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Health condition

Alignment issues, from flat feet to scoliosis - assessed, treated and realigned.

Malalignment across the foot, knee, hip, pelvis and spine is one of the most under-recognised causes of joint pain and early osteoarthritis. Modern imaging, physiotherapy and, when needed, realignment surgery can change the trajectory.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against BOA, NICE and peer-reviewed orthopaedic and podiatric sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including EOS full-length imaging, gait analysis and guided-growth surgery in children.

Key facts

Alignment at a glance.

The essentials, in plain English - what malalignment is, the planes it happens in, and how it is treated in the UK today.

  • What it is

    A broad group of biomechanical and postural deviations from ideal skeletal alignment across the foot, knee, hip, pelvis, spine and shoulder.

  • Planes of deformity

    Coronal (varus and valgus), sagittal (kyphosis and lordosis), rotational (torsion and version) and length (limb-length discrepancy).

  • Common examples

    Flat feet, knock knees, bow legs, patellar maltracking, femoral anteversion, tibial torsion, pelvic obliquity, postural kyphosis.

  • Why it matters

    Malalignment concentrates load on cartilage, tendons and joints - and is a leading modifiable driver of early osteoarthritis.

  • First-line care

    Physiotherapy with strength and gait retraining is the backbone - orthotics, heel lifts and targeted injections support it.

  • Surgery

    Reserved for structural deformity: osteotomies, hip PAO, scoliosis fusion, and guided-growth 8-plates in growing children.

Why this guide matters

Alignment shapes almost every joint problem.

Whether the pain is in the foot, knee, hip or back, the way load moves through the skeleton is usually part of the picture. These three principles shape every plan.

  • Assess the whole chain

    A foot problem can start at the hip and a knee problem can start in the pelvis - imaging and gait analysis should look at the whole limb, not just the painful joint.

  • Rehab is not optional

    Even after surgery, strength and motor-control retraining is what makes a realignment stick. Skipping physio wastes both time and operations.

  • Structural needs structural

    Flexible, postural problems respond to rehab and orthotics. Bony, fixed deformity often needs osteotomy, PAO or fusion to protect the joint.

How alignment is assessed

From standing exam to a mapped mechanical axis.

The steps a UK orthopaedic team or podiatrist will normally follow - so you know what each test adds and why.

  1. 01

    Assessing

    Standing posture and gait

    A structured look at stance, pelvic level, spinal contour, foot arch and how you walk - from the front, side and behind.

  2. 02

    Assessing

    Joint-by-joint examination

    Range, alignment and stability tested at the foot, knee, hip, pelvis and spine - including hip impingement and labral tests.

  3. 03

    Assessing

    Limb-length and pelvic level

    True versus apparent leg-length discrepancy is measured, and pelvic obliquity distinguished from a real bony difference.

  4. 04

    Confirming

    Standing full-length EOS X-ray

    A weight-bearing hip-to-ankle image gives the mechanical and anatomical axes, joint-line angles and true limb lengths at low radiation.

  5. 05

    Confirming

    Gait analysis and pressure plate

    Video gait analysis and podiatry pressure-plate mapping quantify pronation, supination, cadence and load distribution.

  6. 06

    Confirming

    Selective MRI

    Reserved for suspected labral tears, cartilage injury, tendinopathy or spinal pathology contributing to the picture.

  7. 07

    Planning

    Shared plan and referral

    Findings are pulled together into a tiered plan - conservative first, with surgical opinion where the deformity is structural.

Typical pathway: assessment to a full plan within one or two consultations.

Signs

What alignment problems look like.

The most common patterns, from the ground up - and the features that mean specialist review is warranted.

  • Foot pronation or supination

    Flat, rolled-in feet or high-arched, rolled-out feet - often the first link in the kinetic chain.

  • Knock knees or bow legs

    Genu valgum brings the knees together; genu varum leaves them apart - both change load across the joint.

  • Patellofemoral maltracking

    The kneecap does not glide centrally in its groove - a common cause of anterior knee pain in young adults.

  • Femoral and tibial torsion

    In-toeing or out-toeing from twisted thigh or shin bones - often noticed in childhood, sometimes persisting.

  • Hip version and impingement

    Femoral anteversion, retroversion or cam and pincer morphology can pinch the labrum and limit motion.

  • Pelvic obliquity

    One side of the pelvis sits higher - from a true leg-length difference, scoliosis or muscle imbalance.

  • Kyphosis and lordosis

    Rounded upper back or exaggerated lower-back curve - postural, structural (Scheuermann’s) or degenerative.

  • Red flag - progressive deformity

    Rapidly worsening curve, sudden asymmetry or neurological symptoms deserve urgent specialist review.

Treatment

How alignment issues are treated in the UK.

A tiered plan - physiotherapy and orthotics first, injections and bracing as needed, and realignment surgery when the deformity is structural.

  • Physiotherapy and motor control

    The mainstay - strength, mobility and gait retraining rebuild control of the malaligned segment. Give it 12 weeks.

  • Custom foot orthotics

    Prescribed insoles support the arch, correct excessive pronation or supination and redistribute pressure across the foot.

  • Heel lifts for leg-length

    For a true leg-length discrepancy greater than about 1 cm, a heel raise or built-up shoe rebalances the pelvis.

  • Targeted injections

    Image-guided cortisone or hyaluronic acid for symptomatic joints or bursae while the alignment programme continues.

