In-toeing

CHAPTER 24

In-toeing

Introduction/Etiology/Epidemiology

• In-toeing is a general term for deviation of the feet toward the midline. In lay terminology, this is often referred to as “pigeon-toed gait.”

• In-toeing may be unilateral or bilateral. Asymmetry is more noticeable.

• In-toeing stems from one of 3 anatomic variants: metatarsus adductus, internal tibial torsion, or internal femoral torsion.

— Metatarsus adductus presents in the first year after birth.

— Internal tibial torsion presents in toddlers.

— Internal femoral torsion presents in children older than 3 years.

• More than one rotational variant may coexist, accentuating or compensating for the index deformity. For example, a patient with coexistent internal femoral torsion and external tibial torsion may exhibit a neutral gait pattern.

Evaluation

HISTORY

• Young children are generally asymptomatic and present to the physician’s office because of an adult’s concern.

• Older children are usually aware of the condition and may be self-conscious or describe functional problems such as tripping.

PHYSICAL EXAMINATION

• Evaluate the foot progression angle (FPA) during gait.

— FPA (the step imprint on the ground) is the angle produced by the long axis of the foot and the line of forward travel of the body.

— When the foot (imprint on the ground) points inward, toward the midline, the FPA is defined as negative.

— When the foot points outward, away from the midline, FPA is positive.

— Normal FPA ranges from −5 to +20 degrees.

• Determine the rotational profile of the femur, tibia, and foot in the prone position.

— Femur: Measure hip internal and external rotation in prone position with the knees in flexion.

— Tibia: Measure the thigh-foot angle (TFA) in the prone position. With the hips extended and the knees flexed to 90 degrees, measure the angle between the long axis of the foot and the long axis of the thigh.

■In infants, normal TFA ranges from −17 to +5 degrees.

■In children older than 10 years and in adults, normal TFA ranges from −5 to +30 degrees with a mean of 10 to 15 degrees.

— Foot: The lateral border of the foot should be straight.

• Very young children (2 years and younger) may be unwilling to lie prone and therefore may be examined sitting on the parent’s lap to lessen anxiety and encourage cooperation. In this position, hip range of motion is examined supine and tibial rotation can be quantified by comparing the position of the second toe to that of the tibial tubercle.

Differential Diagnosis

• Clarify the exact presenting issue because other musculoskeletal conditions (eg, pes planus, flatfoot) may be misidentified by the layperson as in-toeing.

• Differentiate rotational profile variants from underlying neurologic disorders (eg, cerebral palsy, hemiplegia) by looking for clues such as preterm birth, delayed motor development, or a regression of motor skills.

• Internal femoral torsion is sometimes referred to as “excessive femoral anteversion.”

Internal Femoral Torsion

INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY

• Femoral torsion is the angular difference between the axes of the femoral neck and the transcondylar axis of the knee.

•

Only gold members can continue reading. Log In or Register to continue