What is the treatment for genu valgum (knock knees)?

Treatment for Genu Valgum (Knock Knees)

The treatment for genu valgum should focus on physiotherapy, weight-bearing exercise, and surgical intervention only when deformity persists despite optimized medical management or causes significant functional limitations. 1

Assessment and Classification

Before determining treatment, proper assessment is essential:

• Measure intercondylar and/or intermalleolar distance to quantify severity
• Determine if physiologic (likely to resolve) or pathologic (likely to progress)
• Evaluate mechanical axis deviation using radiographs
• Assess for underlying conditions (metabolic bone disease, skeletal dysplasia)

Non-Surgical Management

First-Line Approach

1. Physical Therapy and Exercise

   • Weight-bearing exercises to improve alignment 1
   • Strengthening exercises for quadriceps, hamstrings, and hip abductors
   • Maintenance of joint range of motion 1
   • Neuromuscular education and gait training 2

2. Orthotic Interventions

   • Custom-molded foot orthoses for mild cases to improve distal alignment 1
   • Ankle foot orthoses may be recommended for more severe malalignment or instability 1
   • Note: The use of insoles or casts is not recommended by some guidelines 1

Additional Conservative Measures

• Weight management for patients with elevated BMI 1
• Activity modifications to prevent joint damage
• Avoidance of activities that may exacerbate the condition, especially with hepatomegaly or hypermobility 1

Surgical Management

Surgery should be considered only after maximizing conservative treatment for at least 12 months 1. The decision depends on:

1. Age and Growth Potential

   • Guided growth techniques require at least 2-3 years of remaining growth potential 1
   • Osteotomies are typically delayed until closer to skeletal maturity 1

2. Severity Indicators for Surgery

   • Mechanical axis deviation into Zone 2 or greater despite optimized medical treatment 1
   • Presence of symptoms interfering with function 1
   • Progressive deformity despite conservative management

3. Surgical Options

   • Guided Growth Surgery: Less invasive technique for growing children

     • Small metal plate placed on the lateral surface of the distal femur 1
     • Acts as a tether to growth, allowing differential growth and gradual correction

   • Osteotomy: For more severe or mature cases

     • Lateral opening wedge distal femoral osteotomy 3
     • Valgus producing proximal tibial osteotomy for medial compartment issues 1
     • Can be performed with acute or gradual correction 1

Special Considerations

1. Underlying Conditions

   • In metabolic bone diseases like X-linked hypophosphatemia, medical optimization should precede surgical intervention 1
   • For patellar instability associated with genu valgum, combined procedures may be necessary 3, 4

2. Post-Treatment Monitoring

   • Regular clinical and radiographic assessments at 12 months post-surgery 1
   • Earlier assessment if deformity worsens or clinical concerns arise
   • Continued monitoring until skeletal maturity

3. Complications to Watch For

   • Recurrence of deformity (reported in up to 29% of surgical cases) 1
   • Overcorrection in guided growth techniques if plates remain too long 1
   • Joint instability in severe cases

Treatment Algorithm

1. Mild Genu Valgum:

   • Physical therapy and exercise program
   • Custom foot orthoses if indicated
   • Regular monitoring for progression

2. Moderate Genu Valgum with Growth Remaining:

   • Intensive physiotherapy 2
   • Consider guided growth surgery if persistent after 12 months of conservative care

3. Severe Genu Valgum or Near Skeletal Maturity:

   • Osteotomy when appropriate
   • Post-surgical rehabilitation

Remember that surgery should be performed by surgeons with expertise in metabolic bone diseases when applicable 1, and that the primary goals are to improve function, reduce pain, and prevent long-term joint damage.