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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.

Figure 212-1.

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 of age.

(With permission from Engel GM. Clin Orthop Relat Res. 1974:12-7.)

Metatarsal Adductus

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 passively ...

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