How To Address Pediatric Intoeing

By Edwin Harris, DPM

      Intoeing is one of the most common pediatric gait disturbances. Prompted by parental concerns, it accounts for a large number of new patient specialist visits. Intoeing is not a diagnosis. It is a complaint and an objective finding on physical examination. In spite of the frequent occurrence of pediatric intoeing, clinical management is complicated by diagnostic confusion and difference of opinion on both the necessity for treatment and its effectiveness. Intoeing has been the topic of many publications directed both toward primary care physicians and parents. However, information expressed in these articles can be confusing to both groups.       The essential question regarding the lower extremity causes of intoeing is whether they represent alterations in the shape and contour of a normal foot and limb or are true structural malformations.1-6 Some authors offer personal bias regarding the cause and treatment of intoeing. The opinions most often expressed are that treatment is not necessary, that most of the problems spontaneously correct on their own, and the benefits attributed to therapy are the result of natural resolution of the conditions as a part of their natural history.7-14 Other authors regard pediatric intoeing as alterations in physiologic developmental stages that have become pathological.5,15,16       Although there are many causes for intoeing, a careful systematic approach will yield a diagnosis and a treatment plan in most cases.17 Organizing the causes for intoeing is simply a matter of considering the anatomical area or areas of potential involvement. It is important to keep in mind that the more common causes of intoeing outside the foot are deviations of normal development while the abnormalities in the foot are purely pathological. An understanding of the natural history of the various pathologies is also crucial in order to offer a correct diagnosis and prognosis as well as facilitate the development of a successful treatment plan.       There are really only two broad categories of pathology to consider. Intoeing is most often caused by static skeletal abnormalities in one or several parts of the lower extremity. Less frequently, intoeing may result from a movement disorder. On some occasions, intoeing is caused by a combination of these two.       The history of the complaint is very helpful in pinpointing the cause of intoeing. Clinicians should place special emphasis on how old the child is when the symptoms first develop. When intoeing is noticed at birth, it is usually the result of some adducting deformity within the foot. These deformities include hallux varus, talipes equinovarus, metatarsus adductus and the various forms of pes cavus. When one first notices intoeing between the ages of 1 and 2, it is most likely caused by abnormality in the tibiofibular segment.18 Intoeing beginning after 18 months is most likely caused by femoral antetorsion (anteversion) and issues within the pelvis.       The child’s neurological status is critical to the diagnosis and treatment of intoeing. The developmental history identifies issues that might place the fetus at risk for central nervous system damage. These issues might include bleeding during early pregnancy, premature labor, difficulty in delivery, meconium aspiration, intracranial hemorrhage and post-delivery seizures. Static encephalopathy (cerebral palsy) is associated with a number of foot deformities.19 Acquisition of the major motor milestones at the appropriate times is a good indicator of normal central nervous system development.20       If the history and physical examination show the child to be neurologically normal, the cause for intoeing is almost certainly a static skeletal abnormality. There are only three anatomical areas where one might note this pathology. These include deformities within the foot and issues with tibial torsion and femoral antetorsion (anteversion). Frequently, intoeing is caused by abnormalities in two or all three of these areas. The sum of the rotational components is known as the rotational or torsional profile.9,21 The overall position of the foot to the line of progression is the algebraic sum of all three of these areas.

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