Alignment Issues

Many alignment variations, particularly in children, cause no symptoms and are noticed by a parent or at a routine check rather than because of pain.

Common signs of an alignment issue include:

• an uneven walking pattern or asymmetric gait

• feet turning inwards or outwards

• knees touching when standing, or legs appearing widely bowed

• flat or low foot arches

• foot, ankle, knee, hip, or back pain — particularly after activity

• clicking or popping sounds in joints

• frequent tripping or clumsiness in young children

• one leg appearing shorter than the other

Seek specialist assessment promptly if:

• symptoms are on one side only

• pain is persistent or during the night

• the problem is getting worse rather than better with age

• the child is limping, avoiding activity, or has changed their walking pattern

• there are systemic features such as fever or unexplained weight loss alongside a musculoskeletal complaint

Bow legs (genu varum)

Bow legs — where the legs curve outward with a gap between the knees — are normal in babies and toddlers and typically resolve by age 2 to 3. If significant bowing persists beyond age 3, or is asymmetrical or worsening, assessment is needed to exclude underlying causes such as Blount's disease or rickets.

Knock knees (genu valgum)

As bow legs resolve, children naturally progress through a phase of knock knees. This is part of the normal developmental sequence:

• birth to ~2 years: bow legs

• ~2–3 years: relatively straight legs

• ~3–5 years: knock knees, most pronounced around age 4

• ~7–8 years: adult alignment established

In most children, knock knees correct naturally without treatment. Assessment is recommended if the gap between the ankles exceeds approximately 8 to 10 cm, if the finding is asymmetrical, if it persists after age 7, or if the child has pain.

Flat feet (pes planus)

Flat feet are extremely common in young children and are usually a normal developmental finding. Flexible flat feet — where the arch appears on tiptoe — require no treatment in the majority of cases, and most children develop a visible arch between ages 6 and 10.

Rigid flat feet, where the arch is absent regardless of foot position, are less common and may indicate an underlying structural abnormality such as tarsal coalition. These require specialist assessment.

In adults, flat feet can develop due to progressive weakness or rupture of the tibialis posterior tendon — known as adult acquired flatfoot deformity — causing medial ankle pain and requiring specific management.

Assessment is recommended if flat feet are rigid, painful, asymmetrical, or if no arch has developed by age 8 to 10.

In-toeing

In-toeing — feet pointing inwards during walking — is one of the most common reasons parents seek orthopaedic advice, and in the majority of cases is a normal developmental variant. There are three main causes:

• metatarsus adductus — inward curve of the front of the foot, present from birth; mild cases resolve spontaneously

• internal tibial torsion — inward twist of the shin bone, most common in toddlers aged 1 to 3; almost always corrects naturally by age 7 to 8

• femoral anteversion — increased inward twist of the thigh bone, presenting between ages 3 and 8; resolves in the majority of cases by mid-adolescence

Rotational braces and corrective shoes are not recommended as they have not been shown to speed up resolution. Assessment is recommended if in-toeing is causing pain, is significantly asymmetrical, or is not improving with age.

Out-toeing

Out-toeing is common in infancy due to external rotation of the hip and usually resolves as the child begins to walk. Persistent or asymmetrical out-toeing in an older child warrants assessment.

Leg length discrepancy

A small difference in leg length — under 1 to 2 cm — is common and usually causes no problems. Larger discrepancies can cause a limp, pelvic tilt, and uneven loading of the hips and spine. 

Assessment involves clinical and radiological measurement, with monitoring through growth to predict the final discrepancy at skeletal maturity. Treatment ranges from a simple shoe raise to surgical options, including epiphysiodesis or limb lengthening, depending on the magnitude and cause.

Patellofemoral maltracking

In adolescents and young adults — particularly females — the kneecap may not track centrally, causing anterior knee pain on stairs, squatting, or prolonged sitting. This is closely linked to overall lower limb alignment and is usually managed with physiotherapy addressing hip and quadriceps strength.

Clicking joints in children

Clicking sounds from joints are usually harmless, arising from tendons moving over bone or gas bubbles in joint fluid. No treatment is needed in the absence of pain, swelling, or restriction of movement.

The important exception is a clunking hip in a newborn or young infant, which should always be assessed urgently to exclude developmental dysplasia of the hip (DDH).

