#intoeing

Does your child walk with their feet turned inward or outward? This could be a sign of a common pediatric orthopedic condition. In this video, Dr. Nargesh Agrawal explains what rotated foot shape means, when it’s a concern, and how Child OrthoCare can help your child walk confidently again.

Every parent would be worried when they realize that their child has in-toeing condition, this is a condition that points the feet in. There are frequently seen developmental disorders and this condition is also known as “pigeon-toeing” and this condition also fades away gradually in childhood but it is crucial to know about them. In-toeing may stem from several factors, such as: 1.Internal Tibial Torsion: Twisting of the shinbone, often from the baby’s position in the womb. 2.Femoral Anteversion: Inward rotation of the thigh bone, noticeable as toddlers begin to walk. 3.Metatarsus Adductus: Inward positioning of the front part of the foot, common at birth. If your child’s in-toeing affects their ability to walk or causes discomfort, consult a podiatrist. Early diagnosis ensures the right care, from simple observation to physical therapy or orthotics.

Intoeing in Children

Got a kid that "toes in" during gait? Are you seeing this?

smaller foot progression angle

greater knee adduction

more internally rotated and flexed hips

greater anterior pelvic tilt

Wondering what could be causing it?

We start life with the hips anteverted (ie, the angle of the neck of the femur with the shaft of the femur is > 12 degrees; in fact at birth it is around 35 degrees) and this angle should decrease as we age to about 8-12 degrees). When we stand, the heads of our femurs point anteriorly; it is just a matter of how much (ante version or ante torsion) or how little (retro version or retro torsion) that is.

The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The angle of the femur neck to its shaft diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

There are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait. In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up, and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. 

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

 The take home message here about femoral torsions is that no matter what the cause:

the angle of the femur neck to shaft values that exist one to two standard deviations outside the range are considered “torsions”

Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”

Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

Ante torsion causes an increase in available internal rotation of the hip and decrease in external rotation

Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

 Great paper here

link to full text: http://onlinelibrary.wiley.com/doi/10.1002/jor.22746/abstract;jsessionid=AC848D963DCA526402D71260BDFC91F6.f04t04

Dr Ivo, one of the Gait Guys

Intoeing means that when a child walks or runs, the feet turn inward instead of pointing straight ahead. It is commonly referred to as being "pigeon-toed."

The cause of intoeing depends on where the change in alignment is centered. There are three common conditions causing intoeing:

Curved foot (metatarsus adductus)

Twisted shin (tibia torsion)

You know what’s not as cute as it seems in fashion photos? Being legitimately pigeon toed. I have fucked up hips that pop out of joint when I am trying to get busy, and I destroy all my shoes. I trip over my feet constantly and people tell me I am disgusting when I stand in line too long.