Choosing Wisely:

Don’t order radiographs or advise bracing or surgery for a child less than eight years of age with simple in-toeing gait.

Rationale and Comments: Mild in-toeing is usually a physiologic phenomenon reflecting ongoing maturation of the skeleton. Metatarsus adductus, femoral anteversion, and tibial torsion all contribute to in-toeing and tend to improve with growth. Simply monitoring gait for continued improvement at normal well child examination intervals is adequate until the age of seven or eight unless there is severe tripping and falling or asymmetry. It is not possible to alter the natural evolution using physical therapy, bracing or shoe inserts.
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America
  • Sources:
  • Prospective cohort studies
  • Disciplines:
  • Orthopedic
  • Pediatric
  • References: • Fabry G, Cheng LX, Molenaers G. Normal and abnormal torsional development in children. Clinical Orthopaedics and Related Research. 1994;(301):22-26.
    • Fabry G, MacEwen GD, Sharnds AR, Jr. Torsion of the femur: A follow up study in normal and abnormal conditions. J Bone Joint Surg. Am. 1973;55(8):1726-1738.
    • Lincoln TL. Suen PW. Common rotational variations in children. The Journal of the American Academy of Orthopaedic Surgeons. 2003;11(5):312-320.
    • 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.
    • Svenningsen S. Apalset K. Terjesen T, Anda S. Regression of femoral anteversion. A prospective study of in-toeing of children. Acta Orthopaedica Scandinavica. 1989;60(2):170-173.

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