Bowed Knees
1. Introduction
The characteristic feature of genu varum – also known as ‘bowed knees’ – is an outward bowing of both knees. This means that when standing with the feet close together, there will be an increased distance between the knees.
Bowed knees can occur in childhood as a result of different conditions ranging from deficiencies, birth abnormalities and systemic metabolic problems (4). In later life, it is possible to develop bowed knees due to degenerative conditions like osteoarthritis or leg trauma (2,6).
In childhood, genu varum can spontaneously resolve (4). In acquired types of the condition in later life, exercise to maintain joint flexibility, improve muscle strength and function, and maintain fitness can be an effective treatment (3). Bracing and footwear changes can provide symptom relief. If all other treatments are exhausted, correctional surgery may be considered (1).
Frequently Asked Questions
- Bowed knees is a condition in which the legs are bowed outwards leaving a greater space in between your knees.
- Bowed knees are common in children aged between 18 – 24 months. This usually resolves by the age of three (4,5).
- In schoolchildren and adolescents, it has been found that 7.1% had bowed knees (7).
- Occurs in adults mainly alongside arthritis (1).
- No, usually bowed knees will resolve by the age of three (2).
- Not generally linked to any other serious pathology.
- In severe cases, where a child’s normal alignment does not resolve, or in cases of trauma or osteoarthritis, you may be referred to an orthopaedic surgeon to establish the suitability of corrective surgery (1).
Risk factors include (2, 3, 7):
- Older adults with osteoarthritis.
- Rickets – long term vitamin D deficiency can lead to this condition where a child’s bones develop abnormally.
- Blount’s disease – where a child’s shin bone develops with a bowing (tibia varum). The exact cause of this condition is unknown, but the risk is greater in children that begin walking (relatively) early.
- Paget’s disease – a metabolic disease that affects the remodelling process of bone cells resulting in brittle and abnormally shaped bones.
- Abnormal bone development.
- Traumatic fracture.
Symptoms experienced by people with bowlegs include (1,2):
- Knee or hip pain.
- Reduced range of motion in hips.
- Difficulty walking or running.
- Knee instability.
- Anxiety relating to physical appearance.
- Most often, children are observed to ensure that normal skeletal alignment returns (1).
- Pain-relieving medication to help manage symptoms.
- Orthotics (the provision and use of artificial devices such as splints and braces) can be used to improve walking mechanics (3).
- Orthopaedic bracing can provide symptom relief (3).
- Physiotherapy can help to maintain joint flexibility, improve muscle strength and function, and maintain fitness (3).
- Most children outgrow this problem (4).
- When persisting past 3 years of age, it suggests there is a bowing deformity (5).
- In severe cases, you may be referred to an orthopaedic surgeon to establish the suitability of correctional surgery (1,2).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
The most common symptom of a bowed leg condition is that a person’s knees do not touch while standing with their feet and ankles together.
Other symptoms experienced by people with bowlegs include (2, 4):
- Knee or hip pain.
- Reduced range of motion in hips.
- Difficulty walking or running.
- Knee instability.
- Anxiety relating to physical appearance.
Progressive knee arthritis is common in adults who were not diagnosed or treated for bowlegs earlier in life. Adult patients who have had bowleg for many years overload the inside of the knee and stretch the outside leading to pain, instability and arthritis (2,6).
3. Causes
As a child develops, different parts of the body grow at a different rate. As a result, skeletal alignment can change causing some unusual appearance of the extremities at specific ages. The most common cause of bowed legs in the toddler age range is simply normal development (4).
In children under the age of 2 years, bowed legs are considered a normal process of the developing skeleton. The angle of the bow tends to peak around the age of 18 months, and then gradually resolves within the following year. Most often, children this age are simply observed to ensure their skeletal alignment returns to normal as they continue to grow (4).
4. Risk Factors
Conditions that cause or increase the risk of bowed legs include (2,5,6):
- Rickets – long term vitamin D deficiency can lead to this condition where a child’s bones will develop abnormally.
- Blount’s disease – where a child’s shin bone develops with a bowing (tibia varum). The exact cause of this condition is unknown, but the risk is greater in children that begin walking (relatively) early.
- Paget’s disease – a metabolic disease that affects the remodelling process of bone cells resulting in brittle and abnormally shaped bones.
- Abnormal bone development.
- Traumatic fracture.
- Osteoarthritis.
5. Prevalence
Bowed legs are a common condition in children under the age of three. In most cases, this represents a variation in the normal growth pattern and is an entirely benign condition. In schoolchildren and adolescents, it has been found that 7.1% had bowed knees (7).
In adults, bowed legs are less common and have links with osteoarthritis, traumatic fractures and obesity (2,4).
