Common Pediatric MSK Concerns


Intoeing is not clasically thought of as a 'limp' - however it is a gait disturbance often of concern to parents (and less commonly, children). While most adults walk with their toes pointing forward or slightly externally rotated (up to 10 degrees in normal) as referenced to the direction of travel of the body, children often deviate from this as part of normal development. This is termed the 'foot progression angle'.

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

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.