In-toeing and Out-toeing are frequent causes for visits to the pediatric orthopaedist for infants and children. Rotation of the lower extremities has a wide range of normal variation and thus most cases of excessive in-toeing or out-toeing are variants of normal in infants and children. These rotational variants are often a cause of concern for family members and occasionally cause minor difficulties for children.
In order to be sure that the in-toeing or out-toeing is a normal variant, the child must be evaluated thoroughly to establish a reason for the toes pointing in or out. A thorough history is taken to make sure that there is no family history of hip or foot problems; that there were no problems with the pregnancy, that the child is developing normally, and whether there is any problem with recent trauma or muscle problems. Occasionally, rotational problems can be a marker for an underlying medical disorder such as cerebral palsy, limb length differences, hip disorders, or angulation of the limb.
Questions about in-toeing and out-toeing are among of the most common reasons parents bring their children to see a pediatric orthopedist. The child’s parents and often, even more so, the child’s grandparents want to know if the way their child walks is normal, and is the in-toeing causing the child to fall more often.
Many parents or their siblings were treated with special shoes or bars for a problem they had with their legs when they were young. Today, more often than not, treatment is not necessary thanks to a better understanding of what causes in-toeing or out-toeing and how these conditions get better over time.
The majority of children’s feet point straight ahead or slightly outward. Children whose feet point inward are said to have “in-toeing” or be “pigeon toed”. In the vast majority of children, in-toeing will go away without any treatment. In the past, braces were used to treat in-toeing; however, recent studies have shown that braces offer no advantages and do not alter the natural history of resolution over time in most cases. The usual progression of rotational growth in the lower extremity leads to correction of most cases of in-toeing by age 6 to 8.
In a small percentage of children, the in-toeing does not completely resolve; however, most of these children will cope just fine without any difficulties in their activities of daily living. Rarely does a child with unresolved in-toeing need surgical treatment to correct the problem. There is no evidence that in-toeing leads to arthritis or causes clumsiness. In fact, many of our best track and field athletes are pigeon toed. Occasionally, in-toeing may cause problems with shoewear, but braces, special shoes, or inserts do not correct the problem.
There are three typical causes for in-toeing:
Metatarsus adductus is an inward curve of the outer border of the foot. It is usually first noticed when the child is an infant and is typically caused by the position of the baby in the uterus. The Metatarsus is either mild, moderate, or severe. In mild feet, the foot can be overcorrected passively. These feet usually resolve on their own by age 2. In moderate feet, the foot can be passively corrected so that the lateral border is straight, but it cannot be overcorrected. These feet also usually improve on their own in the majority of cases, and occasionally may need special shoes to help obtain and maintain the correction.
Both mild and moderate feet also respond well to stretching to help get the foot straighter. This is usually shown to the parents by the doctor and can be done at home at bath time. Stiff feet cannot be stretched so that the outside border of the foot is straight. These feet may be treated with a series of casts to help stretch the feet, followed by special shoes to maintain the correction. Rarely, surgery may be necessary if casting fails or if the deformity recurs during growth and the child has functional problems as a result.
Internal tibial torsion is an inward twist of the tibia bone. This is usually noticed when the child begins to walk. Inward twisting is normal in many babies and often corrects by age 1. However, the inward twist is slower to correct in some children and these are the ones that usually present to the doctor. In about 90% of patients the inward twist slowly corrects by about ages 4-6.
As the child begins to walk with tibial torsion it frequently causes tripping and falls; however, as the child grows and muscles develop, they are better able to cope with the in-toeing until it ultimately resolves in most cases. Studies have shown that bracing does not speed up the correction of inward tibial torsion, so most doctors do not prescribe any treatment other than observation. In about 10% of patients the tibial torsion does not correct, but most children function perfectly well and there is no evidence that tibial torsion causes arthritis or functional problems in the long run. In the rare case that the torsion does not resolve by age 6 to 8 and the child does have a functional problem as a result of the torsion, the treatment is to cut the bone and rotate it outward so the feet point straight. Very few normal children without neuromuscular problems need this surgery and careful discussion with the doctor is necessary before pursuing surgery.
Femoral anteversion is an excessive inward twist of the upper thigh bone at the hip region. This is usually noticed between ages 2 to 4. All children are born with some inward twist of the thigh bone and as they grow and their ligaments around the hip tighten, the anteversion resolves during the first few years of life. In some children, these ligaments never completely tighten up and when the child starts to walk they can become looser, causing the hips to rotate further inward, causing the in-toeing to be noticed between ages 2 and 4.
