Management of Bowed Legs in Toddlers
For most toddlers with bowed legs (genu varum), observation and regular follow-up until spontaneous resolution is the recommended treatment, as physiologic bowing typically resolves without intervention by 30-36 months of age. 1
Understanding Bowed Legs in Toddlers
Bowed legs in toddlers can be categorized into:
Physiologic Bowing (Most Common)
- Normal developmental variant
- Typically appears when child begins walking (around 10-15 months) 1
- Resolves spontaneously by 30-36 months of age
- Usually bilateral and symmetric
Pathologic Bowing
- Blount's disease (tibia vara)
- Rickets
- Skeletal dysplasias
- Metabolic bone disorders
Assessment and Diagnosis
Key Clinical Evaluations:
- Age of onset (physiologic bowing typically appears with early walking)
- Family history
- Symmetry of bowing
- Associated symptoms (pain, limp, developmental delays)
Screening Test:
- "Cover-up" test: A simple clinical examination to differentiate physiologic bowing from pathologic conditions 2
- Cover the thigh and examine alignment of proximal tibia relative to thigh
- Valgus alignment (negative test) suggests physiologic bowing
- Neutral or varus alignment (positive test) suggests higher risk for pathologic conditions like Blount's disease
When to Consider Referral to Pediatric Orthopedic Surgeon:
According to the American Academy of Pediatrics guidelines, referral is indicated for: 3
- Children with significant limb deformity
- Asymmetric bowing
- Bowing that persists beyond 2.5-3 years of age
- Worsening bowing
- Associated pain or functional limitations
- Positive "cover-up" test
Treatment Protocol Based on Diagnosis
1. Physiologic Bowing:
- Observation with regular follow-up
- Follow progression using fingerbreadth measurements at well-child visits 1
- Expected timeline for resolution:
- Children presenting before 18 months: initial correction between 18-24 months, resolution by 30 months
- Children presenting between 18-23 months: initial correction between 24-30 months, resolution by 36 months
2. Pathologic Bowing (Blount's Disease):
- Referral to pediatric orthopedic surgeon for specialized management 3
- Treatment options may include:
- Bracing for early/mild cases
- Surgical intervention for severe or progressive cases
3. Nutritional Rickets:
- Laboratory evaluation (calcium, phosphorus, alkaline phosphatase, vitamin D levels)
- Vitamin D and calcium supplementation if deficient
- Note: Not all bowed legs are due to rickets, and unnecessary treatment should be avoided 4
Follow-up Protocol
For Children <18 months with physiologic bowing:
- Follow-up at regular well-child visits
- Monitor for signs of correction between 18-24 months
- Expect resolution by 30 months
For Children 18-23 months with physiologic bowing:
- Follow-up at regular well-child visits
- Monitor for signs of correction between 24-30 months
- Expect resolution by 36 months
For Children with suspected pathologic bowing:
- Prompt referral to pediatric orthopedic surgeon
- Follow specialist recommendations for treatment and monitoring
Important Considerations
- Physiologic bowing typically resolves spontaneously without intervention
- Unnecessary radiographic evaluation should be avoided to prevent radiation exposure 1
- Children with physiologic bowing often walk earlier than average (10 months vs. 12-15 months) 1
- The most important aspect of evaluation is determining which conditions require treatment versus reassurance 5
Caution
- Avoid misdiagnosing all cases of bowed legs as rickets, as this can lead to unnecessary treatment 4
- Persistent bowing beyond expected age of resolution warrants orthopedic evaluation