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    7 lower limb positional variations

    Although many issues related to walking are benign, early recognition of these classic clinical presentations is essential for initiating further workup when indicated.



    Intoeing gait is the most common parental concern regarding how children walk. Nearly 2 in 1000 children have intoeing gait and it is typically bilateral.6 The 3 most common reasons for intoeing are metatarsus adductus, internal tibial torsion, and femoral anteversion. The conditions classically present in that order: metatarsus adductus in an infant, internal tibial torsion in a toddler, and femoral anteversion is seen most commonly in a school-aged patient.

    Metatarsus adductus

    Metatarsus adductus (MA) is a typically flexible deformation that is believed to occur from intrauterine positioning. It occurs in 1 in 5000 births and is more common in males, twins, and preterm babies.7 There is medial deviation of the forefoot relative to the hindfoot, resulting in a curved foot appearance. The heel bisector will be at the 3rd toe or more lateral. The majority of children improve on their own. More than 90% of children diagnosed before age 1 will self-resolve.8,9

    Management depends on whether the adductus is flexible or rigid. Flexible MA is either actively correctable (the child can make his/her foot point straight) or passively correctable (foot can be stretched to/past neutral by the clinician). Flexible MA is typically managed with observation, gentle stretching, and reassurance. It is best to stretch multiple times/day, such as with each diaper changing or feeding. In some cases, children with flexible MA can benefit from treatment with bracing, orthopedic footwear, or serial casting to more aggressively improve flexibility and position at rest.

    Families can be reassured that surgery to straighten the foot is seldom required. Surgery may be considered if metatarsus adductus is diagnosed late or if there is a rigid deformity. This is typically pursued after age 4 years.

    Internal tibial torsion

    Internal tibial torsion (ITT) occurs when the tibia twists inward. This can occur before birth as the legs rotate to fit in the confined space of the womb. After birth, an infant’s legs should gradually rotate to align properly. If the lower leg remains turned in, the result is ITT. When the child begins walking, the feet turn inward because the tibia in the lower leg points the foot inward.

    Internal tibial torsion typically is bilateral and presents in toddlers aged 1 to 4 years.3 Parents may describe the child as frequently tripping, being clumsy, or stepping on his/her own feet while walking. Torsional issues such as ITT become more obvious with fatigue or fussiness.

    Rotational issues can be seen during gait observation. Children with ITT will have knees directed straight ahead while walking, but inward rotation of the lower leg(s) causing intoed gait. Physical examination shows a thigh-foot angle of at least -10° and an inward foot progression angle.10 No imaging is needed.

    As the tibia grows longer, it usually untwists on its own. Tibial torsion almost always improves without treatment, and usually before school age. Ninety-five percent of children will spontaneously resolve, usually by preschool or kindergarten.11 Splints, special shoes, and exercise programs have not been shown to speed the process. Surgery to reset the bone (tibial rotational osteotomy) may be done in a child who is aged at least 8 to 10 years and has a severe twist that causes significant functional issues. This is rare.

    Femoral anteversion

    Femoral anteversion occurs when the femur is medially rotated on its long axis from birth. The shape of the proximal femur allows the hip joint to have significantly more internal rotation than external. As a result, both the knees and the feet point inward. It is often most obvious in children aged about 5 or 6 years.

    Rotational profile shows the hips to have at least 60° of internal rotation. Families may describe the child as having “poor turnout” in ballet class or may say the child doesn’t like to sit “crisscross applesauce” in school. Children often sit in the W position, with their knees bent and their feet flared out behind them.

    They also may complain of their knees bumping into each other while walking—a finding casually referred to as “kissing knees.”12

    Femoral anteversion is also nearly always a benign condition that improves gradually in most children (>80%) by age 10 years, although it may not ever resolve completely.13 Mild to moderate femoral anteversion should also be considered a variant of normal anatomy, rather than a pathologic entity. There are no braces or exercises that will improve or correct this problem. Imaging typically is not needed. Furthermore, there is no evidence that sitting position, such as W-sitting, impacts this condition, and thus children should be allowed to sit in whatever position they find comfortable. If the femoral anteversion is severe and persists, the only definitive treatment would be rotational osteotomy of the femurs after age 10 years. This surgery is performed very rarely—less than 1% of children with this condition.14

    NEXT: Knock knee, flatfoot, and pronation

    Stacy Frye, MD
    Dr Frye serves as teaching faculty for the Michigan State University College of Human Medicine, East Lansing. She also is a nonsurgical ...


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