Joint Replacement, Sports Medicine, Spine Surgery, Pediatric Orthopaedics, Neurology, Hand and Foot Surgery

Intoeing – Pediatric

Intoeing refers to the general group of conditions in which the child is subject to walk or stand with the toes pointing inward rather than straight ahead. This by definition refers to a malalignment somewhere between the hip and the toes. The condition can run in families and typically is more noticeable in the infant toddler or young child, and in most cases gradually improves with age.

Common Symptoms:

Recurrent tripping and falling can occur and parents believe the child is catching their toe either on the ground or on their other leg due to the intoeing position. Uneven shoe wear or other aesthetic concerns are also raised by the parents. Generally the patient is completely asymptomatic.

Diagnosis:

The key to diagnosis is to determine what level in the leg the intoeing is occurring at. Internal femoral torsion, that is a twist in the femur somewhere between the hip and the knee, is a common cause. This is often caused or exacerbated by abnormal sitting positions where the child either sits on their feet or sits in the so-called “W” position. If the child desists from abnormal sitting postures, the condition usually slowly improves over time up to about the age of 9 or 10. Internal tibial torsion refers to a twist in the shin bone between the knee and the ankle, and is often present at birth and usually slowly improves over time unless the child is doing something to prevent that such as abnormal sitting positions, as in femoral torsion, mentioned previously. Tibial torsion is also commonly associated with increased bowing of the shins as well. Metatarsus adductus refers to the inward curving of the foot causing the great toes to tend to point somewhat towards each other. This can also be exacerbated by abnormal sitting positions.

Treatment Options:

There is really no specific treatment for increased femoral anteversion other than having the child avoid abnormal sitting positions. Encouraging the child to be involving in running and athletic activities is helpful. Some people believe activity such as skating, which forces the leg into an externally rotated position, may be helpful. Occasionally patients will be prescribed a night splint in an externally rotated position attached to a metal bar. This is called a Denis Browne splint and has been around for approximately one hundred years. It is a painless nighttime splinting which, while not accepted in all orthopedic circles, is still frequently used, and in individual cases, provides very good results. It is usually worn at night time or nap time only for approximately 4 to 6 months, in children between the age of 16 months and 2 years of age. With regards to metatarsus adductus, newborn parents are often given stretching exercises for the feet. In the older child, corrective shoes may occasionally used. Commonly used shoes are referred to as straight last shoes, where the medial border of the foot is completely straight. In more severe cases, reverse last shoes can be used. Some children need to wear these shoes for several years.

In the vast majority of children with intoeing, no specific treatment other than observation and attention to proper sitting positions is required. In the small number of children who do need treatment, it is usually mild and benign and good results are expected. The long-term outlook for a majority of children with intoeing is to go on to perfectly normal function regardless of whether or not the overall alignment improves.