Intoeing
Andrew Darmahkasih, MD PGY-
2
UCI-CHOC Pediatric Residency
Program
Introduction
● Intoeing is defined as the rotational
variation of the lower extremity where
the feet or toes point toward the midline
during gait
● One of the most common anatomic
musculoskeletal variations encountered
by pediatric primary care providers
● Accentuated between six months and five
years (when children are developing their
walking and coordination skills)
● Most will improve spontaneously
Determine the location
of the problem to
establish the diagnosis
femur
tibia
foot
Common
Causes for
Intoeing Metatarsus adductus
Internal tibial torsion
Increased femoral anteversion
Metatarsus
Adductus
Metatarsus Adductus
● Age group: <1 year
● Estimated to occur in up to 3% of term newborns, more frequent in girls than
boys, and appears to run in families
● Often bilateral, and when unilateral, it occurs more often on the left than on
the right (for unknown reasons)
● Can be associated with other conditions related to uterine malposition (such
as hip dysplasia), but not all studies support this association
Metatarsus Adductus
● Adduction and inward position of the
forefoot
● Characterized by angulation at the midfoot,
with the metatarsals pointing toward the
midline relative to the hindfoot
● Lateral border of the foot is convex, and the
base of the 5th metatarsal appears
prominent
● Use of the heel bisector line can be helpful to
differentiate degree
○ Usually this line should cross lateral of the 2nd toe
(in the web space between the 2nd and 3rd toe)
○ In metatarsus adductus, this line crosses medially
Metatarsus Adductus
● Differentiate from club foot by:
○ Absence of ankle equines (plantar flexion)
○ Absence of hind foot varus (inward position of the heel)
● Most infants will improve without interference
○ If flexible (forefoot can be passively abducted past the midline), will spontaneously resolve by 1
year
○ If semiflexible (forefoot can be passively abducted only to the midline), can observe for 6
months
■ Can consider passive stretching, but ? efficacy
● If the condition persists beyond 6 months of age and/or deformity is rigid,
orthopedic referral may be indicated for either serial casting or bracing
○ Serial casting has best results if initiated before 8 months of age
○ Surgery is rarely indicated and very controversial
Internal Tibial
Torsion
Internal Tibial Torsion
● Age group: 1-3 or 4 years
● The most common cause of intoeing
● Characterized by internal (medial) rotation of the shaft of the tibia and most
commonly noticed when the child begins to walk
● Affects boys and girls equally and does not occur in premature infants
○ External tibial torsion more likely in premature infants
● Often bilateral (60% of the time), and when unilateral, it occurs more often on
the left than on the right (for unknown reasons)
● Can be associated with metatarsus adductus and may accentuate the
appearance of physiologic tibia vara and bow legs
Internal Tibial Torsion
● Hips and knees are found to be normally aligned, with patellas facing
anteriorly, but lower legs and feet are rotated inward
● When standing or walking, the foot points inward (an inward foot progression
angle)
● When lying prone, the thigh-foot angle is internal
● Typically resolves by age 5
○ There is wide variation of tibial rotation
○ As the child grows, the tibia spontaneously rotates laterally
Internal Tibial Torsion
● Generally corrects spontaneously by the age of 5
● Even if persists, has few long-term sequelae
● The use of special shoes, orthotics, or braces is not recommended
● Surgical treatment is very rarely indicated
○ Only reserved for patients with severe intoeing
○ Patients meeting this criterion who are older than eight years with an internal thigh-foot angle
greater than 15 degrees may be considered for distal tibial derotational osteotomy
● The correct answer on any board exam: parental reassurance
Internal Femoral
Torsion
Increased Femoral Anteversion
● Age group: 3 years or older
● Femoral version: angular difference between the axis of the femoral neck and
the transcondylar axis of the femur
● Femoral anteversion: increased internal rotation and decreased external
rotation at the hip
● Thought to be due to intrauterine molding and genetic inheritance
● Twice as common in females as in males
● May increase until five to six years of age and then gradually decreases
● Increased femoral anteversion does not cause pain
Increased Femoral Anteversion
● Tends to be symmetric
● When standing, the patellae face medially
● When walking, both the toes and the patellae
point towards the midline
● Increased internal rotation and decreased external
rotation of both hips
○ On exam, hip internal rotation > hip external rotation
● Preference for sitting in the "W" position
○ Uncomfortable sitting cross-legged until lateral rotation of
the hip improves
Increased Femoral Anteversion
● Generally no treatment is required and usually resolves spontaneously around
the age of 8 (UpToDate says 11)
● Bracing and orthotics do not change the natural history of the condition
● Keeping kids away from “W” sitting position also does not help with natural
history
● If persists or does not improve by age 11, then refer to orthopedic surgery
○ Femoral derotational osteotomy only effective treatment, but high complication rate so
generally is not recommended
● When combined with external tibial torsion, patients with increased femoral
anteversion may be more likely to develop anterior knee pain from so-called
"miserable malalignment"
Uncommon
Pathologic Causes
Uncommon Pathologic Causes
● Cerebral palsy
○ Spasticity may result in over-pull of the internal rotators of the hip or the adductors and
inverters of the foot, which may cause an asymmetric, unilateral intoeing gait
● Developmental dysplasia or dislocation of the hip
○ Look for limitation of hip abduction, leg-length discrepancy, or persistent increased femoral
anteversion
● Clubfoot
○ Medial deviation of the forefoot is combined with excessive supination (the sole of the foot
faces inward), cavus (high midfoot arch), and ankle plantar flexion (equinus)
● Skewfoot (rare)
○ Medial deviation of the forefoot is combined with lateral translation of the midfoot and valgus
position of the hindfoot
○ head of the talus may be visible and palpable medially.
○ Consider this with unilateral metatarsus adductus
References
● Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM. Nelson
Textbook of Pediatrics. Elsevier Health Sciences. 2020, 21st ed.
● Rosenfeld SB. Approach to the child with in-toeing. UpToDate. 2020. Accessed
April 7, 2020.
● Zitelli BJ, McIntire SC, Nowalk AJ. Zitelli and Davis’ Atlas of Pediatric Physical
Diagnosis. Elsevier Health Sciences. 2018, 7th ed.
