Toeing In
Toeing in, or intoeing, is a commonly referred problem to orthopedic surgeons. The mainstay of treatment includes parental reassurance. Symtoms in the majority of patients resolve spontaneously by 8 years old.
Differential Diagnosis
- Femoral anteversion
–Most common cause of intoeing in children between 2 and 6 years old
–Incidence in females is twice that of males
–Femoral shaft internal alignment leads to
entire lower limb to be inwardly rotated
- Internal tibial torsion
–Most common cause of intoeing in children
less than 2 years of age
–Inward rotation of the tibia leads to intoeing
- Metatarsus adductus
–Forefoot is adducted, with a concave medial foot border with increased space between the first and second toes
–May be due to in utero packaging problems; thus is associated with a higher incidence of hip dysplasia
-
Muscle force imbalance
–Neuromuscular disorders such as cerebral palsy have a higher incidence of lower extremity rotational abnormalities due to increased muscular tone and dynamic imbalance
-
Pronated feet (flatfeet)
–Children typically stand with feet in valgus position, because this is unstable for walking; children toe in to shift the center of gravity to the center of the foot
-
Knock knees
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Maldirection of the acetabulum
–If the acetabulum is directed anteriorly toeing in will stabilize the hip joint
Workup and Diagnosis
-
History is generally limited
–Often the family gives a history that the child tends to
stumble or fall more than other children
–Development and milestones are usually normal
-
Physical exam consists of a rotational profile using four elements to help with diagnosis and monitoring the progression of intoeing
-
- First element: Hip rotation
–Measured with the patient prone, hips extended, and knees flexed 90°
–Lateral rotation; external rotation with <20° indicates femoral anteversion
–Medial rotation; internal rotation with >70° also indicates femoral anteversion
-
- Second element: Thigh-foot angle
–Measurement in prone position of long axis of foot relative to axis of thigh with knee flexed at 90°
–Neutral or foot pointed inward indicates internal tibial torsion
-
Third element: Foot evaluation
–Foot alignment is assessed in prone position, and heel bisector line lines 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 inward, then the femur may be anteverted
–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
-
The use of orthotics, shoe modifications, or exercises is ineffective
-
Femoral anteversion seen in children 2–6 years old usually corrects spontaneously by 10 years old
-
Most cases of tibial torsion resolve spontaneously by 4–6 years old
-
Surgical correction is reserved for severe gait deformity (patients who have persistent rotational abnormality into adolescence and find their gait appearance unacceptable)
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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.
Other Book Chapters Related to Toe pain
Read excerpts from these other book chapters related to Toe pain:
Medical Books Excerpts
- Toeing In
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Toe pain
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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
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» Next page: FOOT, HEEL, AND TOE PAIN (Differential Diagnosis in Primary Care)
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