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A Common childhood orthopedic condition – In-Toeing – Part 1

What is in-toeing?

• The feet of most people’s feet point straight forward or are otherwise slightly outward.
• However, when the feet are not pointed forward, but are pointed inward, it is called an in-toeing condition.
• The problem is essentially a musculoskeletal condition.
• The condition is usually found in young humans – infants and children and can be recognized by observing an inwardly rotated foot or feet.

What is out-toeing?

• On the converse side, if the feet are not pointed forwards or inwards, then the outward rotated foot or feet is known as out-toeing.
• As you would suspect, this problem normally is caused due to abnormalities in the growth or alignment.
• For the majority of cases where such a problem arises, these are merely a physiological variation throughout a normal stage of development.
• When such a variation occurs in one or both feet, the result is that these feet appear splayed outwards.
• In-toeing may differ at different ages that is, from birth to adolescence.

Causes for In-toeing

There are 3 common medical causes of in-toeing:
• Medial femoral torsion: In this condition, the femur or thighbone is rotated inward.
• Medial tibial torsion:
– This problem also has a different name, also called internal tibial torsion.
– The problem, when examined, is marked by an inwardly rotated tibia.
– It is like a shinbone in the lower leg.
• Metatarsus adductus:
– In this condition, the foot of the patient is bent inward.
– If you remember the shape of a kidney bean, well the bent is somewhat similar.

Out-toeing is less common than in-toeing. The problem has same causes.

Some basic facts about In-toeing

• Children who have the condition of in-toeing are otherwise completely healthy.
• People worry a lot when they see this problem, so they should be reassured that these children do not suffer from other congenital abnormalities or any other related diseases.
• Whenever there is a problem relating bones or joints, people suspect problems such as the occurrence of arthritis, but in-toeing does not cause arthritis or clumsiness.
• In-toeing is significantly common compared to many other problems, and is known to occur in about 2 out of every 1000 children.
• Even more so, such rotational problems in joints and in the feet are very common in infants and young children.
• Tibia torsion is the major cause of in-toeing.
• When infants begin to walk, that is when this condition becomes more apparent.
• However, this cannot be extrapolated in the case of adolescents.

Tibia torsion – A major cause of In-Toeing

• This problem affects both boys and girls equally.
• The problem is bilateral about two-thirds of the time and both legs are affected.
• Further, most cases are asymmetrical with the the legs not being affected equally; the net result is that one leg is rotated more than the other.
• With the above condition, there is one more condition – the problem occurs more frequently in the left leg than the right leg and this this is when the problem is unilateral
• Metatarsus adducts is also another frequent cause of in-toeing.
• Tibia torsion is actually the most common deformity in terms of congenital foot.

Femoral Torsion – A major cause of In-Toeing

• This problem is usually diagnosed when the child is less than 3 years of age.
• However, the problem becomes most pronounced when children are between the age of 4 and 6 years and occurs twice as often in girls than boys.
• The problem is almost always symmetric and affects both legs equally.
• This problem is genetic, being inherited to some degree.
• It occurs in siblings or offspring’s of people who themselves had it.
• People affected have an abnormal gait and have a lot of difficulty running.

Lateral tibia torsion – A major cause of In-Toeing

• This problem is frequently unilateral and affects the right side more than the left side.
• When bilateral, the condition is usually symmetrical.
• One of the byproducts of the problem is pain around the knee.
• This pain is called patellofemoral pain.
• It is not uncommon in adolescents.

The Foot Book Orthopedic Physical Assessment Bates’ Guide to Physical Examination and History Taking

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