed intervention. Leg shape is inherited but external factors affect the development.

Depending on the severity of the condition and the aggressiveness of the treatment given. Results can be seen typically from after 6 to 18 months after the prescription of appropriate corrective devices.

A mild case of knock knee that is within the normal variance of growth can be outgrown, however, moderate to severe knock knees or those that are worsening after the age of 4 is unlikely to be resolved without extra attention and correction. It is not recommended to take a wait-and-see approach with Paediatric cases as this reduces vital time necessary for the best treatment outcomes.

Left untreated, knock knees can ossify leading to higher incidences of knee pain and earlier joint degeneration for the patient. Knock knees can also cause children to change their walking and running positions to accommodate the knee position with secondary flat foot or limping. Over time, this can affect the child negatively in sports, daily activities, and overall body image.

Where possible, parents usually opt for non-surgical correction of their children’s knock knees. Surgical techniques used for knock knees vary depending on the age of the patient and the severity of the condition. Parents should be aware that surgery carries risks from anaesthesia to rehabilitation and recovery and should not be seen as a ‘quick fix’. Surgical correction of knock knees should only be considered after all conservative options have been exhausted.

There is research to show a strong genetic link for genu valgum to run in the family. It can also be caused due to biomechanical compensation, injury or infection in the knee or leg.

Pain is not the only symptom that parents should be looking for when it comes to assessing a child’s lower limbs. Alignment of the knees should be monitored and treated with or without pain. Typically, pain will come after years of using a joint that is positioned incorrectly. A child is unlikely to have that much experience with the issue and research also shows that knock knees leads to earlier joint wear and tear compared to more aligned knee positions.

Symptoms to look out for include:

  • visual malalignment
  • reluctance to participate in sports or walking
  • tiredness
  • request for massage at night
  • pain

Children with knock knees walk with their toes pointing inward which naturally makes the child appear uncoordinated. This often results in a clumsier gait as their toes struggle to gain enough ground clearance during walking and running. Children with more pronounced knock knees will trip and fall more which can hinder their natural paediatric movement and motor skill development.

Massage is a great tool to bond with your child while increasing circulation, but massage will not realign a bone misalignment. Massage in the form of soft tissue and bone manipulation for babies is an adjunct therapy to serial casting and helps to release soft tissue tightness and reform the bone position, but this does not help in cases of older children or bone positions that have ossified.

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