Toe anomalies:

• Most toe anomalies are asymptomatic cosmetic defects and do not require referral. Referral to a podiatrist or orthopedist may be indicated if the anomaly leads to pain or uncomfortable shoe wear or ambulation and if these symptoms do not respond to conservative management.

Clubfoot:

• Immediate referral to an orthopedist should be made on diagnosis of clubfoot.

Metatarsus varus:

• Forefoot has limited flexibility.
• Condition appears to be progressing or is not improving with growth.

Pronation:

• Limited flexibility or a suspicion of planovalgus
• Persistence of pronation beyond 2½ years of age
• Symptoms are present that are not relieved through conservative management

Pes cavus:

• All individuals with pes cavus should be referred for evaluation by a neurologist, physiatrist, orthopedist, individually or in collaboration.

Toe-walking:

• Toe-walking that persists beyond 2 years of age
• A child who has an abnormal neurological history or examination

Bowed legs and knock-knees:

• Severe, asymmetric, or unilateral genu varum or genu valgus
• Condition that does not follow the expected physiologic progression with growth

Toeing-in and toeing-out:

• Severe in-toeing
• Unsteady gait (especially while running) that causes stumbling
• Condition that does not follow the expected physiologic progression with growth

Tibial torsion:

• Extreme rotation (especially when associated with difficulty walking or running)
• Significant asymmetry
• Sudden proximal tibial deviation
• Condition that does not follow the typical pattern of improvement with growth

Femoral anteversion:

• Extreme rotation (especially when associated with difficulty walking or running)
• Significant asymmetry of the femoral anteversion
• Condition that does not follow the typical pattern of improvement with growth, by 7 years of age