Most cases of femoral anteversion resolve spontaneously by the time the child is between 6 and 8 years old. Once again, it has been shown that special shoewear and braces do not improve on the natural resolution of the deformity, and may actually cause problems such as discomfort and poor self esteem. A few children will not resolve their anteversion but most function fine without any problems. In the rare case that the anteversion does not resolve by age 6 to 8 and the child does have a functional problem as a result of the torsion, the treatment is to cut the bone and rotate it outward so the feet point straight.
In-toeing arises from one of, or a combination of, three areas; the foot, the leg, or around the hip. Which area is contributing to the in-toeing determines the likelihood that it will correct over time, and determines up until what age one may expect improvement.
The outside border of the foot should make a straight line. In a condition called metatarsus adductus, the front part of the foot will curve inward. The outside border of the foot will then also be curved inward. This leads to the child walking with his or her toes pointing in. Metatarsus adductus is a condition usually diagnosed before the child is walking. It is most often treated with stretching exercises as long as it is flexible or the foot can be placed in a normal position. Occasionally, the stretching is done using reverse last shoes, which are meant to stretch the inside of the foot as they are worn. Even with stretching, a small amount of metatarsus adductus may persist in the walking child, but it is rarely of any clinical significance. Casts have been used but newer adjusting shoe-like bootie braces do the same thing and can be used for the follow up as well.
A more common contributor to in-toeing is a condition called internal tibial torsion. This is a term for an internal twist in the tibia. This is often a normal finding in a newborn. It is caused by the baby’s position in the womb prior to birth. Usually, the baby’s legs are folded over each other giving them an inward twist. With growth this twisting will tend to correct itself. Occasionally, a child who is still walking will still have internal tibial torsion, which causes the feet to point inward when the knees face straight ahead. The Denis-Brown bar (“D-B bar”) was once used to treat internal tibial torsion quite often. It consists of a bar connected to a pair of shoes, which are turned outward. Wearing the bar is supposed to help rotate the tibias outward. It is not used very often anymore because studies have demonstrated that internal tibial torsion tends to get better up until the age of four to six years old. Children wearing the bar have no better outcome than children who do not wear the bar. So why wear it at all? The bar is considered only in severe circumstances, such as complicate club foot.
The third area where in-toeing arises is around the hips. The condition is called femoral anteversion. When a hip can rotate inward much more than outward, femoral anteversion is present. These are children who have trouble sitting cross-legged but find it easy to sit with their legs behind them in a “W” fashion. The internal twist about the hips translates to in-toeing when walking because having the hips turned in a little is a comfortable position for these children. Femoral anteversion, as with tibial torsion, tends to get better on its own. It can correct until the age of eight to ten years.
A great majority of children do not require treatment. Surgery is reserved for severe cases where the in-toeing is affecting the child’s function because the only surgery that helps involves cutting the femur or the tibia and rotating it until the toes point forward. This is big surgery, which can have complications.
For both tibial torsion and femoral anteversion, the mechanism of self correction is walking. Normal walking and functional forces cue the workings of alignment. Children who do not walk (for reasons of neurologic problems etc.) do not correct. Those who walk with severe pathologic patterns may actually worsen. Children lacking some other disorder seldom have any problem. In cultures where sitting on the feet is the norm, so are adaptive turns. It does not look bad nor is there any consequence from it.
Out-toeing is much less common. External tibial torsion or femoral retroversion may cause it. External tibial torsion refers to a tibia, which rotates outward, while femoral retroversion refers to a hip, which can turn out more than it can turn in. The treatment principals are similar to those outlined above. One caution, if an older child who was not known to have outward rotation from the start, begins to develop it, then x-rays of the hips are needed including especially a “lateral hip view” to be sure the hip has not slipped.
Interestingly, some people need retroversion. To get it you have to work at it and begin young, very young. A girl who at 14 years of age decides to be a great ballerina just won’t get there. The retroverting twist required by that art form, which allows those graceful out-turned moves had to be established skeletally. That means young. Sorry. The growth plate of the upper femur that in the older growing child connects the ball of the femur to the neck of the femur (see SCFE), in the younger child covers the entire femoral neck. When that larger scope of growth cartilage recedes, so does self induced rotation.
Out-toeing is much less common than in-toeing. The most typical presentation is within the first or second year of life. Most children are born with external rotation contractures of the hips and this resolves shortly after walking begins. In those children in whom the resolution is slower, out-toeing is the result when they first start walking. This will almost always resolve within a year from the onset of walking.
Out-toeing may also be caused by outward twisting of the tibia or femur bone, and is not usually seen in normal children, but is more common in those with neuromuscular abnormalities. As with in-toeing, bracing and shoewear are not helpful in resolving the deformity. Occasionally, a normal child will have out-toeing from tibial or femoral outward twisting that does not resolve by the end of the first decade and that may cause functional difficulties. If this is the case, surgery can be done to cut the bone and rotate to a more normal position. This is also rarely necessary.
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