Intoeing and Outtoeing: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Intoeing is common in infancy and childhood,while outtoeing is less common. Both may involve abnormalities ofthe feet, knees, legs, and hips. >1 abnormality may occurin an individual child.
Principal Causes of Intoeing and Outtoeing
Intoeing
Foot
Metatarsusadductus
Talipes equinovarus (clubfoot)
Imbalance of abductor and adductormuscles of the great toe
Knee and leg
Internal tibial torsion
Bow legs (genu varum)
Physiologicbowing
Rickets
Blount disease
Knock knees (genu valgum)
Hip
Increased femoral anteversion
Outtoeing
Foot
Calcaneovalgus foot
Spasticity
Hypermobile pes planus
Knee and leg
External tibial torsion
Hip
Femoral retroversion
Clinical Features and Diagnosis
Intoeing
At birth, the foot normally turns inward10–20 degrees. By 2 yrs of age, the foot normally turns outward10–20 degrees.
Foot
Metatarsus Adductus
Medial deviationof forefoot that is thought to occur from in utero positioning.Lateral aspect of forefoot is convex and curves inward, whereasnormally it should be straight.
If foot comes into neutral positionwith passive motion, manual exercises are usually all that are requiredfor correction.
Serial casting should be consideredwith moderate-to-severe foot angulation or inflexibility.
Talipes Equinovarus (Clubfoot)
Deformitycharacterized by adduction of forefoot, turning inward of hindfoot,plantar flexion of ankle (equinus), and high arch (cavus) at midfoot.Foot cannot be passively moved into neutral position.
Spinal dysraphism and arthrogryposismay be associated findings.
Imbalance of Abductor and Adductor Muscles of the Great Toe
Imbalancepulls big toe and sometimes forefoot into varus position. Gap existsbetween first and second toes, but this gap narrows with walking.
This condition may be noted in earlyinfancy but usually resolves spontaneously by 2–3 yrs ofage.
Knee and Leg
Internal Tibial Torsion
Tibia rotatesinward in relation to femur in this disorder, which is thought toarise from in utero positioning. At birth normal children have 0–20degrees of internal tibial torsion. Natural history of this conditionis slow derotation, so that by 7 yrs of age, normal position oftibia is 0–40 degrees of external tibial torsion with averageof 20 degrees.
Tibial torsion can be assessed by measuringthe thigh-foot angle, which is the angle formed by the foot in relationto the thigh with child in prone position and knee flexed to 90degrees (Fig. 34.1).Thigh-foot angle that is ≤0 degrees indicates internal tibialtorsion.
Torsion of lower leg also can be assessedby visualizing both malleoli with knees flexed to 90 degrees. Normally,medial malleolus is anterior to lateral malleolus in normal adultalignment. If lateral malleolus is in a plane in front of medialmalleolus, and feet and hips are normal, internal tibial torsionis present. Resolution usually occurs with onset of walking andrunning.
If significant torsion persists beyond2–3 yrs of age or is severe at any age, orthopedic consultationis recommended.
Fig. 34.1.
Bowlegs (Genu Varum)
Angular deformity at knee where tibia isadducted in relation to femur.
Physiologic Bowing
Physiologicbowing of tibia secondary to in utero positioning may not be noticeduntil child begins walking.
Distance between knees with medialmalleoli held together when child is in supine position with hipsand knees in extension is estimation of severity. Distance of <10cm indicates mild bowing, and child can be observed. Distance of >10cm indicates more severe bowing, and referral to an orthopedic physicianis indicated.
Rickets
Can causesevere bowing of lower extremities. Other findings include rib prominence (rachiticrosary), fragile bones, and widening of wrists.
Radiography of knee can usually distinguishrickets from physiologic bowing. Radiologic changes in rickets includeloss of normal zone of provisional calcification with fraying andcupping of metaphyseal areas, demineralization of bones with lossof normal cortical architecture, and loss of epiphyseal definition.
See further discussion of rickets in Chap. 59, Seizures.
Blount Disease
Dysplasiaof medial aspect of proximal tibial epiphysis, which results indisruption of proximal growth plate and bowing of lower legs.
Can be unilateral or bilateral andshould be suspected when bowing worsens or fails to improve spontaneouslyduring second year of life.
Radiographs of knee show irregularfragmentation of medial aspect of proximal tibia and beaking ofmetaphysis.
