Intoeing or “Pigeon-toeing”

Definition

  • Feet or toes point toward midline
  • Common musculoskeletal finding in pediatrics?    Yes!  
  • Alternatively, may encounter out-toeing.  These both typically present between 6 months - 5 years.   In general, normal growth and improving coordination/walking ability lead to complete resolution of the findings.  

Most common causes

  1. Metatarsus Adductus
  2. Internal Tibial Torsion
  3. Increased femoral anteversion

All three should be initially managed with serial exams and reassurance.  There is currently no accepted guideline for management and recommendations based on expert opinion.  The “use of special shoes, casts, or braces is not empirically supported.”  Surgery is reserved for older children with severe defects.  

1. Metatarsus Adductus

http://graphics8.nytimes.com/images/2007/08/01/health/adam/9052.jpg

Metatarsus adductus.  Image from http://graphics8.nytimes.com/images/2007/08/01/health/adam/9052.jpg

  • Angulation at midfoot (metatarsals)
  • Most common cause of intoeing in infants < 1yr old
  • Intrauterine crowding is most likely cause
  • Affects females more than males
  • Affects left foot more often than right foot
  • May. .
    1. Correct with only lateral stimulation of foot (mild/flexible)
    2. Passively corrects(moderate/less flexible)
    3. Sometimes may not be passively corrected (severe/rigid)
  • Most cases mild/flexible, easily resolve by age 2
  • Management: parental reassurance
  • If Rigid metatarsus adductus persists beyond 6 months, should be referred to pediatric orthopedics for serial casting

2. Internal Tibial Torsion

  • Medial rotation of tibia
    1. when prone, thigh-foot angle neutral or internal
    2.  
  • Most common cause of intoeing in children 1yr - 3/4yrs
  • Associated with Metatarsus adductus in ~1/3 of cases
  • Causes may include intrauterine position, sleeping in the prone position after birth, and sitting on the feet
  • Prevalence equal in males and females
  • Often asymmetricalAffects left foot more often than right foot
  • With growth, tibia rotates laterally, usually resolved by 5 yrs old
  • Management: parental reassurance
  • If persists until mid-childhood, should be referred for surgical correction

3. Increased femoral anteversion

  • Femur internally rotated
    1. when standing, patellas point medially
    2. when walking, toes and patellas point midline
    3. may see decreased external rotation of hips
    4. prefer to sit in “W” position
  • Presents at 3-6 yrs
  • Result of intrauterine molding and genetic inheritance
  • Often familial
  • Usually bilateral
  • Twice as common in girls as in boys
  • Usually spontaneously resolves by 11 yrs,
  •                      if persists, few long term sequelae (eg. no link to osteoarthritis)
  • Management: observation and parental reassurance
  • If persists past 8-10yrs old, should be referred for surgical correction

Note: Pathologic causes do not resolve spontaneously and may include:

  • Cerebral palsy
  • Developmental dysplasia of hip
  • Lower leg deformities (eg. clubfoot, skewfoot)

Again, these are uncommon and can often been ruled out by history & physical, but are good to have considered in the differential.  

References:

1.  FPIN's clin inquiries: managing intoeing in children. Talley W, Goodemote P, Henry SL.  Am Fam Physician. 2011 Oct 15;84(8):937-44.

2.  www.uptodate.com

3.  Mankin, Keith. and Zimbier, Seymour. Gait and leg alignment: What's normal and what's not Contemporary Pediatrics. November 1997.
Scherl S. Common Lower Extremity Problems in Children. Pedatrics in Review February 2004

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