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Approach to the child with in-toeing

Approach to the child with in-toeing
Author:
Scott B Rosenfeld, MD
Section Editor:
William A Phillips, MD
Deputy Editor:
Diane Blake, MD
Literature review current through: Jan 2024.
This topic last updated: Apr 07, 2022.

INTRODUCTION — In-toeing ("pigeon-toeing") is a rotational variation of the lower extremity where the feet or toes point toward the midline during gait (figure 1).

In-toeing is one of the most common anatomic musculoskeletal variations encountered by pediatric primary care providers and a frequent reason for referral to a pediatric orthopedic surgeon. However, most children with in-toeing have variations of normal lower-extremity development that will improve spontaneously and can be monitored by the primary care provider.

This topic will provide an overview of lower-extremity rotational development, common causes of in-toeing, pathologic causes of in-toeing that must be excluded, and an approach to the evaluation and management of the child with in-toeing. Out-toeing is discussed separately. (See "Approach to the child with out-toeing".)

NORMAL PHYSIOLOGIC ALIGNMENT — An understanding of the normal growth and development of the lower extremity is essential in evaluating a child's rotational alignment and helps to elucidate the mechanism of in-toeing. Rotational alignment of the lower extremity is determined by the alignment of the foot, the rotation of the tibia in relation to the transcondylar axis of the femur (tibial torsion), and the rotation of the neck of the femur in relation to the transcondylar axis of the femur (femoral anteversion) (figure 2). In-toeing may be accentuated between six months and five years, when children are developing their walking and coordination skills [1]. Normal growth and improved coordination typically lead to spontaneous resolution of rotational variations (table 1).

Intrauterine positioning has an important influence on the rotational alignment of the legs. At the seventh week of gestation, the lower limb rotates medially (internally), followed by external (lateral) rotation of the upper leg. For the remainder of gestation, the tibiae and feet are medially (internally) rotated, and the hips and femora are laterally (externally) rotated, resulting in an external rotation contracture at the hip joint (figure 3) [2]. A small observational study suggests that postnatal foot rotation is similar among infants with vertex and breech intrauterine position [3].

Normal newborn posture reflects intrauterine positioning. The hips are flexed and externally rotated, with the patellae pointing outward. The tibiae and feet remain relatively internally rotated, but this is overshadowed by the external rotation contracture at the hip [4].

COMMON CAUSES OF IN-TOEING — The most common causes of in-toeing originate from the foot (metatarsus adductus), lower leg (internal tibial torsion), and hip (increased femoral anteversion) (figure 4) [5]. These conditions may occur in combination, which increases the severity of in-toeing [6,7]. They generally do not cause pain or interfere with development or stability of gait, although children with in-toeing may stumble or trip more frequently than other children, particularly when they are tired [8].

Age <1 year: Metatarsus adductus — Metatarsus adductus is characterized by angulation at the midfoot, with the metatarsals pointing toward the midline relative to the hindfoot. This gives the foot a "kidney bean" or "C" shape (picture 1). Metatarsus adductus is the most common congenital foot deformation and the most common cause of in-toeing in infants younger than one year [9,10].

Metatarsus adductus is thought to result from intrauterine molding or variations in anatomy [11]. It may be associated with other "packaging problems," such as torticollis [12]. It appears to be more common in twins, although the incidence is similar in preterm and term infants [13]. An association between metatarsus adductus and developmental dysplasia of the hip has been noted in some, but not all, studies [14-18]. (See "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Clinical features' and "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Examination'.)

The true incidence of metatarsus adductus is difficult to determine because mild variations generally are not reported. It is estimated to occur in up to 3 percent of term newborns [19,20]. It is more frequent in females than males and appears to run in families [8,13,20].

Metatarsus adductus is often bilateral; when unilateral, it occurs more often on the left than on the right (for unknown reasons) [8]. On examination of the foot, the heel bisector line is lateral to the second toe web space (figure 5). The hindfoot is in the neutral or valgus position, and the range of motion of the ankle and subtalar joint are normal [21]. (See 'Focused examination of the lower extremities' below.)

The differential diagnosis and treatment of metatarsus adductus are discussed below. (See 'Uncommon pathologic causes of in-toeing' below and 'Metatarsus adductus' below.)

Age 1 to 3 years: Internal tibial torsion — Internal tibial torsion is characterized by internal (medial) rotation of the tibia. It is the most common cause of in-toeing in children between one and three to four years of age and typically noticed when children begin to walk [21,22].

Internal tibial torsion affects males and females equally [8]. It does not occur in premature infants [23,24]. External tibial torsion is more likely in premature infants. (See "Approach to the child with out-toeing", section on 'External tibial torsion'.)

Internal tibial torsion is bilateral in approximately two-thirds of cases; in unilateral cases, the left side is more commonly involved for unknown reasons [21,23,25]. Internal tibial torsion is associated with metatarsus adductus in approximately one-third of cases. It is often associated with, and may accentuate the appearance of, physiologic tibia vara and bow legs. (See "Approach to the child with bow-legs", section on 'Physiologic varus'.)

