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Intoeing and Outtoeing

In-toeing is very common and the parents complain that the childís feet turn in. There are three possible places where this could be coming from intoeing and outtoeing. It could be coming from the foot itself which is metatarsus adductus if the foot is sort of a bean-shaped foot, like you see at the top there, it could be coming from the area between the knee and the ankle, and we call that tibial torsion. What they are showing you in this drawing is that if you sit the child up and point their knees straight ahead, there toes are going to be pointed inward because you have a twist from here to here, or it could be between the hip and the knee and that is femoral torsion and what their showing up here is how much rotation the child has, she is lying on her back, but you can kind of point her knees.

This child has metatarsus adductus on this side, they have this curved border here, the tilting in, little depression here, but a pretty straight foot on the other side, normal foot here. We divide this into a classification based on how correctable it is, and we say itís actively or passively correctable or rigid. Actively correctable means that if you just kind of tickle the side of the childís foot, they will straighten out themselves.

The other way you can classify it is to imagine a bisector drawn down the line of the heel, and it should head around the third ray, between the second or third or third ray. If you do that on this child, their hitting at the fourth, hitting the third would be mild metatarsus adductus, the fourth is moderate, the fifth is severe. Itís not the most scientific thing in the world but it gives you an idea from time to time if youíve written that down. There is a differential diagnosis here and thatís clubfoot. Metatarsus adductus is part of clubfoot. Clubfoot consists of three different things of which metatarsus adductus is one, but metatarsus adductus alone is not the same thing as clubfoot and the big differential here is going to be that in clubfoot.

In terms of the treatment, if this is actively correctable, you donít really have to treat it at all, they will grow out of it. If itís possibly correctable, you can give the parents instruction exercises to do, tell them to hold the childís heel and then push on the first metatarsal, correct it, hold it there for five seconds and repeat that 10 times with every diaper change. You can tell the parents with actively correctable feet to do the same thing because itís good for them to get involved and do something, but they donít have to for the actively correctable ones. If they are rigid, you can either cast it out with stretch castor you can use this little device here called a Wheaten brace which does basically the same thing, itís an off the shelf device.

Femoral torsion is a little different. Itís not a packaging defect, itís an acquired defect, itís associated with ligamentous laxity, in order to get significant firmer torsion you need to be ligamentously lax, ligamentous laxity is not pathologic in and of itself, half the people in this room have it, but it allows one to have a whole host of other sort of quasi normal conditions, femoral torsion is one of which. This is the most common cause of in-toeing in children over the age of three, remember, that the in-toers from tibial torsion will have grown out of this usually by three, so femoral torsion is whatís left over after the age of three.

When the child comes to your office, how do you tell which of these three things they have, and you do a little series of tests called rotational profile and you can make a fancy little chart like this in your record and over time, see how this is progressing, and it looks kind of intimidating here, but it takes about 30 seconds to do.

Then you are going to look at the internal and external rotation of the hip, and you do that with the child in the prone position. Their lying on their stomach and typically, children will have 45 degrees in each direction, adults have less internal rotation than that, but children are pretty equal. What theyíre showing you here with the feet heading out this way, thatís internal rotation at the hip, this is internal rotation of the hips, this is external. You should have 45 degrees in both directions.

To check for internal tibial torsion, have the child in the same position, lying prone and you measure something called the five foot angle which is what they are showing you here, a bisector down the thigh, the bisector down the foot and this angle. This child doesnít have internal tibial torsion, this is a normal thigh foot angle of positive 10 degrees out away from the body.

Out-toeing is another packaging defect, most kids of sort of positioned in this fetal position with their legs turned in, but some are positioned with their legs turned out and their feet dorsiflexed up, and they are going to end up with external tibial torsion and calcaneal valgus feet as opposed to internal tibial torsion and metatarsus adductus and thatís what they are showing you here, just like in that first slide with this childís knees pointing straight ahead, their feet are turned out and thatís external tibial torsion, and just like in internal tibial torsion, this improves with the first year of walking.