Knock Knees (Genu Valgum)
Knees angulateaway from midline, but toes turn in. Tibias are abducted in relationto femurs.
Common in children 2–6 yrsof age.
With knees held together and childsupine, distance between medial malleoli is measured. If distanceis >10 cm, condition may require orthopedic management.Otherwise, spontaneous resolution often occurs by 8 yrs of age.
Hip
Increased Femoral Anteversion
Laxity ofligaments around hip joint contributes to femoral anteversion, whichoccurs primarily in girls, usually 3–7 yrs of age. Allindividuals have some degree of anteversion, which is forward positionof femoral head in relation to femoral shaft. In adults normal anteversionangle is 10–15 degrees, whereas in developing child itis somewhat wider.
Femoral anteversion may be assessedby measuring hip rotation (Fig.34.2).
With child in prone position and hips in fullextension with knees flexed to 90 degrees, legs are rotated throughaxis of hip joint.
In girls from middle of childhood on,mean medial rotation of hip is about 40 degrees, with normal rangeof 15–60 degrees, whereas in boys mean rotation is about50 degrees, with normal range of 25–65 degrees.
In both girls and boys from middleof childhood on, mean lateral rotation of hip is about 45 degreeswith normal range of 25–65 degrees.
If lateral rotation is >25degrees, normal gait usually can be achieved. With <15–20degrees of lateral rotation, compensation is difficult and gaitmay be abnormal.
Femoral anteversion tends to improveuntil 7–9 yrs of age. In severe cases, rotational osteotomymay be indicated.
Fig. 34.2.
Outtoeing
Foot
Calcaneovalgus Foot
Thoughtto arise from in utero positioning and characterized by hyperdorsiflexionand varying degrees of eversion and forefoot abduction. Can be unilateralor bilateral and is often associated with external tibial torsion.
Passive exercises with plantar flexionand inversion are all that is usually required for correction.
Spasticity
Increasedresistance to joint movement and usually accompanied by hyperreflexia. Anklesare in equinus position, and feet are in valgus position.
Common causes include hypoxic-ischemicencephalopathy, cerebral palsy, head trauma, bacterial meningitis,and stroke.
Hypermobile Pes Planus
Children with flexible flat feet are usuallyasymptomatic. In non–weight-bearing position, normal mediallongitudinal arch is visible, but with weight bearing, arch is nolonger visible and shift in weight medially causes foot to pointoutward.
Knee and Leg
External Tibial Torsion
Attributedto in utero positioning and is often associated with calcaneovalgusfoot. It is much less common than internal tibial torsion.
Thigh-foot angle of ≥40 degreesindicates excessive external tibial torsion, which begins to improvewith walking and usually resolves by 2–3 yrs of age.
Medial malleolus is also noted to bemore anterior than lateral malleolus with knee in 90 degrees offlexion.
External tibial torsion may developin compensation for excessive femoral anteversion.
If severe at any age, orthopedic consultationis recommended.
Hip
Femoral Retroversion
Much lesscommon than femoral anteversion. It may be noted in early childhoodand is usually bilateral.
There is excessive lateral rotationof hips, usually to 60–80 degrees, and limited medial rotationof 10–30 degrees. Entire lower extremity rotates outward.Functional impairment does not usually occur, but if severe, surgerymay be necessary.
Diagnostic Approach
Historyand physical exam can usually reveal causes of intoeing and outtoeing.
It is important to note age of childbecause many of these disorders present at specific ages. Metatarsusadductus, talipes equinovarus, and calcaneovalgus deformity areusually noted at birth; internal tibial torsion, external tibialtorsion, and bowed legs in infancy; and knock knees, femoral anteversion,and femoral retroversion in childhood.
Radiography is useful, especially withsuspected rickets or Blount disease.
References
Alexander IJ. The foot: examination anddiagnosis. New York: Churchill Livingstone, 1990.
Crawford AH, Bagamery N. Handbook of pediatric orthopaedics,3rd ed. Cincinnati: Children's Hospital Medical Center,1996.
Greene WB, Heckman JD, eds. The clinical measurementof joint motion. Rosemont, IL: American Academy of Orthopaedic Surgeons,1994.
Mankin KP, Zimbler S. Gait and leg alignment: what'snormal and what's not. Contemp Pediatr 1997;14:41–70.
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