Characteristic examination features of internal tibial torsion include [26]:

When standing or walking, the foot points inward (an inward foot progression angle), and the patella points straight ahead or outward (a neutral or external patellar progression angle) (see 'Observation of gait' below)

The medial malleolus is level with or posterior to the lateral malleolus (with the child seated with the thigh directly in front of the hip joint and the knee pointed straight ahead)

In the prone position, the thigh-foot angle is internal (figure 6)

Internal tibial torsion typically resolves by five years of age [27]. As the child grows, the tibia spontaneously rotates laterally. The average thigh-foot angle changes from -5 degrees (medial or internal) at birth to 15 degrees (lateral or external) at maturity [27]. However, wide variation of tibial rotation is common. An internal thigh-foot angle of 20 degrees falls within 2 standard deviations (SD) of the mean in infants and toddlers.

Management of internal tibial torsion is discussed below. (See 'Internal tibial torsion' below.)

Age 3 and older: Increased femoral anteversion — Femoral version is the angular difference between the axis of the femoral neck and the transcondylar axis of the femur (figure 7). Increased femoral anteversion (picture 2) (also called medial femoral torsion) is associated with increased internal rotation and decreased external rotation at the hip.

Increased femoral anteversion is the result of intrauterine molding and genetic inheritance. It is twice as common in females as in males [6,8].

Increased femoral anteversion usually is diagnosed between three and six years of age; before three years, it is masked by the physiologic external rotation contracture of the hip. In-toeing due to increased femoral anteversion may increase until five to six years of age and then gradually decreases [23]. Increased femoral anteversion does not cause pain. (See 'Normal physiologic alignment' above.)

Characteristic clinical features of increased femoral anteversion include [4,6-8,23]:

When standing, the patellae face medially

When walking, the toes and patella point toward the midline (internal foot progression angle and internal patellar progression angle) (see 'Observation of gait' below)

"Egg-beater" or "windmill" pattern during running (the legs flip laterally during the swing phase, when the foot is off the ground)

Increased internal rotation and decreased external rotation of both hips (symmetric) (see 'Focused examination of the lower extremities' below)

Preference for sitting in the "W" position (figure 8); uncomfortable sitting cross-legged until lateral rotation of the hip improves

The natural history and management of increased femoral anteversion is discussed below. (See 'Increased femoral anteversion' below.)

UNCOMMON PATHOLOGIC CAUSES OF IN-TOEING — Uncommon, pathologic causes of in-toeing in children include neuromuscular diseases (eg, cerebral palsy), disorders of the hip (eg, developmental dysplasia of the hip [DDH]), and lower leg deformities (eg, clubfoot, skewfoot). Although these conditions are uncommon, they must be considered in the evaluation of a child with in-toeing because they do not resolve spontaneously. They can generally be excluded through history and physical examination.

Cerebral palsy – Mild hemiplegic cerebral palsy rarely may present with an in-toeing gait [28]. Spasticity secondary to cerebral palsy may result in over-pull of the internal rotators of the hip or the adductors and inverters of the foot, which may cause an asymmetric, unilateral in-toeing gait. Asymmetry is a red flag. The history may reveal perinatal problems or delayed developmental milestones. Examination may demonstrate spasticity of the gastro-soleus, hamstrings, and hip adductors [23]. Such findings should prompt referral to a specialist (eg, neurologist, physical medicine and rehabilitation specialist) for evaluation for cerebral palsy. (See "Cerebral palsy: Classification and clinical features".)

DDH – Developmental dysplasia or dislocation of the hip may present with in-toeing related to limitation of hip abduction, leg-length discrepancy, or persistent increased femoral anteversion [4,7,29]. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Embryology and pathogenesis' and "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Age-specific findings of DDH'.)

Clubfoot – Clubfoot is a foot deformity in which medial deviation of the forefoot is combined with excessive supination (the sole of the foot faces inward), cavus (high midfoot arch), and ankle plantar flexion (equinus) (picture 3). It is distinguished from metatarsus adductus by the presence of these additional deformities and inability to dorsiflex the foot.

Skewfoot – Skewfoot is a rare foot deformity in which medial deviation of the forefoot is combined with lateral translation of the midfoot and valgus position of the hindfoot. The possibility of skewfoot should be considered in infants with unilateral metatarsus adductus. In infants with skewfoot, the head of the talus may be visible and palpable medially.

CLINICAL PRESENTATION — The presenting complaints for a child with in-toeing may include concerns about appearance of the legs or foot, excessive falling, awkward running style, uneven shoe wear, and/or bowed legs (which is often associated with in-toeing). (See "Approach to the child with bow-legs", section on 'Clinical presentation'.)

EVALUATION — The objectives of the evaluation are to identify caregiver concerns (eg, cosmesis, frequent falling, permanent disability, interference with sports performance), identify the cause of in-toeing, and exclude pathologic etiologies. The history and physical examination usually are sufficient to achieve these goals.

