May 30, 2024

In-toeing gait is usually attributed to metatarsal adductus (in infants), internal tibial torsion (in toddlers), and femoral ante version (in children <10 years)

The child walks with foot will turn inwards instead of pointing straight ahead

Etiology:

  1. Excessive femoral anteversion
  2. Internal tibial torsion
  3. Metatarsal adductus

Excessive femoral anteversion:

The angle between the neck of the femur and shaft in the sagittal plane internally rotated

The commonest cause of in-toeing is between 3-8 years

The angle is about 40° at birth and decreases when the child starts walking.

In a disease that affects a child’s ability to walk, the child continues to have a high angle of anteversion

It reaches normal (about 17°) by age of 8 years.

Clinical Features

  • May presents with apparent genu valgum, may lead to patellofemoral problems
  • W position upon sitting
  • Patella is facing inward (During gait)
  • Awkard running style and frequent falls
  • The examination will show that hip IR exceeds hip ER
    • IR > 70° (n=20°-60°)
    • ER <20° (n=30°-60°)

Child with this problem classically sits with legs in ‘W’ shape

Anteversion degree

Treatment:

  • No treatment required
  • Usually resolved spontaneously around the age of 8
  • Brace and orthotics don’t change the natural history of the disease

Femoral derotational osteotomy (rarely needed): If the condition does not improve by age of 9. ( Not functional but for cosmesis)

Internal Tibial Torsion

Inward rotation of the shaft of the tibia

Most common cause of in-toeing

Normal finding in the newborn: due to intrauterine position

The commonest cause of in-toeing gait:- Usually seen in infants, aged 2-3

Diagnosed by a negative femoral thigh angle > 15° (n=0,+20)

> 15 ° transmalleolar angle

Internal rotation of tibia causes pigeon-toed gait

Treatment:

  • No treatment is required , patient reassurances
  • Usually resolves spontaneously around the age of 6
  • Bracing and orthotics don’t change the natural history of the disease
  • If the condition does not improve by the age of 8 (Supramalleolar derotational osteotomy)

Metatarsal adductus

Adduction and inward rotation of the forefoot (tarsometatarsal joint) in relation to the hindfoot

Usually seen in 1st year of life

Classification:

Heel bisector method (Beck, 1983)

NormalHeel bisector angle through 2/3 toe web space
Mild Heel bisector angle through 3 toe
ModerateHeel bisector angle through 3/4 toe web space
SevereHeel bisector angle through 4/5 toe web space

Clinical Features

The foot has a curved lateral border rather than the straight one

It May be associated with other conditions related to uterine malposition (DDH and torticollis)

In-toeing gait

Treatment

  • Most infants will improve without interference
  • Observation is recommended in the first 6 months of life with stretching exercises
  • If the condition persists beyond 6 months and the deformity is rigid, serial casting or bracing may be required
  • Surgery is rarely indicated
    • Lateral column shortening and medial column lengthening if patient older than 5 years old (mixed result)