Assessment is also recommended if clicking is associated with pain, swelling, locking, or giving way.

Spinal alignment

Abnormal sideways curvature of the spine (scoliosis) is covered in detail on our dedicated scoliosis page Please visit that page or contact us directly if you have concerns about spinal alignment.

Most childhood alignment variants are bilateral, symmetrical, and improve with age. However, we recommend specialist review if:

• an alignment concern is on one side only, or significantly more pronounced on one side

• there’s associated pain, particularly if persistent or present at night

• the child is limping, avoiding activity, or has changed their walking pattern

• a variant is not improving with age, or appears to be worsening

• there’s a family history of a connective tissue or skeletal condition

• a newborn has a hip click or asymmetric leg creases – developmental dysplasia of the hip must be excluded promptly

At Welbeck, our paediatric orthopaedic consultants take a conservative, evidence-based approach. We will tell you clearly when reassurance is appropriate, and recommend intervention only when there’s a clear clinical indication.

Your consultant will begin with a thorough history and physical examination. For children, this includes observation of posture and walking pattern, rotational profile assessment, foot assessment in weight-bearing and non-weight-bearing positions, and hip examination where indicated.

Imaging and investigations may include:

• standing X-rays – to measure alignment and monitor change over time

• ultrasound – particularly for hip assessment in infants

• MRI – for soft tissue or joint concerns

• gait analysis – computerised assessment of joint movement and forces during walking, particularly useful for complex presentations or surgical planning

Developmental alignment variants cannot be prevented, they are part of normal skeletal maturation. The following may support healthy joint development more generally:

• regular physical activity and weight-bearing exercise

• maintaining a healthy body weight

• well-fitting, supportive footwear

• strengthening the hips, core, and lower limb muscles

Most childhood alignment variants resolve without complications. In more significant or untreated cases, possible complications include:

• joint pain due to altered load distribution

• accelerated joint wear and increased risk of early osteoarthritis

• gait abnormalities causing secondary problems in other joints

• reduced activity tolerance

• psychological impact, particularly in adolescents who may be self-conscious about visible differences

• scoliosis and hip pain in an untreated significant leg length discrepancy

For many childhood presentations, reassurance and monitoring is the most appropriate management. Where treatment is needed, options include:

Observation and monitoring – most childhood alignment variants resolve naturally; regular review confirms the expected trajectory.

Physiotherapy – targeted exercise addressing hip and core strength, muscle balance, and movement patterns; first-line treatment for patellofemoral maltracking and alignment-related pain.

Orthotics – foot insoles for symptom management in flat feet and alignment-related lower limb pain. Orthotics manage symptoms; they do not correct alignment or accelerate arch development in flexible flat feet.

Footwear advice – appropriate footwear supports healthy foot development and symptom management; your consultant or podiatrist can advise.

Bracing and casting – used selectively in younger children for specific conditions such as metatarsus adductus or significant tibial bowing that’s not following the expected course of resolution.

Surgery – reserved for significant alignment problems that won’t resolve with growth, where the predicted deformity at skeletal maturity warrants correction, or where symptoms are severe and not responding to conservative management. Options include guided growth procedures, corrective osteotomy, epiphysiodesis, and limb lengthening.

At Welbeck, our orthopaedic consultants have extensive experience assessing and managing alignment concerns across all ages.

We understand that a concern about a child's walking pattern or posture can be genuinely worrying, even when the answer is reassurance. Our approach is thorough, unhurried, and honest. We’ll tell you clearly what we find, what it means, and what, if anything, needs to be done.

We offer:

• same-day appointments wherever possible

• specialist paediatric orthopaedic consultations for patients aged 4 and above

• on-site imaging, including X-ray, ultrasound, and MRI

• access to physiotherapy and podiatry

• multidisciplinary input where needed

• care recognised by all major private health insurers, with self-pay options available

If you’re concerned about alignment in yourself or your child, whether that’s a walking pattern, foot position, knee appearance, or something less easy to define, we encourage you to seek specialist assessment. In most cases, the answer is reassurance, but early review ensures that the cases that do need treatment are identified at the right time.

Get in touch today to book an appointment with one of our orthopaedic specialists.

Our consultants are recognised by all major health insurance providers. We also offer care to self-paying patients.