History — Important aspects of the history include:

Birth history, including gestational age and complications (prematurity may be a clue to cerebral palsy)

Developmental milestones (delayed milestones may be a clue to cerebral palsy)

Early hand preference (preference for one side before three years of age may be a sign of hemiplegia) [23,30]

Family history of in-toeing (internal tibial torsion and femoral anteversion run in families); the clinical course of these problems in a sibling or parent may help to reassure the family about spontaneous resolution and lack of long-term sequelae

Onset:

At birth (metatarsus adductus)

When the child began walking (internal tibial torsion or [rarely] hip dislocation)

After age three years (increased femoral anteversion)

Recent change (may indicate pathologic cause)

Clinical course (recent change may indicate pathologic cause)

Unilateral or bilateral? Symmetric or asymmetric? Unilateral or asymmetric in-toeing is a red flag for cerebral palsy, clubfoot, or skewfoot

Associated complaints:

Pain or limp (red flags for pathologic conditions such as hemiplegia or injury) (see "Evaluation of limp in children");

Tripping or falling (may occur in children with internal tibial torsion or increased femoral anteversion, particularly when they are tired (figure 9), but may be an indication for referral if they persist beyond the normal age of resolution and are severe and disabling); bow-legs (often associated with internal tibial torsion)

Perceived difficulties caused by in-toeing (must be addressed during management) (see 'Management' below)

Examination

Objectives and components — The examination serves to exclude pathologic causes of in-toeing, pinpoint rotational contributions, and identify associated angular problems (eg, bow legs).

It also serves to evaluate associated conditions, such as the possibility of torticollis or developmental dysplasia of the hip (DDH) in children with metatarsus adductus. The neck of infants with metatarsus adductus should be examined for torticollis. The hips should be examined for DDH (table 2). However, isolated metatarsus adductus is not an indication for hip imaging to exclude DDH because the association between metatarsus adductus and DDH in observational studies is inconsistent [14-18]. (See "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Clinical features' and "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Examination'.)

The examination should include observation of gait, focused examination of the lower extremity, and neurologic examination. In some cases, evaluation of the parental rotational profile also may be helpful.

Observation of gait — If the child is ambulatory, the child's gait should be observed as the child walks toward and away from the examiner [2]. The presence or absence of a limp should be noted. Additionally, the foot progression and patellar progression angles should be noted. These angles describe the alignment of the foot and patella, respectively, as they relate to the direction that the patient is moving. An internal foot progression angle describes a foot that points toward the midline as the patient walks forward (figure 1). An external patellar progression angle describes a patella that points away from the midline as the patient walks forward. The common causes of in-toeing generally have reproducible gait patterns:

Metatarsus adductus – Internal foot progression angle, neutral or external patella progression angle.

Internal tibial torsion – Internal foot progression angle, neutral or external patella progression angle.

Increased femoral anteversion – Internal foot progression angle, internal patella progression angle.

The child should also be observed while running [7,8]. A child with increased femoral anteversion may be described to have an egg-beater running pattern with medial rotation of the thighs and outward rotation of the feet during swing phase [8]. Furthermore, running may accentuate neurologic dysfunction and rotational variations. Unilateral limp while walking or running should raise suspicion of pathologic causes of in-toeing.

Focused examination of the lower extremities — Examination of the rotational alignment of the lower extremities is best done with the patient lying prone on the examination table [1]. The caregivers should be encouraged to stand with the examiner next to the patient so that they can appreciate the findings as the examination is performed. The examination should progress through the three main sites for rotational variations: foot, tibia, and femur/hip. This can be accomplished by making the following measurements:

Heel bisector line – The heel bisector line is measured in the prone position with the knee flexed and ankle dorsiflexed so that the plantar surface of the foot is parallel to the ceiling. The heel bisector line bisects the heel pad and is extended through the toes (figure 5). A normal heel bisector line crosses the second toe or the second toe web space. Metatarsus adductus is diagnosed when the heel bisector line is lateral to the second toe web space. The more severe the metatarsus adductus, the more lateral the toes that the line crosses. The severity based upon the heel bisector line does not correlate with the prognosis. (See 'Metatarsus adductus' below.)

Flexibility of metatarsus adductus – In children with metatarsus adductus, the flexibility should be assessed by applying lateral pressure to the forefoot over the first metatarsal with one hand while firmly holding the heel in a neutral position with the other hand (figure 5). [31]. Flexibility is classified as follows (see 'Age <1 year: Metatarsus adductus' above):

Flexible (mild) – The forefoot can be passively abducted past the midline (ie, into abduction) with little effort

Semiflexible (moderate) – The forefoot can be passively abducted only to the midline position

Rigid (severe) – The forefoot cannot be passively abducted to the midline position; may be associated with a medial skin crease

Most cases of metatarsus adductus are mild/flexible and resolve spontaneously by one year of age [32].

Thigh-foot angle – The thigh-foot angle is measured with the knee flexed and the ankle dorsiflexed so that the plantar surface of the foot is parallel to the ceiling. Allow the foot to fall into a neutral position. A visual line is approximated along the long axis of the thigh and a second line along the long axis of the heel. The angle between these two lines is the thigh-foot angle (figure 6). If the line of the heel points toward the midline relative to the thigh, it suggests internal torsion of the tibia. If the line of the heel points away from the midline relative to the thigh, it suggests external torsion of the tibia.

Normal values for the thigh-foot angle were determined in a study of 1000 limbs of 500 subjects (all of whom were White) ranging in age from <1 to 70 years [27]. The average thigh-foot angle at birth is -5 degrees (internal) and increases to 15 degrees (external) at maturity.

