Intoeing presents in children at certain ages as a feature of normal development. Normal ontogenic development typically resolves intoeing by the age of 8. However, it can also be a sign of delayed or abnormal development with associated falling/tripping, limping and muscular pain. The long term ramifications of this gait pattern cited within the literature include patella-femoral pathology, abnormal subtalar joint pronation, hip joint arthrosis and patella instability (1). It is important to assess the cause of the intoeing to determine what type of management, if any is required.
There are many reasons a child may present with intoeing which is not a feature of normal development. The three primary causes of an intoeing gait that may not resolve are:
Metatarsus Adductus where the forefoot is adducted on the rearfoot in the transverse plane. Mild forefoot adduction is present at birth but should correct itself within the first year, however more severe adduction requiring intervention is estimated to occur in 1/1000 births (2).
Internal Tibial Torsion occurs due to insufficient untwisting of the tibial shaft, leaving the distal end internally rotated in relation to the proximal end. At birth the medial and lateral malleoli are in line, and by age 8 the tibia should have untwisted, leaving the medial malleoli anterior to the lateral (3).
Internal femoral position occurs when the distal end of the femur is internally positioned due to either insufficient untwisting of the femoral shaft, issues with the femoral head position in relation to the acetabulum or soft tissue tightness. Internal femoral position typically resolves itself by age six.
Assessment of Primary Causes
A mean foot progression angle value of -10° is typical in an intoeing gait (3). This can be easily assessed in the clinic using basic talcum powder footprints. Whilst further assessments may be required the following offer a basic screening to establish the likely cause of intoeing.
Metatarsus Adductus on standing displays the patellae pointing forwards and the feet pointing inwards. To assess, draw a line bisecting the plantar surface of the heel, in a normal foot the line will transverse between the 2nd and 3rd toes, whereas in Metatarsus Adductus the line will be directed laterally. The severity can be classified in terms of foot flexibility and forefoot adduction angle.
Internal tibial torsion on standing displays the patellae pointing forwards and the feet pointing inwards. Simple observation of the malleoli position is easy, by age 8 the medial malleoli should sit approximately a thumb width anteriorly to the lateral. This can also be assessed by comparing the angle of the thigh to the foot, a normal range being +10-15°, the figure illustrating minus 20°.
Internal femoral position on standing displays the patellae pointing inwards. Assessing hip/femoral position, rotation and range of motion will indicate issues. Unlike shown in Fig 5, internal and external rotation would be expected to be even. Comparison of range with hips flexed and extended will indicate muscular and ligamentous tightness which can be done with child sitting on a bench or lying prone.
The management of intoeing in children will depend on the specific diagnosis, severity and the age of the child. Conservative management focuses on giving the child the best chance to develop normally.
Metatarsus Adductus responds well to conservative treatment via stretching and splinting if identified early. Generally more severe Metatarsus Adductus is identified very early and if bony or persisting past six months old then corrective serial casting is used (3). Milder Metatarsus Adductus is often first identified via intoeing when the child is older and ossification is progressed. If the child is under 8-9 then reverse lasted boots, or swapping left for right shoes accompanied by stretching programs are also commonly used (5).
Internal tibial torsion is difficult to treat conservatively, if severe and disabling rotational osteotomy may be considered.
Internal femoral position is often associated with soft tissue tightness. It should be notes 30% of intoeing at age 4 is due to medial hamstring tightness (6). If there is a soft tissue issue, conservative management includes stretching exercises, the monitoring of sitting positions and the prescription of devices that encourage external rotation at the hip. Gait plates are an orthotic device with a lateral forefoot extension which encourage more external rotation at the hip, and have been shown to produce a statistically significant improvement to an intoed gait pattern (5). If the issue is bony and severe and past age eight to ten a rotational osteotomy or other surgery may be considered. In general, orthopaedic referral should be considered if the limb cannot be brought back to a neutral position or if doing so involves pain or discomfort.
As well as identifying if the intoeing is just part of normal development, you should initially consider and rule out the possibility of differential diagnosis such as clubfoot, cerebral palsy and hip dysplasia. Identifying the underlying issue is critical to determining your management strategy.
While in most cases intoeing corrects itself given time, most parents will feel anxious about their child’s condition. It is important to reassure them that the condition is common and that you are confident of your management approach. Regular reviews are important to ensure the conditions are not worsening over time.
It appears from the available research that conservative treatment accompanied by observation and repeat screening is the best form of management for most cases of intoeing. Surgical intervention should generally be necessary in severe cases which are painful and disabling.
- Uden H, Kumar S. Non-surgical management of a pediatric "intoed" gait pattern - a systematic review of the current best evidence. JMDH. 2012;5:27-35.
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- Li, Y.H. & Leong J.C.Y. Intoeing Gait in Children. HKMJ Vol 5 No 4 December 1999.
- Redmond AC. An evaluation of the use of gait plate inlays in the short-term management of the intoeing child. Foot Ankle Int. 1998;19(3):144–148.
- Munuera PV, Castillo JM, Dominguez G, Lafuente G. Orthotic devices with out-toeing wedge as treatment for in-toes gait in children. J Am Podiatr Med Assoc. 2010;100(6):472–478.
- Svenningsen S, Terjesen T, Auflem M, Berg V. Hip rotation and in-toeing gait. A study of normal subjects from four years until adult age. CIin Orthop 1990; 25 1: 177-82.
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- Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985;67(1):39-47.
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