Concern about intoeing in children is a common presenting complaint in primary care. Parents may expect this condition to require referral to and treatment with an orthopedic specialist and/or physical therapist. However, intoeing is one of the most common musculoskeletal findings and is frequently due to normal variations in development.
An intoeing clinic conducted by advanced practice providers (NPs, clinical nurse specialists, and physician assistants) with an orthopedic surgeon as consultant evaluated 926 otherwise healthy pediatric patients with intoeing and found that approximately 95% had a benign diagnosis that did not require any treatment.1 This is consistent with other research studies and supports that the majority of children with intoeing can be managed in primary care.2
However, there is a small subset of patients for whom intoeing is a sign of an underlying pathologic condition or who will require interventions led by an orthopedic specialist. The patient's history and physical exam will guide the NP to determine whether the patient can be managed in primary care or requires a specialty care referral.
The three most common causes of intoeing are metatarsus adductus, internal tibial torsion, and increased femoral anteversion. These conditions can be diagnosed by physical exam without the use of radiographical studies and can be managed by primary care providers.3
Anatomy and pathophysiology
The formation of lower extremity alignment begins at the seventh week of intrauterine life when the lower limbs rotate medially and bring the great toe toward midline.4 This intrauterine positioning is hypothesized to influence limb rotational deformities. Metatarsus adductus is characterized by the medial deviation of the metatarsals. This most often occurs bilaterally and is thought to be a result of intrauterine positioning.3
Internal tibial torsion is internal rotation of the tibia on its long axis.5 The exact etiology is unknown; however, it is also thought to be a result of intrauterine positioning.6 A newborn normally has approximately 40 degrees of femoral anteversion at birth, which decreases to 15 to 20 degrees by the age of 8 to 10 years.4 Some believe that increased femoral anteversion is a result of persistent infantile anteversion, whereas others believe it is acquired secondary to abnormal sitting habits (W leg position) or the prone sleeping position.4
The clinician should elicit a complete birth and medical history, including developmental milestones, presence of chronic illnesses, and any associated complaints.6,7 A family history of intoeing may suggest a genetic variation and/or may be used to reassure parents that these conditions frequently resolve with growth.7,8 It is also helpful to gain information regarding the onset and clinical course of intoeing. (See Expected clinical course of intoeing.)
It is important to remember that these conditions can often occur in combination.2,8,9 Red flags obtained while acquiring the patient's history may include unilateral or asymmetric intoeing, with findings suggestive of cerebral palsy or developmental dysplasia of the hip, delayed developmental milestones, associated pain or limping, daily recurrent trips or falls, or a positive family history for disorders that can lead to intoeing requiring treatment.7,10
A thorough developmental, musculoskeletal, and neurologic exam must be completed for the child presenting with intoeing. An age-appropriate assessment of developmental social and emotional, language and communication, cognitive, and gross and fine motor milestones should be documented.7 If the patient is ambulatory, he or she should be assessed while standing, walking, and running while observing for symmetry, limping, and foot or patellar progression angles.2,3,7 Specific physical exam techniques are used to determine the origin of intoeing (see Physical exam techniques to identify intoeing).2,3,11-14
When a patient's presentation is consistent with one of these three diagnoses and there is a lack of red flags or significant physical exam findings indicative of another diagnosis, the NP can properly educate the family about the condition and manage the patient in primary care. (See Physical exam findings of intoeing.)
Pathologic conditions associated with the presence of red flags discussed in the history of intoeing include neuromuscular diseases (cerebral palsy), developmental dysplasia of the hip, lower leg deformities such as club foot and skewfoot, infection, and bone tumor or lesion.8,10 It is also key to differentiate intoeing from genu varum (bowleg). Genu varum is most often physiologic and a normal variation seen in 1- to 3-year-olds. Similar to internal tibial torsion, it is often first noticed once the child begins ambulation. On physical exam, there is typically a waddling gait with symmetrical and diffuse lower extremity bowing and an increased distance between the knees when standing.