Hip rotation – Hip rotation is measured with the knees flexed. Internal rotation is measured by rotating the leg away from the axis of the body (rotating the hip internally). External rotation is measured by rotating the leg towards the axis of the body (rotating the hip externally).

Normal values for hip rotation were determined in a study of 1000 limbs of 500 subjects (all of whom were White) ranging in age from <1 to 70 years (figure 10) [27]. The average amount of internal hip rotation during childhood is between 40 and 50 degrees. The average amount of external hip rotation during childhood is between 40 and 70 degrees.

Patients with increased femoral anteversion may have as much as 90 degrees of internal rotation, allowing the legs to rotate flat against the examination table [23]. Similarly, they will have a decreased amount of external rotation, often only to neutral. Conversely, patients with femoral retroversion will have increased external rotation (to almost 90 degrees) and very little internal rotation.

Other aspects of the lower-extremity examination that may be helpful in identifying associated conditions and excluding pathologic causes of in-toeing include:

Assessment for associated angular variations (bow legs are associated with internal tibial torsion; knock-knees are associated with external tibial torsion) (see "Approach to the child with bow-legs", section on 'Physiologic varus' and "Approach to the child with knock-knees", section on 'Physiologic valgus')

Examination of the hips for DDH (table 2) (see "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Examination')

Range of motion at the ankle; the ability to dorsiflex the ankle above neutral helps to exclude true clubfoot

Observation and palpation of the medial aspect of the foot; a visible or palpable head of the talus may indicate skewfoot although additional evaluation is necessary

Parental rotational profiles — Increased femoral anteversion and internal tibial torsion tend to run in families. Assessment of the parents' rotational profiles may help to predict how the child is likely to be affected as an adult [8]. Such information may help to reassure the family about the lack of long-term functional problems. (See 'Management' below.)

Focused neurologic examination — A focused neurologic examination is important to exclude cerebral palsy. The minimal neurologic examination should include:

Upper- and lower-extremity reflexes.

Ankle clonus.

Measurement of popliteal angles to assess hamstring spasticity. The popliteal angle is measured by flexing the hip and the knee to 90 degrees and then extending the knee up to the point of mild resistance (figure 11). The popliteal angle is the angle between the tibia and the extension of the femur. Values ≥50 to 55 degrees are considered abnormal in children [33,34].

Asking the child to walk on their heels and toes and to hop on each leg. Heel walking demonstrates the ability to dorsiflex the ankle. Toe walking and hopping help to evaluate the child's overall motor coordination level (which varies with age).

Red flags for pathologic conditions — Red flags for pathologic conditions in include:

Asymmetry or unilateral in-toeing (possible cerebral palsy, clubfoot, or skewfoot) (see 'Uncommon pathologic causes of in-toeing' above)

Delayed developmental milestones (possible cerebral palsy) (see "Cerebral palsy: Classification and clinical features", section on 'Classification')

Breech positioning at ≥34 weeks gestation, family history of DDH, apparent leg length discrepancy (possible DDH) (see "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Risk factors')

Pain or limp (see "Evaluation of limp in children")

Radiographs — Radiographs generally are not necessary in the assessment of in-toeing. In patients with residual metatarsus adductus, radiographs may be necessary for surgical planning. In the rare patient in whom skewfoot is a consideration, radiographs may exclude the diagnosis. Clubfoot can be excluded clinically. Internal tibial torsion and femoral anteversion, the most common causes of in-toeing in infants and school-age children, are diagnosed clinically.

INDICATIONS FOR REFERRAL — Most patients with rotational variations of the lower extremity can be followed in the primary care office [35,36]. In a retrospective review of 202 children (median age four years) with in-toeing who were referred for orthopedic surgery consultation by primary care providers, 86 percent were discharged after their first visit [35]. Most of the referred children had increased femoral anteversion (61 percent), internal tibial torsion (15 percent), or physiologic in-toeing (14 percent); 5 percent had foot pathology (eg, metatarsus adductus, pes planus, pronation of the forefoot) and 4 percent had bow legs or knock-knees.

Indications for referral include:

Semiflexible metatarsus adductus that persists at age six months, which may require serial casting (refer to pediatric orthopedic surgeon or an orthopedic surgeon with expertise in rotational problems)

Rigid metatarsus adductus (at any age), which may require serial casting (refer to pediatric orthopedic surgeon or an orthopedic surgeon with expertise in rotational problems)

Unilateral or asymmetric in-toeing associated with clinical findings suggestive of neurologic disorder (refer to a pediatric orthopedic surgeon, pediatric neurologist, or physical medicine and rehabilitation specialist)

Children ≥8 years with activity limiting or cosmetically unacceptable in-toeing due to internal tibial torsion (may be candidates for derotational osteotomy; refer to an orthopedic surgeon with expertise in rotational problems)

Children ≥11 years with activity limiting or cosmetically unacceptable in-toeing due to increased femoral anteversion (may be candidates for derotational osteotomy; refer to an orthopedic surgeon with expertise in rotational problems)

In-toeing that does not follow the expected course (eg, increased femoral anteversion that progresses after age five or six years) [21] (refer to pediatric orthopedic surgeon or an orthopedic surgeon with expertise in rotational problems)

MANAGEMENT — The first step in the management of in-toeing is establishing a correct diagnosis [4]. The natural history of most rotational variations is spontaneous resolution as the child grows and develops.

