++
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.
++
++
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 correctable but does not actively
correct itself to neutral. A severe or grade 3 foot cannot be completely
corrected with stretching.2 Because developmental
dysplasia of the hip has been identified in up to 10% of
the children with metatarsal adductus, a careful hip exam is paramount
in these children.
++
There are no well-defined treatment indications for metatarsal
adductus. Infants less than 3 months of age with moderate to severe
metatarsus adductus may be treated with serial casting; children
between 3 and 12 months can be treated with straight or reverse
last shoes. The natural history of metatarsal adductus is usually
quite benign. Parents can be assured that this is seldom, if ever,
a functional problem, and improvement can be seen into adolescence.3,4
+++
Internal Tibial
Torsion
++
Internal tibial torsion is the most common cause of intoeing
in children between the ages of 12 and 36 months. Parents of patients
with significant internal tibial torsion may note bowed legs as
well as intoeing, as it is often difficult to differentiate between
the two in this age group. Internal tibial torsion can be identified
by assessing the thigh–foot angle in the prone position
(Fig. 212-2). As with all lower extremity
rotational parameters, the thigh–foot angle varies with
age (Fig. 212-1). Internal tibial torsion
usually spontaneously improves throughout skeletal growth, and treatment
is seldom required. Historically, special shoes connected to a bar
(Denis Browne splint) were a popular treatment for internal tibial
torsion; however, there has never been any scientific validation
that these splints are efficacious.1,5
++
+++
Excessive Femoral
Anteversion
++
Excessive femoral anteversion is the most common etiology of
intoeing in children over 4 years of age. Parents of these children
often report a preference for sitting in the “W” position.
(These children sit in this position because it is comfortable for
them, and there is no evidence that doing so causes the abnormality.)
Femoral anteversion is associated with increased internal rotation
of the hip which is best assessed with the patient in the prone
position6 (Fig. 212-3).
As with other lower extremity rotational characteristics, hip rotation
is dynamic and changes throughout growth (Fig.
212-1). Although some authors suggested a correlation between
excessive femoral anteversion and osteoarthritis of the hip, the
vast majority of literature indicates that the natural history of
increased femoral anteversion is completely benign without functional
or degenerative impact. Orthotic management of increased femoral
anteversion has not been shown to be efficacious.1,6-11
++
++
Correction of both internal tibial torsion and excessive femoral
anteversion can be accomplished surgically through rotational osteotomy.
However, because of the benign natural history of these conditions,
it is important to recognize that such treatment is essentially
for “aesthetic” rather than functional purposes, and
as a result, it should be considered with great trepidation by the
pediatric orthopedist. It is important that parents and patients
be fully apprised of the risks and benefits before surgical procedures
are entertained. We have found it helpful to include a physiological evaluation
to access for other body image concerns.6,9
++
Complaints of out-toeing are less common than those of intoeing,
and these patients rarely have more than normal physiological variance. As
with intoeing, it is important to remember that patients with out-toeing
may have subtle occult neuromuscular pathology; thus, a careful
developmental history and neurologic assessment are of paramount
importance. Adolescents with slipped capital femoral epiphyses may
develop new onset out-toeing which may be asymmetrical.12