From the Guidelines
The best next step in management for this 15-month-old boy with bowed legs is reassurance and observation (option C). This clinical presentation is consistent with physiologic genu varum, also known as physiologic bowlegs, which is a normal developmental variant in children under 2 years of age 1. The condition typically resolves spontaneously by age 3-4 without intervention. Several factors support this approach:
- the child has no pain,
- maintains normal activity,
- has normal joint examination,
- demonstrates symmetrical bowing that worsened with walking (typical of physiologic bowing),
- has adequate nutrition including appropriate milk intake,
- and shows normal growth parameters. Physiologic bowing occurs because toddlers naturally have external tibial torsion that corrects as they grow. Imaging, orthotics, surgery, or supplementation would be unnecessary and inappropriate at this stage unless there were concerning features such as asymmetry, pain, growth abnormalities, or family history of bone disorders. Parents should be educated about the benign nature of the condition and advised to follow up if the bowing persists beyond age 3, worsens significantly, or if the child develops pain or other concerning symptoms. According to the clinical practice recommendations for the diagnosis and management of x-linked hypophosphataemia 1, regular follow-up is essential, but in this case, the child's presentation does not suggest a need for immediate intervention. The focus should be on monitoring the child's growth and development, and reassessing if any concerning features arise, prioritizing the child's quality of life and minimizing unnecessary interventions.
From the Research
Management of Bowed Legs in Children
The patient's condition, bowed legs, is a common finding in children. The management of this condition depends on the underlying cause and the severity of the deformity.
- The patient's age and the fact that the bowing has worsened since he started walking suggest that this could be a case of physiologic genu varum, which is a normal condition in early childhood that typically resolves on its own 2, 3.
- However, some studies suggest that physiologic genu varum may be associated with vitamin D disorders in toddlers, which could require treatment 4.
- The patient's diet, which includes 16 ounces of whole milk a day, and the lack of any other symptoms or abnormalities, suggest that vitamin D deficiency may not be a concern in this case.
Next Steps in Management
Given the patient's age and the fact that the bowing is not severe, the best next step in management would be to reassure the patient's mother and observe the patient's condition over time.
- This approach is supported by studies that show that physiologic genu varum typically resolves on its own without treatment 2, 3.
- Regular follow-up appointments can be scheduled to monitor the patient's condition and ensure that the bowing does not worsen over time.
- Other options, such as bilateral leg x-rays, leg orthotics and physical therapy, or surgical correction, are not necessary at this time and may be considered only if the patient's condition worsens or if other symptoms develop 5, 6.
- Vitamin D and calcium supplementation may be considered if the patient is found to have a vitamin D deficiency or insufficiency, but this is not indicated in this case based on the information provided 4.