There is no casting, bracing, or surgery indicated for physiologic bowing.3 If genu varum continues to worsen or is seen beyond the age of 3 or 4 years, a referral to an orthopedist for additional investigation is warranted. Pathologic causes of genu varum include rickets, epiphyseal dysplasia, dwarfism, and other metabolic abnormalities or growth disturbances.3
Routine radiographs are not recommended for children with intoeing and are typically only indicated if there are complaints of pain to rule out hip dysplasia after an abnormal hip exam or if there are additional risk factors present for a pathologic condition. Furthermore, surgical management is not necessary for these conditions most of the time.1,7,8 Orthotics (braces and splints) do not change the natural history or advance resolution.7
For patients with metatarsus adductus, providers can encourage families to massage and lightly stretch the inside of the foot into a neutral position; however, no research consistently supports the use of specific stretching or exercise to resolve intoeing quicker than the child's natural growth and development.8
Families were previously educated to discourage their children with increased femoral anteversion from sitting in the “W” position (sitting on the bottom with knees bent in the front center and legs splayed out toward the back of each side); however, research has shown this is unlikely to change the natural history as well.6,7 The “W” position is comfortable for the child and this sitting position is not detrimental to normal development. The child will stop sitting in this position once they can sit cross-legged more comfortably as natural improvement occurs.6
One of the most important aspects to the management of intoeing is family reassurance. If the child's parents or guardians choose not to seek further workup treatment after obtaining the patient's history and performing a physical exam, families should be educated on the prevalence of these conditions and their expected resolutions.
For long-term prognosis, these rotational deformities do not lead to an increased risk of hip or knee arthritis.7,15 Children with metatarsus adductus, internal tibial torsion, and increased femoral anteversion do not require activity restrictions or additional precautions. These conditions are common developmental variations that often resolve without treatment as the child grows.7
When to refer
Any of the red flags discussed in the history section indicate a need for referral to an orthopedic specialist. Physical exam findings of limb length discrepancy and deformity progression should be referred as well.6 (See Indications for orthopedic referral.)
Implications for practice
Intoeing can be distressing to pediatric patients and families, especially as patients get older and begin school and activities. NPs can reassure patients and families that these benign conditions resolve with growth and development and the child can participate in activities the same as other children. Awareness of the red flags and indications for referral can help NPs identify patients who require additional specialty care and allow them to manage the majority of intoeing patients who will not need referral.
1. Faulks S, Brown K, Birch JG. Spectrum of diagnosis and disposition of patients referred to a pediatric orthopaedic center for a diagnosis of intoeing
. J Pediatr Orthop
2. Sielatycki JA, Hennrikus WL, Swenson RD, Fanelli MG, Reighard CJ, Hamp JA. In-toeing is often a primary care orthopedic condition. J Pediatr
3. Zitelli BJ, McIntire S, Nowalk AJ. Atlas of Pediatric Physical Diagnosis
. 7th ed. Philadelphia, PA: Elsevier; 2017.
4. Kliegman RM, Stanton B, Geme J, Schor NF. Nelson Textbook of Pediatrics
. 20th ed. Philadelphia, PA: Elsevier; 2015.
5. Iannotti JP, Parker RD. Netter Collection of Medical Illustrations: Musculoskeletal System, Volume 6, Part II—Spine and Lower Limb
. 2nd ed. Philadelphia, PA: Saunders; 2013.
6. Mooney JF 3rd. Lower extremity rotational and angular issues in children. Pediatr Clin North Am
7. Rerucha CM, Dickison C, Baird DC. Lower extremity abnormalities in children. Am Fam Physician
8. Spiegel DA, Horn BD. Lippincott's Primary Care Orthopaedics
. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
9. Harris E. The intoeing
child: etiology, prognosis, and current treatment options. Clin Podiatr Med Surg
10. Evans AM. Mitigating clinician and community concerns about children's flatfeet, intoeing
gait, knock knees or bow legs. J Paediatr Child Health
11. Carr JB 2nd, Yang S, Lather LA. Pediatric pes planus: a state-of-the-art review. Pediatrics
12. Merens TA. The toddler gait—normal or not. Pediatr Ann
14. William P, Polley HF, Slocumb CH, Beetham WFW. Physical Examination of the Joints
. Philadelphia, PA: Saunders; 1965.
15. Weinberg DS, Park PJ, Morris WZ, Liu RW. Femoral version and tibial torsion
are not associated with hip or knee arthritis in a large osteological collection. J Pediatr Orthop
Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
femoral anteversion; intoeing; metatarsus adductus; pediatric physical exam; tibial torsion