Caregiver reassurance — The most important (and usually only) intervention that is necessary for the majority of children with in-toeing is reassurance that:

In-toeing is a common developmental variation related to intrauterine positioning.

In-toeing resolves spontaneously as the child grows. In an observational study of 761 normal subjects (students from kindergarten, elementary, intermediate, nursing, and technical schools), the overall prevalence of in-toeing was 16 percent; the frequency decreased from 30 percent in four-year-old children to 4 percent in adults [37].

Even if in-toeing does not completely resolve, long-term functional problems are rare (occurring in approximately 1 in 1000 children) [8].

When reassuring the family, it can sometimes be helpful to explain that the approach to management has changed over time. This is of particular importance when there is a family history of in-toeing. Parents and grandparents may recall a time when rotational variations were considered serious problems and were treated with interventions now known to be ineffective (eg, special shoes, orthotics). A brief explanation of how our understanding of these problems has evolved can help reassure families.

To demonstrate the benign nature of in-toeing, one simple exercise is to have the family member sit down in a public place and observe people walking past. They will notice considerable variation in the direction that people's feet point when they walk. In addition, some families may be relieved to know that many sprinters and other running athletes in-toe when running [38].

Management of specific conditions

Metatarsus adductus

Treatment of metatarsus is determined by the degree of flexibility (figure 5) [11]:

Flexible (the forefoot can be passively abducted past the midline) – For children with flexible metatarsus adductus, treatment is not necessary. Flexible metatarsus adductus resolves spontaneously over time, usually by age one year [20,32]. Stretching exercises are not recommended; they have not been proven to be more efficacious than observation [39,40].

In a case-series of seven patients (nine feet) with mild metatarsus adductus who had no treatment and were followed for a mean of 32.5 years, all patients had normal clinical appearance and normal function at follow-up [41].

Semiflexible (the forefoot can be passively abducted only to the midline) – For infants with semiflexible metatarsus adductus, we suggest observation for six months. Some families prefer to be more active in this process, and for those patients we teach them how to perform passive stretching.

Although passive stretching exercises are commonly recommended, it is not clear that they are efficacious [39,42]. In a randomized trial, caregiver stretching initiated in the newborn period was not found to be more effective than observation in resolving moderate to severe metatarsus adductus [39]. In a case series of five patients (seven feet) with moderate metatarsus adductus who had no treatment and were followed for a mean of 32.5 years, all patients had normal clinical appearance and normal function at follow-up [41].

Stretching consists of laterally directed pressure on the head of the first metatarsal to correct the malalignment; the position should be held for 10 seconds; it should be performed five times per foot whenever the infant's diaper is changed [22].

For children with semiflexible metatarsus adductus, we do not suggest special footwear, monitoring sitting or sleeping postures, or initial treatment with casting or orthoses. These treatments have not been shown to be beneficial [40].

Patients should be reevaluated for improvement/resolution on a regular basis. For patients whose metatarsus adductus has not improved by six months of age, serial casting may be warranted [11,43,44]. In a case series of 37 feet with moderate metatarsus adductus, below-knee plaster casting corrected the abnormality within six to eight weeks in all patients [43]. Correction is maintained for many years. In another case-series, all 13 patients (19 feet) with moderate metatarsus adductus who were treated with casting and followed for a mean of 32.5 years had normal clinical appearance and function at follow-up [41].

Orthotic splints may be a less expensive alternative to casting for children with semiflexible metatarsus adductus [45], but additional study is necessary.

Treatment with corrective shoes has not been shown to be beneficial and is not recommended.

Rigid – In rigid metatarsus adductus, the forefoot cannot be passively abducted to the midline. Rigid metatarsus tends to worsen with time [42]; it may require corrective casting. Results are best when treatment is initiated before eight months of age [31,42,44].

In a case series of 48 feet with severe metatarsus adductus, below-knee plaster casting corrected the deformation within six to eight weeks in all patients [43]. At a mean follow-up of four years, 44 feet were available for follow-up: 37 maintained correction, six had a moderate deformation, and one had a severe deformation; all of the forefeet were flexible and none of the children required further treatment. In another case-series, eight patients (10 feet) with severe/rigid metatarsus adductus were treated with casting and followed for a mean of 32.5 years [41]. Six of eight patients had normal clinical appearance and function at follow-up and two had fair outcomes (mild residual deformity and/or decreased function).

Surgical correction is controversial. It may be an option for the older child with persistent metatarsus adductus, but the reported incidences are high for failure (approximately 40 percent) and complications (approximately 50 percent) [46,47]. Complications include skin slough and persistent pain with prominence of the tarsal metatarsal joints.

Internal tibial torsion — Internal tibial torsion generally corrects spontaneously by five years of age [27]. Most patients can be managed with observation and caregiver reassurance that tibial torsion is physiologic, often resolves spontaneously, and, even if it persists, has few long-term sequelae [38].

The use of special shoes, orthotics, or braces is not recommended. Prospective observational and randomized studies have found them to be ineffective [48,49]. Adverse effects of orthotics during childhood include unnecessary costs, negative psychosocial sequelae, and interference with sleep or play [8,50].

