FPIN's Clinical Inquiries

Managing Intoeing in Children

Am Fam Physician. 2011 Oct 15;84(8):937-944.

Clinical Question

What is the best way to evaluate and manage intoeing in children?

Evidence-Based Answer

Intoeing can be accurately diagnosed using a history, physical examination, and torsional profile. (Strength of Recommendation [SOR]: C, based on expert consensus.) The three most common causes of intoeing (i.e., metatarsus adductus, internal tibial torsion, and increased femoral anteversion) initially should be managed conservatively with serial examinations and reassurance. (SOR: C, based on expert consensus.) Patients with rigid metatarsus adductus should have serial casting if it persists beyond six months of age. (SOR: C, based on expert consensus.) Patients with internal tibial torsion that persists into midchildhood should be referred for surgical correction. (SOR: C, based on expert consensus.) Patients with increased femoral anteversion that persists past eight to 10 years of age should be referred for surgical correction. (SOR: C, based on expert consensus.)

Evidence Summary

The etiology of intoeing (i.e., metatarsus adductus, internal tibial torsion, and increased femoral anteversion) is debated, although the causes generally can be correlated with the patient's age at onset.1,2  An accurate diagnosis can be made with a history and physical examination (Table 114).5  The history should include the age at onset, associated symptoms (e.g., pain, limping, tripping), seating style, and the main concerns of the patient and parents. Medical history (e.g., birth complications, development, injuries) and family history (e.g., similar conditions in other family members) should be obtained. A torsional profile (Table 21) can be performed quickly, and can enhance assessment and prompt referral if needed.15

Table 1.

Etiologies of Rotational Deformities with Associated Clinical Findings

Deformity Etiology and prevalence Clinical findings

Metatarsus adductus

Intrauterine crowding is most likely cause

Adduction of forefoot with convex lateral border

Ankle has normal motion

Affects females more than males

Affects left foot more often than right foot

Internal tibial torsion

Most common cause of intoeing

Child walks with patella facing forward and feet pointing inward

Internal foot progression angle and an internal foot-thigh angle

Causes may include intrauterine position, sleeping in the prone position after birth, and sitting on the feet

Prevalence equal in males and females

Often asymmetrical

Affects left foot more often than right foot

Increased femoral anteversion

Often familial

Increased internal hip rotation (up to 90 degrees) and decreased external rotation

Child sits in a “W” position

Patellae and feet point inward when walking

Gait is clumsy with tripping resulting from crossing the feet

Usually bilateral

Affects females more often than males


Information from references 1 through 4.

Table 1.   Etiologies of Rotational Deformities with Associated Clinical Findings

View Table

Table 1.

Etiologies of Rotational Deformities with Associated Clinical Findings

Deformity Etiology and prevalence Clinical findings

Metatarsus adductus

Intrauterine crowding is most likely cause

Adduction of forefoot with convex lateral border

Ankle has normal motion

Affects females more than males

Affects left foot more often than right foot

Internal tibial torsion

Most common cause of intoeing

Child walks with patella facing forward and feet pointing inward

Internal foot progression angle and an internal foot-thigh angle

Causes may include intrauterine position, sleeping in the prone position after birth, and sitting on the feet

Prevalence equal in males and females

Often asymmetrical

Affects left foot more often than right foot

Increased femoral anteversion

Often familial

Increased internal hip rotation (up to 90 degrees) and decreased external rotation

Child sits in a “W” position

Patellae and feet point inward when walking

Gait is clumsy with tripping resulting from crossing the feet

Usually bilateral

Affects females more often than males


Information from references 1 through 4.

Table 2.

Torsional Profile

Cause of intoeing Clinical findings

Forefoot alignment

In metatarsus adductus, the sole of the foot is adducted (i.e., deviates medially) and the lateral border is “C” shaped

Holding the heel in neutral position, abduct forefoot to test flexibility

Correction

Grade I = past neutral position

Grade II = neutral

Grade III = less than neutral

Foot progression angle

Angle made by foot with respect to a straight line plotted in the direction the child is walking

Intoeing angles are negative values; outtoeing angles are positive values

Mean = 10 degrees (norm, –3 to 20)

Angle may be normal in children with combined torsional deformity (e.g., medial femoral torsion compensated by lateral tibial torsion)

Thigh-foot angle

Angle between the foot axis and thigh axis measured with child prone and knees flexed to 90 degrees

Intoeing angles are negative values; outtoeing angles are positive values

Mean = 10 degrees (norm, –5 to 30)

Both legs should be measured because the problem may be unilateral or legs may differ in degree of torsion

Negative values less than –5 degrees indicate internal tibial torsion

Hip rotation External

Measured with child prone and knees flexed to 90 degrees

External rotation = fully adducting legs

Mean for males and females = 45 degrees (norm, 25 to 65)

Internal

Internal rotation = fully abducting legs

Mean for males = 50 degrees (norm, 25 to 65)

Mean for females = 40 degrees (norm, 15 to 60)

Children with excess femoral anteversion have femoral neck axis rotated anteriorly in relation to frontal plane of femoral condyles


Information from reference 1.

