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Toeing Out

Contents
  1. Read book excerpt
  2. Restless Legs Syndrome: Introduction
  3. Restless Legs Syndrome Misdiagnosis
  4. Restless Legs Syndrome Causes
  5. Restless Legs Syndrome Complications
  6. Restless Legs Syndrome Treatments
  7. Clinical trials
  8. Diagnosis of Restless Legs Syndrome
  9. Restless Legs Syndrome Overview
  10. More book excerpts for Restless Legs Syndrome

Toeing Out: Excerpt from In A Page: Pediatric Signs and Symptoms

Toeing out, or out-toeing, is not as common as intoeing. Excessive out-toeing is considered a normal variant. Observation and parental reassurance are the mainstays of therapy.

Differential Diagnosis

  • Femoral retroverson
    –Usually bilateral with excessive external and limited internal range of motion of both hips
  • External tibial torsion
    –More common than femoral retroversion
    –May be related to in utero positioning and is sometimes associated with calcaneovalgus foot
  • Slipped capital femoral epiphysis (SCFE)
    –Most common in obese adolescent boys
    –Unilateral out-toeing with painful hip
    –Pain and limited range of motion or antalgic externally rotated gait pattern
  • Talipes calcaneovalgus
    –Positional deformity in which the foot is extremely dorseflexed and everted
  • Everted flat feet
    –Children stand in a toe out position but toe in when walking
  • Triceps surae muscle contracture
    –Can be seen with cerebral palsy
  • Vertical talus (rocker-bottom foot)
  • Congenital absence of the fibula
    –Shortening of the peroneal and triceps surae muscles result in bowing of the tibia and equinovalgus
  • Maldirection of the acetabulum
    –If the acetabulum faces posteriorly, leg position is everted

Workup and Diagnosis

  • History is generally limited
    –Development and milestones are generally normal
    –Hip pain and limp are red flags for SCFE
  • Physical examination consists of a rotational profile using four elements to help with diagnosis and monitoring
  • First element: Hip rotation
    –Measurement is performed in prone position, hips extended and knees flexed to 90°
    –Lateral rotation; external rotation with >70° indicates femoral retroversion
    –Medial rotation; internal rotation with <20° also indicates femoral retroversion
  • Second element: Thigh-foot angle
    –Measurement is performed in prone position, hips extended, and knee flexed at 90°, evaluating long axis of foot relative to axis of thigh
    –Neutral or foot pointed outward >40° (normal 0–30°) indicates external tibial torsion
  • Third element: Foot evaluation
    –Foot alignment is assessed in prone and standing position; heel bisector line should line up with second metatarsal
  • Fourth element: Foot progression angle (gait evaluation)
    –When the child walks, estimate the angle of the foot relative to the line of progression
    –If patella is outward, then the femur may be retroverted
    –If patella points straight, then the tibia or foot is causing the deviation

Treatment

  • Natural history of rotational variations is gradual normalization and is not altered by nonsurgical methods
  • Out-toeing is generally self-limited and improves at 2–3 years old until 8 years old; reassurance that the condition will improve is the most important component of treatment
  • The use of orthotics, shoe modifications, or exercises is ineffective
  • Surgical correction is reserved for severe gait deformity or when related to SCFE
  • Even after surgical intervention for SCFE, external rotational abnormality into adolescence may persist, and derotational osteotomy may be beneficial
>

Book Source Details

  • Book Title: In A Page: Pediatric Signs and Symptoms
  • Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
  • Year of Publication: 2007
  • Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Restless Legs Syndrome

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  • Chest pain
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  • Facial pain
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  • Flank pain
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  • Jaw pain
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  • Neck pain
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  • Chronic Pelvic Pain
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  • Hip Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Knee Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Neck Pain
  • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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  • Pleuritic Pain
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  • Shoulder Pain
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  • Scrotal Pain
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  • Seizures
  • "Field Guide to Bedside Diagnosis" (2007)
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  • Eye Pain
  • "Field Guide to Bedside Diagnosis" (2007)
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  • Hip Pain
  • "Field Guide to Bedside Diagnosis" (2007)
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  • Myoclonus
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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  • Abdominal pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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  • Back pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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  • Chest pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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  • Eye pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Flank pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Jaw pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
  • [ read ]
  • Neck pain
  • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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  • Myoclonus
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Arm pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Back pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Breast pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Chest pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Eye pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Facial pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Flank pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Jaw pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Neck pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
  • [ read ]
  • Rectal pain
  • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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  • Seizures
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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  • Abdominal Pain
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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  • Back Pain
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
  • [ read ]
  • Chest Pain
  • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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  • Myoclonus
  • "Nursing: Interpreting Signs and Symptoms" (2007)
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  • Arm pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Back pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Chest pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Flank pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Jaw pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • Neck pain
  • "Nursing: Interpreting Signs and Symptoms" (2007)
  • [ read ]
  • ARM PAIN
  • "Differential Diagnosis in Primary Care" (2007)
  • [ read ]
  • EYE PAIN
  • "Differential Diagnosis in Primary Care" (2007)
  • [ read ]
  • HIP PAIN
  • "Differential Diagnosis in Primary Care" (2007)
  • [ read ]
 

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.



More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9

 » Next page: Toeing In (In A Page: Pediatric Signs and Symptoms)

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