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Intoeing: When to Worry?

Sukhdeep K. Dulai
SPORC 2018
Intoeing: When to worry?
• What is it?
• Why isn’t it always cause for worry?
• What are the benign causes of intoeing?
• What are the pathologic causes of intoeing
and how are they identified?
• What are the red flags in intoeing?
What is it?

• Internal Foot Progression Angle

• Normal Range: -3° to +20°, Mean +10°

Reference: Lower-extremity rotational

problems in children. Normal values to
guide management.L T Staheli ; M
Corbett ; C Wyss ; H KingJ Bone Joint
Surg Am, 1985 Jan; 67 (1): 39 -47 .
Why It Isn’t Always Cause for Worry?
• Normal evolution of rotational limb alignment
– Birth: tibia and femur are internally rotated
(disguised by flexion and external rotation
contracture of hips)
– Gradual resolution of external rotation contracture
of the hips over first year  internal tibial torsion
and femoral anteversion become apparent
– Gradual correction of tibial and femoral rotation up
to approx. 8 years of age
Normal Rotational Profile
• Femoral anteversion:
– Newborn: 40°  8 years: 10-15°
• Internal rotation of the hip:
– Up to: 70° for girls, 60° for boys
• Thigh Foot Angle:
– 10° external (range -3° to 20°)
• Bimalleolar Axis
– Newborn: 5° external Adults: 20–40°
Benign Causes of Intoeing

Pictures from: http://orthoinfo.aaos.org, Courtesy of Texas Scottish Rite Hospital

for Children
Diagnosis Metatarsus Adductus

Typical Infancy
Presenting Age
Signs/Symptom Medially curved lateral and
s Medial Foot Borders, Heel
bisector lateral to 2nd web
space Picture from: http://orthoinfo.aaos.org,
Courtesy of TSRH for Children
Natural History 85% resolve spontaneously

Indications for Failure to resolve, Rigidity,

Intervention Pain, Shoewear problems

Treatment Early: Observation,

Stretching, Serial Casts Reference: E. E. Bleck, “Metatarsus
Late: Medial release or Mid- Adductus: Classification and
foot/metatarsal osteotomy Relationship to Outcomes of
Treatment,” Journal of Pediatric
Orthopaedics, Vol. 3, No. 1, 1983, pp.
Diagnosis Internal Tibial Torsion

Presenting 1-3 years

Signs/Sympto Tripping, bowleg appearance,
ms Increased Thigh-Foot Angle and
Bimalleolar Angle

Natural 99% resolve

Indications for Persistent deformity and functional
Intervention disability at >6 yo

Picture from:
Treatment Early: Reassurance
*Tip: Sprinters have more ITT than
, Courtesy of TSRH for
non-athletes (Fuchs & Staheli JPO
Late: Supramalleolar derotation
Diagnosis Femoral Anteversion

Presenting >3 years

Age Picture from:
Signs/Sympto Awkward gait (eggbeater aaos.org,
ms running), tripping, patellar Courtesy of
winking, W-sitting, increased TSRH for
IR/decreased ER of hip Children

Natural History Most resolve

Indications for Persistent deformity and

Intervention functional disability at >8 yo

Treatment Early: Reassurance only

Late: proximal or distal femoral
derotation osteotomy (significant
risk of complications)
Intoeing: Pathologic Causes
• Miserable Malalignment Syndrome
• Cerebral Palsy
• Developmental Hip Dysplasia
• Genu Varum/Tibia Vara associated
• Clubfoot/Cavovarus foot
• Skewfoot
• Metatarsus Primus Varus
• Hallux Vatus
Miserable Malalignment Syndrome
• Femoral anteversion, external tibial torsion
and pes planovalgus
• Presents with anterior knee pain with
activity (usually in adolescents) due to
patellofemoral overload
• Treatment: Femoral and Tibial derotation
osteotomies +/- flatfoot reconstruction
Cerebral Palsy
• Esp. mild spastic hemiparesis  unilateral intoeing
• Intoeing can be due to pes varus, metatarsus
adductus, femoral anteversion, internal tibial torsion
and/or internal pelvic rotation
• Look for significant birth history and physical exam
findings of spasticity
• Can result in lever arm dysfunction and tripping
• Treatment: often surgical as they do not remodel
Developmental Hip Dysplasia
• Intoeing (due to femoral anteversion)
• Associated with Trendelenburg sign/gait
• Investigate with hip xray
Genu Varum/ Tibia Vara
• Appearance of bowing also present in ITT
• Assess coronal plane alignment with the
patellae pointing directly forwards
• Potential diagnoses:
– Blount’s disease
– Metabolic Bone Disease
– Skeletal Dysplasia
Clubfoot/Cavovarus foot
• In addition to metatarsus
adductus, look for cavus, varus
and/or equinus
• History may suggest recent
development of deformity with
neurologic findings on
examination Courtesy: CDC
• Adducted forefoot and valgus
hindfoot and plantarflexed talus
• May resolve; May require
surgery if symptomatic
• Surgical intervention: calcaneal
and cuneiform opening wedge
Metatarsus Primus Varus
• Straight lateral border
• Medial deviation of first metatarsal (increased
intermetatarsal angle)
• Associated with development of hallux valgus
• Treatment:
– Early casting recommended by some
– May require corrective osteotomy later if
Hallux varus
• Medial border of the foot is straight
but the great toe is medially deviated
• Abnormal pull of the Abductor
• Often associated with anatomic
abnormalities of preaxial polydactyly
• If anatomic abnormalities or does not
resolve by age 2 years, surgical
intervention is recommended
Summary: Red Flags in Intoeing
• History:
– Developmental delay
– History of prematurity
– Progressive or new-onset deformity
– Pain
– Persistent functional disability
Summary: Red Flags in Intoeing
• Physical Examination:
– Neuromuscular abnormalities
– Marked limb asymmetry
– Syndromic features
– Short stature
– Abnormal hip exam
– Abnormal hindfoot position
– Isolated toe deformity
– Rigid foot deformity
Thank you