6. Assessment & Diagnosis
A musculoskeletal physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your physiotherapist will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. An X-ray may be requested to review any bone abnormalities in greater detail. Blood tests can also help ascertain if your bowed legs are caused by other conditions, such as those outlined in the causation section (5).
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help recovery from your bowed knees. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
There is no treatment for childhood bowed knees and it usually resolves on its own. However, if symptoms persist past 3 and a half years of age, treatment may be indicated. This involves exercise, special footwear and braces (3). In some cases, surgery may be required in children when the deformity does not resolve on its own or with other treatments (2).
The only permanent treatment for bowed knees is surgery, which is also performed on people who have undergone trauma or age-related changes causing bowed knees (1). Although exercise cannot resolve the deformity, it can help maintain flexibility and strength, which are important in reducing secondary problems from bowed knees (3).
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing bowed knees. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clear exercise progression.
9. Bowed Knees
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
The focus is basic exercises to help increase movement and strength around the area. This should not exceed more than 4/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you may benefit from further assessment to ensure the progression of rehabilitation and treatment.
11. Other Treatment Options
Treatment is not usually recommended for infants and toddlers unless an underlying condition has been identified. Treatment may be recommended if your case of bowlegs is extreme or getting worse, or if an accompanying condition is diagnosed. Treatment options include (2,3):
- Special shoes
- Braces
- Casts
- Surgery to correct bone abnormalities.
- Treatment of diseases or conditions that cause bowed legs.
12. Links for Further Reading
Oxford Health NHS Foundation Trust – information leaflet on knock knees and bowed legs in children. Click here.
References
- Sharma, L., Song, J., Dunlop, D., Felson, D., Lewis, C.E., Segal, N., Torner, J., Cooke, T.D.V., Hietpas, J., Lynch, J. and Nevitt, M. (2010) Varus and valgus alignment and incident and progressive knee osteoarthritis. Annals of the rheumatic diseases, 69(11), 1940-1945.
- Soheilipour, F., Pazouki, A., Mazaherinezhad, A., Yagoubzadeh, K., Dadgostar, H. and Rouhani, F. (2020). The prevalence of genu varum and genu valgum in overweight and obese patients: assessing the relationship between body mass index and knee angular deformities. Acta Bio Medica: Atenei Parmensis, 91(4).
- Hunter, D. J., & Eckstein, F. (2009). Exercise and osteoarthritis. Journal of anatomy, 214(2), 197–207. https://doi.org/10.1111/j.1469-7580.2008.01013.x
- Killen, M. C., & DeKiewiet, G. (2020). Genu varum in children. Orthopaedics and Trauma, 34(6), 369-378.
- Brooks, W. C., & Gross, R. H. (1995). Genu varum in children: diagnosis and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 3(6), 326-335.
- Fahlman, L., Sangeorzan, E., Chheda, N., & Lambright, D. (2014). Older Adults without Radiographic Knee Osteoarthritis: Knee Alignment and Knee Range of Motion. Clinical medicine insights. Arthritis and musculoskeletal disorders, 7, 1–11. https://doi.org/10.4137/CMAMD.S13009
- Ciaccia, M., Pinto, C. N., Golfieri, F., Machado, T. F., Lozano, L. L., Silva, J., & Rullo, V. (2017). PREVALENCE OF GENU VALGUM IN PUBLIC ELEMENTARY SCHOOLS IN THE CITY OF SANTOS (SP), BRAZIL. PREVALÊNCIA DE GENUVALGO EM ESCOLAS PÚBLICAS DO ENSINO FUNDAMENTAL NA CIDADE DE SANTOS (SP), BRASIL. Revista paulista de pediatria : orgao oficial da Sociedade de Pediatria de Sao Paulo, 35(4), 443–447. https://doi.org/10.1590/1984-0462/;2017;35;4;00002
Other Conditions in
Knees
Patellofemoral Pain Syndrome (PFPS)
Knee pain around the kneecap usually worse in static positions, squatting or kneeling.
Patellar Tendinopathy
Knee pain at the lower border of the kneecap which is also known as ‘jumper’s knee’.
Osgood-Schlatter Disease
Pain in an area just below the knee on the shin bone, often with a lump.
Meniscus Injury
Structural knee injury, triggered either by a tear or through wear and tear.
Knee Replacement Surgery
Replacement of the knee hinge joint, typically as a result of severe osteoarthritis or trauma.
Knee Osteoarthritis
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Fat Pad Impingement
A rare condition affecting the adipose (fat) tissue that sits under the kneecap (patella) between the joint spaces of the knee.
Degenerative Meniscus
Seen to be normal as we age, but in some situations can result in knee aches, pain or joint swelling.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Baker’s Cyst
Swelling in the popliteal space (space behind the knee) that causes a visible lump.
Anterior Cruciate Ligament (ACL) Injury
Injury to a major stability ligmant in the knee, normally occuring following a significant twisting injury.