  • Bracing and postural support

    For flexible spinal curves in growing children, or short-term relief for painful segments during rehabilitation.

  • Osteotomy realignment

    HTO for valgus-shifting a varus knee, DFO for varus-shifting a valgus knee - preserving the joint in medial or lateral OA.

  • PAO and scoliosis surgery

    Ganz periacetabular osteotomy reorients a dysplastic hip; scoliosis and spinal osteotomy correct severe fixed deformity.

  • Guided growth (8-plates)

    In growing children, small tension-band plates gradually correct coronal deformity by modulating one side of the physis.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, physiotherapist, podiatrist or orthopaedic surgeon knows your history and imaging, and can tell you which parts of this apply to you.

  • British Orthopaedic Association (BOA). Standards for trauma and orthopaedics.

  • NICE. Guidance on osteoarthritis (NG226) and scoliosis assessment.

  • British Scoliosis Society. Guidance on adolescent idiopathic scoliosis.

  • Journal of Bone and Joint Surgery. Reviews on knee and hip osteotomy outcomes.

Red flags

When alignment problems need urgent attention.

Most malalignment can be worked up calmly. These are the situations where the pace changes and a specialist opinion is needed.

  • Rapidly progressive spinal curve

    A curve worsening month on month in a growing child needs urgent scoliosis service review before it becomes fixed.

  • New neurological symptoms

    Numbness, weakness, foot drop or bladder or bowel change with a deformity - urgent spinal review, not orthotics.

  • Sudden pelvic asymmetry

    A new limp or visible pelvic drop can flag hip pathology, fracture or a slipped upper femoral epiphysis in adolescents.

  • Locking or giving way

    A mechanical block with malalignment suggests a labral tear, meniscal injury or loose body - imaging is warranted.

  • Painful adolescent kyphosis

    Fixed, painful thoracic kyphosis raises Scheuermann’s disease - not simply poor posture.

  • True limb-length difference > 2 cm

    Larger discrepancies drive spine, hip and knee overload and usually need a formal lengthening or equalisation plan.

  • Deep groin or C-sign hip pain

    Classic for femoroacetabular impingement or a labral tear - MRI arthrogram and specialist opinion are appropriate.

  • Fracture-related malunion

    Angular deformity after a healed fracture may need corrective osteotomy rather than a brace or insole.

  • Cauda equina symptoms

    Saddle numbness, urinary retention or bilateral leg weakness - a same-day emergency, whatever the underlying alignment.

Living with it

A treatable problem, with a clear ladder.

Four things that make the biggest difference day to day - the right assessment, a proper rehab run, sensible use of aids, and knowing when structural means surgical.

A quiet reminder

Rehab that is boring but consistent beats heroic weeks.

Two or three targeted sessions a week, kept up for months, do more for alignment than any single treatment.

  1. 01 Assess

    Get the full picture first

    A standing EOS X-ray and gait analysis map the real problem - guessing from a single joint often misses the driver.

  2. 02 Rehab

    Give physio a fair run

    Strength and control take at least 12 weeks - a well-run programme prevents many surgeries and improves the ones that happen.

  3. 03 Support

    Use aids without shame

    Custom insoles, heel lifts and braces are tools, not failures - they let you train and live while the plan works.

  4. 04 Escalate

    Structural means surgical

    When deformity is bony and progressive, osteotomy, PAO or fusion can be life-changing - do not delay a specialist opinion.

Frequently asked

Everything we get asked about alignment.

Quick answers on assessment, physio, leg-length, surgery and paediatric alignment.

  • What counts as an alignment issue?

    Any deviation from ideal skeletal alignment that changes how load passes through the body - in the coronal plane (varus and valgus), sagittal plane (kyphosis and lordosis), rotationally (torsion and version) or as a limb-length difference. It can affect the foot, knee, hip, pelvis, spine or shoulder, alone or in combination.

  • How is alignment properly assessed?

    A comprehensive orthopaedic examination is combined with a standing full-length EOS X-ray that shows the hip, knee and ankle joint centres and the mechanical and anatomical axes. Gait analysis and podiatry pressure-plate testing quantify how the alignment behaves in movement, and MRI is added selectively when soft-tissue or joint pathology is suspected.

  • What is the difference between true and apparent leg-length discrepancy?

    True discrepancy is a real bony difference between the two legs, measured from the anterior superior iliac spine to the medial malleolus. Apparent discrepancy is functional - driven by pelvic obliquity, scoliosis or contractures - and often resolves with rehabilitation rather than a heel lift.

  • Can physiotherapy really correct alignment problems?

    It cannot straighten bone, but it can transform how a malaligned skeleton loads and moves. Strength, motor control and gait retraining reduce pain, improve function and often defer or avoid surgery. It is the first-line treatment for almost every flexible or postural alignment issue.

  • When is surgery the right answer?

    When deformity is structural, progressive or causing accelerated joint damage. Options include high tibial or distal femoral osteotomy to realign the knee, Ganz periacetabular osteotomy for hip dysplasia, scoliosis correction and, in growing children, guided-growth 8-plate surgery to modulate the physis and gently steer the limb straight.

  • Are knock knees or bow legs in children always a problem?

    No. Most young children pass through phases of bow legs and knock knees as part of normal development. Persistent, asymmetric or severe deformity - especially with pain, a limp or a positive family history - deserves paediatric orthopaedic assessment and, if needed, guided-growth treatment before the growth plates close.

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