The parents of four month old Stacey brought her to the office because they had some concerns and questions. I am reminded that she was in just last week for her regular well-check, and all seemed well at the time. The parents were worried because one of the grandparents had made a comment that her feet turned in...they weren't straight, and that this could be a problem. The parents were anxious because they too, had noticed this but were afraid to mention it to each other. When the grandmother "broke her silence", they immediately made the appointment.
Joshua is a portly toddler of 16 months and a bundle of energy. He moves around the room like a tank, in constant motion. Despite being built like a bruiser, he is really quite coordinated. He runs well and climbs on just about everything. Although he is being seen for an ear infection, mom's real concern is the fact that his feet turn in when he walks. It is much more noticeable when he runs. Mom's not quite sure, but she thinks it has gotten worse over the past couple of months.
Marie is a sweet five year old who has come in for her kindergarten physical. With all the paperwork, shot records and labs required of this visit, the first thing that mom asks about (before I even sit down) is for me to please check Marie's legs. When she walks, her feet turn in...so much so that the pre-school teacher is the one who brought it to mom's attention.
These three patients exemplify three of the most common torsional (toeing in) deformities seem in pediatrics: metatarsus adductus, internal tibial torsion and anteversion of the femoral head.
Four month old Stacey has what is known as metatarsus adductus. This is a congenital disorder of the foot that causes an inward angulation, or a deviation toward the mid-line, of the toes of the forefoot (see Fig. 1). The hindfoot, heel and ankle are normal. Metatarsus adductus is thought to be the result of overcrowding while the fetus is in the uterus, hence, it is a "positional" problem that is present at birth. The degree of the inward angulation is variable. As a rule, if the forefoot can be easily brought to, and beyond the mid-line, it should not pose any problem to the child, and should correct itself with time. The foot undergoes extensive remodeling as the child starts to walk and the muscles of balance about the foot mature. Some physicians have the parents "massage" the feet and hold the feet in an outward position to overcome the varus (inward) deformity, but this has not been shown to be of any real benefit.
Severe cases of metatarsus adductus in which the foot cannot be brought to the mid-line, or conditions which interfere with proper footwear use should be referred to a specialist. It may be necessary to have the child wear corrective shoes or even cast the feet, although this is not very common.
Stacey's feet were very flexible and I was able to move her forefoot well beyond the mid-line with ease. After double checking her hips, knees and ankles, I assured her parents that she was fine and would outgrow this in time. We all had a good laugh when dad said in a serious voice, "I knew that this wasn't anything to worry about", to which mom replied, "Oh yeah, then why did you have ME make the appointment as soon as possible?"
Joshua has a condition that involves the lower leg unit. It is known as internal tibial torsion (ITT). The lower leg has two bones, the larger tibia, and the fibula. In ITT, the tibia is turned inward which causes the child to toe-in (see Fig. 2). ITT, like metatarsus adductus, is also felt to be the result of overcrowding in utero. It usually doesn't become obvious until the child starts walking, and the parents often report that the toeing-in seems to be fixed regardless of how fast the child walks or runs. The majority of cases of ITT do resolve with time as the child develops good walking balance. It seldom causes the child any difficulty in walking or "being clumsy".
Severe cases of ITT may require bracing to correct the torsional deformity. One such brace consists of a metal bar that has shoes attached to the ends of it. The shoes are positioned at an outward angle (30-45 degrees) so that when the child is wearing the brace, the lower leg unit is rotated beyond the mid-line. This is to overcome the torsion. The braces are worn for varying periods of time, usually for an eight hour stretch at bedtime. Specialists have the patients use the braces for months (3-9 months) depending on how responsive the ITT is to bracing. If it is determined that a child will need bracing, it is best done at an early age because older children are more resistant to wearing it at night. It can become quite a struggle for the parents.
Joshua did have a mild degree of ITT but it did not interfere with his gait or mobility. We elected to observe, and by the time he was 20 months, you could hardly detect that he had ITT. At his two year visit it had completely resolved.
Marie has the third condition that commonly causes toe-ing in, anteversion of the femoral head (AVFH). The femur is the large bone of the upper leg. It forms joints with the hip and the knee. In AVFH, there is an increased forward placement (anteversion) of the head of the femur where it joins the hip. This causes an internal rotation of the entire leg which results in the child toe-ing in when they walk. They seem to "throw" the foot inward with each step. It can be more pronounced with running. When the child stands however, the leg lines up perfectly straight.
Children with AVFH tend to have highly flexible joints and can often sit comfortably in the "W-position": on their bottom with the knees bent and the legs behind them. This is not harmful to the hips, but should be discouraged because it may compromise the external rotation flexibility of the hip. AVFH does not cause any functional problems for a child, but it does not resolve completely either. Fortunately, many of the activities that children like to do such a bike-riding, roller-blading, ballet etc. help to improve the situation. Severe cases of AVFH that require bracing or surgery are extremely rare, and are usually associated with neuro-muscular disorders.
Marie had perfectly straight legs when she stood upright. When she walked however, she did throw her leg inwards and toe-in. To allay mom's concerns, I had Marie see an orthopedist who confirmed the diagnosis of AVFH and agreed with observing the condition. Although the toe-ing in has not changed, it has not interfered with her activities. She is in her second year of gymnastics, and is the best player on her soccer team.