Surgical treatment for internal tibial torsion rarely is indicated. It should be reserved for patients with severe in-toeing causing functional or cosmetic deformity [4,8]. Patients meeting this criterion who are older than eight years with an internal thigh-foot angle greater than 15 degrees may be considered for distal tibial derotational osteotomy [8].

The most important aspect of treatment is caregiver reassurance that internal tibial torsion is physiologic and often resolves spontaneously [51]. Even cases that do not completely resolve tend to have a benign natural history. In a case-control study, high-school sprinters had a lower mean thigh-foot angle than high-school controls (+3 versus +10 degrees), and in-toed gait during sprinting (but not during walking) was more common among sprinters than controls [52].

Increased femoral anteversion — The natural history of in-toeing secondary to increased femoral anteversion is that of spontaneous resolution, usually by 11 years of age [29,37]. The average amount of femoral anteversion at birth is 40 degrees. With normal growth, femoral anteversion decreases approximately 1.5 degrees per year, resulting in an average of 8 to 14 degrees by maturity. Pathologic sequelae of increased femoral anteversion are rare, even in persistent cases. There is no link between increased femoral anteversion and osteoarthritis [38,53-55]. However, when combined with external tibial torsion, patients with increased femoral anteversion may be more likely to develop anterior knee pain from so-called "miserable malalignment" [56]. (See "Approach to the child with out-toeing", section on 'External tibial torsion'.)

Most children with increased femoral anteversion can be managed with observation and caregiver reassurance that increased femoral anteversion is physiologic, often resolves spontaneously and, even if it does not, has few long-term sequelae. Prospective observational and randomized studies have found shoe wedges, twister cables, bracing, and splinting to be ineffective [29,49]. These interventions are not recommended. Likewise, keeping the child from sitting in the "W" position (figure 8) is not recommended because it is unlikely to change the natural history.

Femoral derotational osteotomy is the only treatment that is effective in decreasing femoral anteversion. Given the high likelihood of spontaneous resolution and the historically high complication rate of femoral derotation osteotomy, femoral derotation osteotomy generally is not recommended. It should be reserved for the child ≥11 years of age who complains of severe functional or cosmetic deformity and has femoral anteversion of greater than 50 degrees (measured radiographically) and internal hip rotation of greater than 80 degrees [8].

SUMMARY AND RECOMMENDATIONS

Common causes – The most common causes of in-toeing in children are related to intrauterine molding and resolve spontaneously through normal growth and development. They include (see 'Common causes of in-toeing' above):

Metatarsus adductus – Metatarsus adductus is medial deviation of the forefoot on the hindfoot (picture 1). It is characterized by a "kidney bean" or "C" shape, heel bisector line that is lateral to the second toe (figure 5), normal range of motion of the ankle and subtalar joint, internal foot progression angle, and a neutral or external patella progression angle. Metatarsus adductus is the most common cause of in-toeing in infants younger than one year. It usually resolves spontaneously by one year of age. (See 'Age <1 year: Metatarsus adductus' above.)

Internal tibial torsion – Internal tibial torsion is internal (medial) rotation of the tibia in relation to the transcondylar axis of the femur. It is the most common cause of in-toeing in children between one and three to four years of age. Internal tibial torsion is characterized by a foot that points inward when the patella faces forward or externally, medial malleolus level with or posterior to the lateral malleolus (with the knee pointed straight), and neutral or internal thigh-foot angle (figure 6). Internal tibial torsion usually resolves spontaneously by five years of age. (See 'Age 1 to 3 years: Internal tibial torsion' above.)

Increased femoral anteversion – Increased femoral anteversion is an increased angle of rotation of the femoral neck in relation to transcondylar axis of the femur (figure 7 and picture 2). It is the most common cause of in-toeing in children older than three years of age. Increased femoral anteversion is characterized by inward facing feet and patella during walking and standing; "egg-beater" pattern during running the legs flip laterally during the swing phase, when the foot is off the ground; symmetrically increased internal rotation and decreased external rotation of the hips; and preference for sitting in the "W" position (figure 8). Increased femoral anteversion tends to improve spontaneously by 11 years of age. (See 'Increased femoral anteversion' above.)

Uncommon pathologic causes – Pathologic conditions that must be considered in the evaluation of the child with in-toeing include neuromuscular diseases (eg, cerebral palsy), disorders of the hip (eg, developmental dysplasia), and lower leg deformities (eg, skewfoot, clubfoot). These conditions usually can be excluded through history and examination. (See 'Uncommon pathologic causes of in-toeing' above and 'Evaluation' above.)

Management – Most children with rotational variations of the lower extremity can be followed in the primary care office. The most important aspect of management of rotational causes of in-toeing is caregiver reassurance that most "deformities" correct spontaneously and that, even in persistent cases, adverse long-term sequelae are rare. (See 'Caregiver reassurance' above.)

Metatarsus adductus – Management of metatarsus adductus is determined by the degree of flexibility (figure 5) (see 'Metatarsus adductus' above):

-Flexible metatarsus resolves spontaneously; treatment, including passive stretching exercises, is not necessary.

-For infants <6 months of age with semiflexible metatarsus adductus (the forefoot can be passively abducted only to the midline), we suggest initial observation (Grade 2C). However, if the family prefers more active therapy, we teach them how to perform passive stretching.

