There are three common causes for intoeing noted in childhood:
1. Forefoot adductus
| Correctable forefoot adductus deformity in infant. Credit: L. Davidson |
Infants may have "intoeing" due to a foot deformity called forefoot adductus (synonyms are metatarsus adductus or metatarsus varus). This is often a positional deformity due to prenatal factors. In many children, the foot curvature resolves with simple stretching exercises. Persistent foot deformity may cause shoe-fitting and cosmetic concerns and so casting is initiated if the deformity has not improved by 4- 6 months.
2. Internal tibial torsion
Toddlers often present with intoeing secondary to internal tibial torsion. Similar to metatarsus adductus, this is often a reflection of prenatal positioning and almost always corrects with normal skeletal growth by the age of 5. The only treatment is surgical (braces and orthopaedic shoes, previously recommended for this condition, have been proven ineffective) and this is usually deferred until at least age 8.
3. Femoral anteversion
Another common cause of intoeing is femoral anterversion. This term describes the relative rotation of the femoral neck away (anterior to) the coronal plane. Most adults have about 10 degrees of femoral anteversion. Children may have higher degrees of femoral anteversion as a normal anatomical variant. This gradually corrects in most individuals over time (by adolescence). An increased amount of femoral anteversion allows the patient an increased amount of hip internal rotation (and decreases the hip external rotation) thus creating a tendency to turn the whole leg in during gait. Individuals with increased femoral anteversion often prefer to sit on their knees ("W" sit) rather than sit cross-legged as this is more comfortable. Prone examination of hip rotation useful to diagnose femoral anteversion as this allows assessment of hip rotational motion with the joint in extension (as during gait). Excessive internal rotation of the hip ('femoral anteversion') can be corrected by derotational femoral osteotomy however this is generally deferred until late childhood or adolescence the deformity resolves with growth in the majority of patients.
2. Internal tibial torsion
| Diagnosis is facilitated by prone examination of the lower extremities. The patient lies on their front on the examining table and flexes up the knees. The "foot-thigh" angle is assessed and if the toes point towards the midline, internal tibial torsion is diagnosed. This 3-year old girl has right internal tibial torsion. The foot points medial to a line drawn down the middle of the thigh. Credit: L. Davidson |
Toddlers often present with intoeing secondary to internal tibial torsion. Similar to metatarsus adductus, this is often a reflection of prenatal positioning and almost always corrects with normal skeletal growth by the age of 5. The only treatment is surgical (braces and orthopaedic shoes, previously recommended for this condition, have been proven ineffective) and this is usually deferred until at least age 8.
3. Femoral anteversion
Another common cause of intoeing is femoral anterversion. This term describes the relative rotation of the femoral neck away (anterior to) the coronal plane. Most adults have about 10 degrees of femoral anteversion. Children may have higher degrees of femoral anteversion as a normal anatomical variant. This gradually corrects in most individuals over time (by adolescence). An increased amount of femoral anteversion allows the patient an increased amount of hip internal rotation (and decreases the hip external rotation) thus creating a tendency to turn the whole leg in during gait. Individuals with increased femoral anteversion often prefer to sit on their knees ("W" sit) rather than sit cross-legged as this is more comfortable. Prone examination of hip rotation useful to diagnose femoral anteversion as this allows assessment of hip rotational motion with the joint in extension (as during gait). Excessive internal rotation of the hip ('femoral anteversion') can be corrected by derotational femoral osteotomy however this is generally deferred until late childhood or adolescence the deformity resolves with growth in the majority of patients.