Rotational and angular deformities of the lower extremities are
among the most common orthopedic complaints to primary care providers. Fortunately,
most patients have nothing more than normal physiologic variance,
and the majority may be treated with education and observation.
However, there are a variety of uncommon, but significant, orthopedic
and neuromuscular conditions that may present as rotational or angular
deformity. Thus, an understanding of both anatomy as well as potential
pathologies is important.
Although the vast majority of parental concerns regarding rotational
difference will represent nothing more than developmental norms,
it is paramount to remember that rotational differences may be the
presenting complaint in patients with mild neuromuscular differences;
thus, a careful history and physical exam focusing on neuromuscular
development should be incorporated with every patient who presents
for evaluation of in- or out-toeing.
Intoeing is perhaps the most common gait deviation that presents
for medical assessment. Assessment should begin with observation
of the gait to determine the foot progression angle. The foot progression
angle is the angle described by the intersection of the axis of
the foot with the axis of progression. Although the torsional alignment
of the lower extremities changes during skeletal development, most
parents are unaware of this and will consider any deviation from
the normal adult value of 10 to 20 degrees external as pathologic1 (Fig. 212-1). If an internal foot progression
angle is identified, careful examination of the lower extremities
can identify the anatomical location responsible for the inward deviation.
Fortunately, because of normal physiologic variance, there is usually
a strong correlation between the age of the patient and the anatomical
location producing the inward deviation.
The normal evolution of hip rotation, knee angle (aka
mechanical axis), tibial torsion, angle of gait (aka foot progression
angle), and arch development in children between 0 and 14 years
(With permission from Engel GM. Clin Orthop Relat
Metatarsal adductus is the most frequent reason for intoeing
in the first year of life and is the most common congenital foot
deformity, affecting approximately 3% of all births. Metatarsus
adductus occurs when there is inward torsion of the mid or forefoot
with the hindfoot in normal position or slight valgus. It is bilateral
in 60% of children. It is important to distinguish metatarsal adductus
for more significant foot pathology—namely, talipes equinovarus
(clubfoot). This may be accomplished by assessing the position of
the hindfoot or heel. In clubfoot, the heel will be in equinus (plantar
flexion), and the foot will not achieve neutral dorsiflexion. The
severity of metatarsal adductus is determined by the amount of flexibility
to the forefoot. A foot that neutralizes itself spontaneously with
tickling of lateral border is termed mild or Grade 1. A moderate,
or grade 2, foot is ...