Infants with semiflexible metatarsus adductus that persists at age six months or rigid metatarsus adductus at any age should be referred to a pediatric orthopedic surgeon or an orthopedic surgeon with expertise in rotational problems; corrective casting may be necessary.

Internal tibial torsion – For children with internal tibial torsion who are <8 years of age, management consists of observation and caregiver reassurance. The natural history is one of spontaneous resolution. (See 'Internal tibial torsion' above.)

Increased femoral anteversion – For children with increased femoral anteversion who are <11 years of age, management consists of observation and caregiver reassurance. The natural history is one of spontaneous resolution. (See 'Increased femoral anteversion' above.)

Indications for referral – Indications for referral include semiflexible metatarsus adductus that persists at age six months, rigid metatarsus adductus, unilateral or asymmetric in-toeing with findings suggestive of cerebral palsy or developmental dysplasia/dislocation of the hip, cosmetically or functionally unacceptable in-toeing due to internal tibial torsion in a child older than eight years, cosmetically or functionally unacceptable in-toeing due to femoral anteversion in a child older than 11 years, and in-toeing that does not follow the expected clinical course. (See 'Indications for referral' above.)

  1. Schoenecker PL, Rich MM, Gordon JE. The lower extremity. In: Lovell and Winter’s Pediatric Orthopaedics, 7th ed, Weinstein SL, Flynn JM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.1261.
  2. LeDamany P. La torsion du tibia, normal, pathologique, experimentale. J Anat Physiol 1909; 45:598.
  3. Fong B, Ledebt A, Zwart R, et al. Is there an effect of prenatal breech position on locomotion at 2.5 years? Early Hum Dev 2008; 84:211.
  4. Staheli LT. Lower limb. In: Fundamentals of Pediatric Orthopedics, 4th ed, Lippincott Williams & Wilkins, Philadelphia 2008. p.135.
  5. Faulks S, Brown K, Birch JG. Spectrum of Diagnosis and Disposition of Patients Referred to a Pediatric Orthopaedic Center for a Diagnosis of Intoeing. J Pediatr Orthop 2017; 37:e432.
  6. Li YH, Leong JC. Intoeing gait in children. Hong Kong Med J 1999; 5:360.
  7. Bruce RW Jr. Torsional and angular deformities. Pediatr Clin North Am 1996; 43:867.
  8. Staheli LT. Rotational problems in children. Instr Course Lect 1994; 43:199.
  9. Widhe T, Aaro S, Elmstedt E. Foot deformities in the newborn--incidence and prognosis. Acta Orthop Scand 1988; 59:176.
  10. Glass SM. Abnormal Physical Findings. In: Assessment and Care of the Well Newborn, Thureen PJ, et al (Eds), WB Saunders, Philadelphia 1999. p.206.
  11. Mosca VS. The foot. In: Lovell and Winter’s Pediatric Orthopaedics, 7th ed, Weinstein SL, Flynn JM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.1388.
  12. Herring JA, Karol LA, Richards BS, Johnston CE. Disorders of the foot. In: Tachdjian's Pediatric Orthopaedics, 4th ed, Herring JA (Ed), Saunders, Philadelphia 2008. p.1035.
  13. Hunziker UA, Largo RH, Duc G. Neonatal metatarsus adductus, joint mobility, axis and rotation of the lower extremity in preterm and term children 0-5 years of age. Eur J Pediatr 1988; 148:19.
  14. JACOBS JE. Metatarsus varus and hip dysplasia. Clin Orthop 1960; 16:203.
  15. Kumar SJ, MacEwen GD. The incidence of hip dysplasia with metatarsus adductus. Clin Orthop Relat Res 1982; :234.
  16. Gruber MA, Lozano JA. Metatarsus varus and developmental dysplasia of the hip: is there a relationship? Orthop Trans 1991; 15:336.
  17. Paton RW, Choudry Q. Neonatal foot deformities and their relationship to developmental dysplasia of the hip: an 11-year prospective, longitudinal observational study. J Bone Joint Surg Br 2009; 91:655.
  18. Vafaee AR, Baghdadi T, Baghdadi A, Jamnani RK. DDH Epidemiology Revisited: Do We Need New Strategies? Arch Bone Jt Surg 2017; 5:440.
  19. Wynne-Davies R. Family studies and the cause of congenital club foot. Talipes equinovarus, talipes calcaneo-valgus and metatarsus varus. J Bone Joint Surg Br 1964; 46:445.
  20. Widhe T. Foot deformities at birth: a longitudinal prospective study over a 16-year period. J Pediatr Orthop 1997; 17:20.
  21. Lincoln TL, Suen PW. Common rotational variations in children. J Am Acad Orthop Surg 2003; 11:312.
  22. Scherl SA. Common lower extremity problems in children. Pediatr Rev 2004; 25:52.
  23. Tachdjian MO. The knee and leg. In: Clinical Pediatric Orthopedics: The Art of Diagnosis and Principles of Management, Appleton and Lange, Stamford 1997. p.87.
