Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

no comorbidity

1st line – reassurance

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ONGOING
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no comorbidity
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rotational profile within 2 standard deviations of the mean for age: in-toeing or out-toeing
1st line – 

reassurance

Treatment of torsional problems in healthy children is both unnecessary and ineffective.[1][2]

Twister cables, night splints, shoe wedges, physiotherapy, or a combination of these is ineffective at altering limb alignment or normalising gait.[1][3][74]​ In fact, studies have shown that bracing such as these can have negative psychological effects on paediatric patients.[75]

Consider – orthopaedist referral

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ONGOING
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no comorbidity
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rotational profile within 2 standard deviations of the mean for age: in-toeing or out-toeing
Consider – 

orthopaedist referral

Additional treatment recommended for SOME patients in selected patient group

Referral to an orthopaedist should be considered for: 1) families who require additional reassurance; 2) uncertain diagnosis or inconclusive screening examination; 3) children with stiff forefoot adductus; and 4) older children or adolescents with leg pain or disability.

1st line – observation

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ONGOING
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no comorbidity
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rotational profile beyond 2 standard deviations of the mean for age: in-toeing
1st line – 

observation

Initial treatment is parental reassurance and education. Arrangements for regular follow-up should be provided. Corrective shoe wedges, night splints, twister cables, and physiotherapy have not been shown to alter the natural history or ensure normal gait.[1][3][74]​​​ In fact, studies have shown that bracing such as these can have negative psychological effects on paediatric patients.[75]

In otherwise healthy children, operative treatment consisting of derotational osteotomy is rarely indicated.

Consider – surgical correction

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ONGOING
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no comorbidity
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rotational profile beyond 2 standard deviations of the mean for age: in-toeing
Consider – 

surgical correction

Additional treatment recommended for SOME patients in selected patient group

Indicated in selected children aged >8 years with significant deformity that disrupts gait function, and with thigh-foot angle >3 standard deviations (SDs) beyond the mean.[26][28][77][78]​ Femoral alignment must be considered before surgical treatment, as femoral rotation can aggravate or compensate for tibial torsion.

Surgical correction has classically consisted of a derotational osteotomy, which involves cutting the bone, acutely correcting the rotational deformity, and fixing of the bone fragments with orthopaedic hardware. Recovery requires a period of non-weight bearing to the operative extremity, usually 6 weeks, and possible casting. A novel surgical option is rotational guided growth. See Emerging treaments.

In rare cases (<1%) medial femoral torsion may persist and be severe enough to cause disability in late childhood or adolescence. Surgical treatment is never indicated prophylactically. Surgical correction, consisting of a rotational femoral osteotomy (usually performed at the proximal femur), may be indicated in older children with severe deformities >3 standard deviations beyond the mean, medial hip rotation 80° to 90° or lateral rotation 0°, external rotation ≤20°, and significant functional disability.[77][78]

1st line – surgical correction

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ONGOING
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no comorbidity
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rotational profile beyond 2 standard deviations of the mean for age: out-toeing
1st line – 

surgical correction

Out-toeing due to lateral tibial torsion is generally more problematic than medial tibial torsion and more likely to require operative correction. Indicated in selected children aged >8 years, with significant functional deformity, and with thigh-foot angle >40° or 3 standard deviations beyond the mean.[77][78]

specific comorbidity

1st line – conservative management ± physiotherapy

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ONGOING
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specific comorbidity
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torsional malalignment: without cerebral palsy
1st line – 

conservative management ± physiotherapy

Excessive lateral tibial torsion and medial femoral torsion (miserable malalignment) associated with anterior knee symptoms, including patellofemoral pain, patella subluxation, or, rarely, dislocation, are initially treated conservatively. Physiotherapy is prescribed for knee pain and patella instability. If pain or instability persist after a course of physiotherapy, surgical treatment with derotation tibial and femoral osteotomy may be considered.

1st line – surgery or botulinum toxin

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ONGOING
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specific comorbidity
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torsional malalignment: with cerebral palsy
1st line – 

surgery or botulinum toxin

Torsional deformity is just one factor that contributes to pathological gait in patients with cerebral palsy.[79] Muscle imbalance, spasticity, and contractures may require tone-reducing medications (e.g., botulinum toxin type A) or soft-tissue procedures (e.g., tenotomy, tendon transfer, and muscle release) before bony procedures.[11][80][81]​​[82]​ Some patients may benefit from derotation osteotomies to improve limb alignment and gait.[83] Although gait analysis may aid decision making, indications for operative intervention are less clear in the literature in this population.[45][74]

Primary options

botulinum toxin type A: consult specialist for guidance on dose

1st line – stretching and serial casting

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ONGOING
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specific comorbidity
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metatarsus adductus
1st line – 

stretching and serial casting

A flexible foot (the forefoot can be passively abducted so that the heel-bisector line is beyond the second web space) can be observed. A flexible foot that corrects to midline may be treated with a home stretching programme.[86] A foot that does not correct to midline or does not improve with stretching may be serially casted every 1 to 2 weeks. Casting results are best when initiated before age 8 months.

Consider – surgery

Back
ONGOING
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specific comorbidity
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metatarsus adductus
Consider – 

surgery

Additional treatment recommended for SOME patients in selected patient group

Surgery is occasionally considered in children >4 years old for feet with severe deformity.

1st line – orthopaedic referral

Back
ONGOING
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specific comorbidity
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clubfeet
1st line – 

orthopaedic referral

Require referral to an orthopaedist for treatment.

1st line – reassurance

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ONGOING
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specific comorbidity
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flat feet: without pain
1st line – 

reassurance

Flexible, painless, flat feet are typically not pathological and do not predispose a child to foot pain as an adult. Flexible, asymptomatic flat feet do not require intervention and there is no evidence that corrective shoes or inserts are effective for painless flat feet.[46][86]

1st line – supportive care

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ONGOING
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specific comorbidity
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flat feet: with pain
1st line – 

supportive care

Initial treatment is reassurance and shoes with well-formed arch support in older children. A custom orthotic may be prescribed if pain persists despite the use of an off-the-shelf orthotic. Flexible flat feet associated with hindfoot pain resulting from a contracted gastrocnemius-soleus may be treated with Achilles tendon stretching exercises.

Consider – orthopaedic referral

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ONGOING
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specific comorbidity
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flat feet: with pain
Consider – 

orthopaedic referral

Additional treatment recommended for SOME patients in selected patient group

Painful and stiff flat feet require referral to an orthopaedist.

1st line – observation

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ONGOING
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specific comorbidity
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infantile Blount's disease
1st line – 

observation

For children <3 years old, observation every 3 to 6 months is recommended.

Consider – bracing

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ONGOING
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specific comorbidity
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infantile Blount's disease
Consider – 

bracing

Additional treatment recommended for SOME patients in selected patient group

Bracing (with a medial upright knee-ankle-foot orthosis) has limited effectiveness in certain patients in the early stages of the disease.

Consider – surgery

Back
ONGOING
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specific comorbidity
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infantile Blount's disease
Consider – 

surgery

Additional treatment recommended for SOME patients in selected patient group

Surgical correction is required for brace failure or for severe deformity before age 4 years.

1st line – orthopaedic referral

Back
ONGOING
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specific comorbidity
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adolescent Blount's disease
1st line – 

orthopaedic referral

Surgery to restore the normal anatomical alignment is the mainstay of treatment.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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