What is Intoeing?

Intoeing means that one or both feet point inward instead of pointing straight ahead when walking or running.  If the child is intoeing the toes of the feet will be closer together than the heels.  As the child walks, his or her feet will point towards the line of progression.

What is the line of progression?
The line of progression is an imaginary straight line. A child’s foot progression angle can be determined as a child is observed while attempting to walk in a straight line. The angle between the longitudinal axis of the foot and the imaginary straight line determines the foot progression angle. By convention, intoeing has been assigned a negative angular value and outoeing a positive value. Each foot is recorded separately.

How is intoeing diagnosed?
Intoeing is most commonly caused by one of three diagnosis including internal rotation deformity of the femur (femoral anteversion), the tibia (internal tibial torsion), and the foot (metatarsus adductus). Any combination of these three can also occur. The correct diagnosis is made by analyzing the data gathered from the torsional profile. The torsional profile consists of five clinical measurements listed as follows: (1) foot progression angle (FPA); (2) thigh-foot angle (TFA); (3) hip internal rotation (HIR); (4) hip external rotation (HER); (5) heel bisector line (HBL). These measurements are gathered during the child’s physical exam. The foot progression angle has already been described above. The remaining measurements are best done with the child prone on the examining table and the knees flexed 90 degrees. The thigh-foot angle is determined by measuring the angle between the longitudinal axis of the foot and the long axis of the thigh. A reproducible technique for measuring hip internal rotation is to use the leg to rotate the hip internally from the neutral or zero-degree position where the leg is perpendicular to the floor (beginning point) to maximum internal rotation (end point) and then measure the angle of the leg compared to the zero starting point. External rotation of the hip is also measured in this manner by maximally externally rotating the hips. Finally the heel bisector line is determined by constructing a line that bisects the hindfoot and then observing which toe or interspace is intersected. This data can be organized by listing the values obtained from these measurements in a table for both the left and the right foot. See Table 1.

Table 1. Torsional Profile: Example of a normal child’s values.

How is femoral anteversion diagnosed?
The diagnosis of femoral anteversion is determined by analyzing hip rotation. Rotation of the hips will demonstrate an increase in hip internal rotation (HIR) and a decrease in hip external rotation (HER). Table 2 is an example of a patient with femoral anteversion. Observation of gait reveals intoeing with the “kissing patella sign” being diagnostic. Clinically children with femoral anteversion prefer to sit in a “W” position.

Table 2. Torsional Profile: Child with femoral anteversion.

How is internal tibial torsion diagnosed?
Some internal tibial torsion is normally present at birth; the extent is determined by familial tendencies and intrauterine positioning. The tibial rotation then slowly “unwinds” with normal growth and development. The diagnosis is made by analyzing the data gathered in the torsional profile. The thigh-foot angle (TFA) measurement determines the exact nature of the tibial rotation. The normal adult measurement is 10 to 15 degrees. At birth, the thigh-foot angle typically measures about 5 degrees. Children with significant internal tibial torsion will have a thigh-foot angle greater than negative 30 degrees. Hip rotation is symmetric in isolated tibial torsion; the patellae should not appear medially deviated, as with femoral anteversion. See Table 3 for an example of internal tibial torsion.

Table 3. Torsional Profile: Child with internal tibial torsion.

How is metatarsus adductus diagnosed?
Utilizing the heel bisector line (HBL) measurement in the torsional profile (see Table 4) makes the diagnosis of metatarsus adductus. This measurement is determined by constructing a line that bisects the hindfoot and then observing which toe or interspace is intersected. A normal value for this measurement is 3. If the heel bisector line intersects laterally from the third toe, the diagnosis is suggestive of metatarsus adductus. Upon physical exam, the lateral border of the foot should be straight. In metatarsus adductus it is always curved.

Table 4. Torsional Profile: Child with metatarsus adductus of the left foot.

What is the treatment for femoral anteversion and internal tibial torsion and when should physicians refer these patients to orthopedics?
A referral to orthopedics should be made if a physician feels that the patient needs treatment and/or if the parents/guardians need to be reassured.

The majority of femoral anteversion and tibial torsion cases will resolve spontaneously by age eight to ten years. Some physicians choose to accelerate the correction process by using a Denis-Browne bar. Treatment of severe cases is also performed with Denis-Browne bars usually between the ages of one and two years before the child is weaned from his/her crib. Surgery involving a correctional osteotomy is considered in severe cases for a child eight years or older.

What is the treatment for metatarsus adductus?
Metatarsus adductus frequently improves spontaneously. In moderate or severe deformities that are not passively correctable, serial casting is indicated. Serial casting is done until the lateral border of the foot can be actively corrected to the straight position. Possible indications for surgery would be for children over age four with a stiff residual deformity.