Illustrations by Charles Boyter

Table 2.   Torsional Profile

View Table

Table 2.

Torsional Profile

Cause of intoeing Clinical findings

Forefoot alignment

In metatarsus adductus, the sole of the foot is adducted (i.e., deviates medially) and the lateral border is “C” shaped

Holding the heel in neutral position, abduct forefoot to test flexibility

Correction

Grade I = past neutral position

Grade II = neutral

Grade III = less than neutral

Foot progression angle

Angle made by foot with respect to a straight line plotted in the direction the child is walking

Intoeing angles are negative values; outtoeing angles are positive values

Mean = 10 degrees (norm, –3 to 20)

Angle may be normal in children with combined torsional deformity (e.g., medial femoral torsion compensated by lateral tibial torsion)

Thigh-foot angle

Angle between the foot axis and thigh axis measured with child prone and knees flexed to 90 degrees

Intoeing angles are negative values; outtoeing angles are positive values

Mean = 10 degrees (norm, –5 to 30)

Both legs should be measured because the problem may be unilateral or legs may differ in degree of torsion

Negative values less than –5 degrees indicate internal tibial torsion

Hip rotation External

Measured with child prone and knees flexed to 90 degrees

External rotation = fully adducting legs

Mean for males and females = 45 degrees (norm, 25 to 65)

Internal

Internal rotation = fully abducting legs

Mean for males = 50 degrees (norm, 25 to 65)

Mean for females = 40 degrees (norm, 15 to 60)

Children with excess femoral anteversion have femoral neck axis rotated anteriorly in relation to frontal plane of femoral condyles


Information from reference 1.

Illustrations by Charles Boyter

Metatarsus adductus occurs in one in 1,000 live births.6 Grades I and II can be observed for resolution by 12 months of age.7 Grade III is commonly treated with six weeks of serial casting.7 Studies have found that only patients with metatarsus adductus showed a benefit with casting, and the condition usually corrects itself without treatment within the first year of life.2,4

Internal tibial torsion usually is noticed after a child begins to walk. It gradually resolves on its own by eight years of age in more than 95 percent of patients.2,4 Residual deformities have not been shown to affect running, jumping, or risk of future arthritis.7,8 However, if the deformity persists into skeletal maturity and causes functional problems, a tibia derotation osteotomy may be performed to improve alignment.1,2

Increased femoral anteversion describes the normal position of the femur, which is medially rotated on its long axis at birth. Braces or shoe modifications typically are not helpful.6 Femoral anteversion is a benign condition with spontaneous resolution by late childhood in more than 80 percent of patients.1,2 Surgical correction can be associated with significant complications.1,2,4 Conditions that may warrant a surgical approach include persistence after eight years of age, severe deformity causing considerable cosmetic and functional disability, anteversion in excess of 50 degrees, and deformity more than three standard deviations above the mean.1

Recommendations from Others

No standard guidelines or recommendations on the treatment of intoeing have been accepted. Expert consensus continues to advise that torsional problems follow a benign and predictable course, with most cases resolving without intervention.1,5 Conservative treatment and reassurance continue to be the recommended initial responses to intoeing in children, whereas the use of special shoes, casts, or braces is not empirically supported. Surgery is reserved for older children with pronounced deformities.5

Several studies agree with expert consensus that physicians should talk with parents about the risks and benefits of treatment in children with a torsional deformity.1,2,4,9 Two systematic reviews confirm that derotation osteotomies of the femur and tibia are effective but are associated with statistically significant complication rates.2,9

Address correspondence to William Talley, MD, at wtalley87@yahoo.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official, or as reflecting the views of the U.S. Air Force Medical Service or the U.S. Air Force at large.


Copyright Family Physicians Inquiries Network. Used with permission.

REFERENCES

1. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985;67(1):39–47.

2. Bruce RW Jr. Torsional and angular deformities. Pediatr Clin North Am. 1996;43(4):867–881.

3. Fabry G, Cheng LX, Molenaers G. Normal and abnormal torsional development in children. Clin Orthop Relat Res. . 1994;(302): 22–26.

4. Wall EJ. Practical primary pediatric orthopedics. Nurs Clin North Am. 2000;35(1):95–113.

5. Sass P, Hassan G. Lower extremity abnormalities in children [published correction appears in Am Fam Physician. 2004; 69(5):1049]. Am Fam Physician. 2003;68(3):461–468.

6. Gore AI, Spencer JP. The newborn foot. Am Fam Physician. 2004;69(4):865–872.

7. Liu XC, Fabry G, Van Audekercke R, Molenaers G, Govaerts S. The ground reaction force in the gait of intoeing children. J Pediatr Orthop B. 1995;4(1):80–85.

8. Fuchs R, Staheli LT. Sprinting and intoeing. J Pediatr Orthop. 1996;16(4):489–491.

9. Molony D, Hefferman G, Dodds M, McCormack D. Normal variants in the paediatric orthopaedic population. Ir Med J. 2006;99(1):13–14.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

A collection of FPIN's Clinical Inquiries published in AFP is available at http://www.aafp.org/afp/fpin.


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