In-toeing and Out-toeing What is all the fuss about? Natalie Stork, MD Assistant Professor University of Missouri-Kansas City School of Medicine, Department of Orthopaedic Surgery and Department of Pediatrics Children s Mercy Kansas City, Division of Orthopaedics and Section of Sports Medicine The Children s Mercy Hospital, 2016 The Children's Mercy Hospital, 2015
Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation 2
Practice Gap Many primary care physicians lack training in the diagnosis and management of common lower extremity rotation variations in children 3
Objectives Review the musculoskeletal exam when evaluating for rotational variations Discuss the diagnosis, natural history and treatment of common lower extremity rotational variations 4
Embryology/Development Limb bud development Medial rotation Intrauterine positioning Increased relative external rotation of hip Relative internal rotation of tibia Variable positioning of feet 5
Development External rotation of the lower extremity Femur ~25 0 Tibia ~15 0 Adult alignment ~ 8-10 years of age 6
Evaluation Identify the concerns Current appearance of the feet? Function? Persistence of the appearance? 7
Evaluation History Onset, Function, Progression/Improvement Past Medical History Birth history, Developmental milestones Family History Rotational variations in family members 8
Differential Diagnosis Intoeing Metatarsus Adductus Internal tibial torsion Femoral anteversion Clubfoot (Talipes equinovarus) Skew foot Spastic Hemiparesis Out toeing External tibial torsion Femoral retroversion Pes plano valgus Slipped capital femoral epiphysis Painful limb 9
Exam Dynamic (Gait) Static Heel bisector Hip rotation Thigh foot angle FPA R: +10 0 L: +10 0 Heel Bisector TFA R: +10 0 L: +10 0 Hip Rotation Rotational Profile R: 2 nd webspace L: 2 nd webspace Internal Rotation External Rotation R:50 0 R:50 0 L: 50 0 L: 50 0 10
Feet Exam - Dynamic Knees Hips Other Symmetry Posturing with running Hip/Knee flexion 11
General appearance Exam - Static Facial features, asymmetry, maturity/development Lower extremities Range of motion, Asymmetry Spine 12
Heel bisector Exam - Static Line intersecting the midline of the hindfoot and forefoot Neutral should pass through the 2 nd metatarsal Shape of the foot Convex border 13
Thigh foot axis Exam - Static Angle created between: Long axis of the thigh and Axis of the tibia/hindfoot Infant ~ -5 0 (-30 - +20 0 ) Child ~ +10 0 (-5 0 to +30 0 ) 14
Exam - Static Hip rotation Internal rotation Infant ~ 40 0 (10-60 0 ) Child ~ 50 0 (25-65 0 ) External rotation Infant ~70 0 (45-90 0 ) Child ~ 45 0 (25-65 0 ) 15
Metatarsus Adductus Common congenital foot deformity Medial forefoot deviation relative to the hindfoot First year of life Etiology Unknown More common: Males, Twin births, Premature births 16
Metatarsus Adductus Convex border of the lateral foot Medial crease Normal ankle range of motion Classification Flexibility Severity 17
Metatarsus Adductus Treatment Observation Flexible Stretching* Casts Rigid metatarsus adductus Residual deformity 18
Internal Tibial Torsion Common Intoeing etiology in toddlers 2/3 bilateral Parents report frequent tripping, clumsy 19
Internal Tibial Torsion Treatment Observation/Education Tibia continues to externally rotate with growth Bracing/Splints are NOT effective Surgical intervention Rare 20
Internal Tibial Torsion 100 high school students 50 sprinters, 50 controls Mean thigh-foot angle was lower in the sprinters relative to the controls More sprinters intoed during sprinting Fuchs R, Staheli LT. Sprinting and intoeing. J Pediatr Orthop. 1996 Jul-Aug; 16(4); 489-91. 21
Femoral Anteversion Common intoeing etiology of childhood Refers to angle between the axis of femoral feck and the condyles (M/L) knee Natural history Infant ~40 0 Adult ~ 15 0 Symmetric 22
Femoral Anteversion Report of W sitting Eggbeater running motion Knee caps point medially Excessive internal rotation relative to external rotation 23
Treatment Femoral Anteversion Observation/Education Surgical Severe anteversion Functional limitations 24
Out-toeing Positive foot progression angle Unilateral or bilateral Progressive vs. Static Differential diagnosis External tibial torsion, femoral retroversion, pes plano valgus Slipped femoral capital epiphysis 25
Exam Out-toeing Positive foot progression angle Hip range of motion External rotation > Internal rotation (femoral retroversion) Red flags (limp, decreased flexion, abduction, internal rotation) Thigh foot angle Foot/Ankle Achilles contracture 26
Identify the cause Out toeing Hip/Acute injury External tibial torsion/femoral retroversion Pes plano valgus External tibial torsion may progress with age 27
Practice Gap Many primary care physicians lack training in the diagnosis and management of common lower extremity rotation variations in children 28
Practice Change The learner will possess the skills and knowledge to diagnose and manage common cases of intoeing and out-toeing which do not require a need for an orthopaedic referral 29
References 1. Lincoln TL, Suen PW. Common rotational variations in children. J Am Acad Orthop Surg. 2003;11(5):312-320. 2. Staheli LT. Rotational problems in children. Instr Course Lect. 1994;43:199-209. 3. Staheli LT. In-toeing and out-toeing in children. J Fam Pract. 1983;16(5):1005-1011. 4. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985;67(1):39-47. 5. Fabry G, Cheng LX, Molenaers G. Normal and abnormal torsional development in children. Clin Orthop. 1994;(302):22-26. 6. Fuchs R, Staheli LT. Sprinting and intoeing. J Pediatr Orthop. 1996;16(4):489-491. 7. Engel GM, Staheli LT. The natural history of torsion and other factors influencing gait in childhood. A study of the angle of gait, tibial torsion, knee angle, hip rotation, and development of the arch in normal children. Clin Orthop. 1974;(99):12-17. 8. Jacquemier M, Glard Y, Pomero V, Viehweger E, Jouve J-L, Bollini G. Rotational profile of the lower limb in 1319 healthy children. Gait Posture. 2008;28(2):187-193. doi:10.1016/j.gaitpost.2007.11.011. 30