  24. Katz K, Naor N, Merlob P, Wielunsky E. Rotational deformities of the tibia and foot in preterm infants. J Pediatr Orthop 1990; 10:483.
  25. Katz JF. Behavior of internal tibial torsion in infancy. Mt Sinai J Med 1982; 49:7.
  26. Staheli LT, Engel GM. Tibial torsion: a method of assessment and a survey of normal children. Clin Orthop Relat Res 1972; 86:183.
  27. 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; 67:39.
  28. Muscular Affectations of the Muscular System. In: Clinical Pediatric Orthopaedics: The Art of Diagnosis and Principles of Management, Tachdjians, MO (Eds), Appleton and Lange, Stamford 1997. p.381.
  29. Fabry G, MacEwen GD, Shands AR Jr. Torsion of the femur. A follow-up study in normal and abnormal conditions. J Bone Joint Surg Am 1973; 55:1726.
  30. Tachdjian MO. Generalized affectations of the muscular skeletal system. In: Clinical Pediatric Orthopedics: The Art of Diagnosis and Principles of Management, Appleton and Lange, Stamford 1997. p.369.
  31. Bleck EE. Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatr Orthop 1983; 3:2.
  32. Rushforth GF. The natural history of hooked forefoot. J Bone Joint Surg Br 1978; 60-B:530.
  33. Katz K, Rosenthal A, Yosipovitch Z. Normal ranges of popliteal angle in children. J Pediatr Orthop 1992; 12:229.
  34. Kuo L, Chung W, Bates E, Stephen J. The hamstring index. J Pediatr Orthop 1997; 17:78.
  35. Blackmur JP, Murray AW. Do children who in-toe need to be referred to an orthopaedic clinic? J Pediatr Orthop B 2010; 19:415.
  36. Sielatycki JA, Hennrikus WL, Swenson RD, et al. In-Toeing Is Often a Primary Care Orthopedic Condition. J Pediatr 2016; 177:297.
  37. Svenningsen S, Apalset K, Terjesen T, Anda S. Regression of femoral anteversion. A prospective study of intoeing children. Acta Orthop Scand 1989; 60:170.
  38. Weinberg DS, Park PJ, Morris WZ, Liu RW. Femoral Version and Tibial Torsion are Not Associated With Hip or Knee Arthritis in a Large Osteological Collection. J Pediatr Orthop 2017; 37:e120.
  39. Eamsobhana P, Rojjananukulpong K, Ariyawatkul T, et al. Does the parental stretching programs improve metatarsus adductus in newborns? J Orthop Surg (Hong Kong) 2017; 25:2309499017690320.
  40. Williams CM, James AM, Tran T. Metatarsus adductus: development of a non-surgical treatment pathway. J Paediatr Child Health 2013; 49:E428.
  41. Farsetti P, Weinstein SL, Ponseti IV. The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994; 76:257.
  42. Ponseti IV, Becker JR. Congenital metatarsus adductus: the results of treatment. J Bone Joint Surg Am 1966; 48:702.
  43. Katz K, David R, Soudry M. Below-knee plaster cast for the treatment of metatarsus adductus. J Pediatr Orthop 1999; 19:49.
  44. Bohne W. Metatarsus adductus. Bull N Y Acad Med 1987; 63:835.
  45. Herzenberg JE, Burghardt RD. Resistant metatarsus adductus: prospective randomized trial of casting versus orthosis. J Orthop Sci 2014; 19:250.
  46. Stark JG, Johanson JE, Winter RB. The Heyman-Herndon tarsometatarsal capsulotomy for metatarsus adductus: results in 48 feet. J Pediatr Orthop 1987; 7:305.
  47. Berman A, Gartland JJ. Metatarsal osteotomy for the correction of adduction of the fore part of the foot in children. J Bone Joint Surg Am 1971; 53:498.
  48. Heinrich SD, Sharps CH. Lower extremity torsional deformities in children: a prospective comparison of two treatment modalities. Orthopedics 1991; 14:655.
  49. Knittel G, Staheli LT. The effectiveness of shoe modifications for intoeing. Orthop Clin North Am 1976; 7:1019.
  50. Driano AN, Staheli L, Staheli LT. Psychosocial development and corrective shoewear use in childhood. J Pediatr Orthop 1998; 18:346.
  51. Weseley MS, Barenfeld PA, Eisenstein AL. Thoughts on in-toeing and out-toeing: twenty years' experience with over 5000 cases and a review of the literature. Foot Ankle 1981; 2:49.
  52. Fuchs R, Staheli LT. Sprinting and intoeing. J Pediatr Orthop 1996; 16:489.
  53. Wedge JH, Munkacsi I, Loback D. Anteversion of the femur and idiopathic osteoarthrosis of the hip. J Bone Joint Surg Am 1989; 71:1040.
  54. Hubbard DD, Staheli LT, Chew DE, Mosca VS. Medial femoral torsion and osteoarthritis. J Pediatr Orthop 1988; 8:540.
  55. Kitaoka HB, Weiner DS, Cook AJ, et al. Relationship between femoral anteversion and osteoarthritis of the hip. J Pediatr Orthop 1989; 9:396.
  56. Delgado ED, Schoenecker PL, Rich MM, Capelli AM. Treatment of severe torsional malalignment syndrome. J Pediatr Orthop 1996; 16:484.
Topic 14481 Version 23.0

References

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