How to recognize in-toeing, out-toeing

Donya Betancourt, Pediatrician, Sanur, Bali, drdonya@hotmail.com

Parents always want their children to grow up with healthy feet. Children begin life with two feet and 10 tiny toes, and their first steps occur between the ages of 12 and 15 months.

At first they tend to walk with their feet wide apart for balance called a waddling gait. Gait disturbances (abnormal development of the foot displacement) is a common parental concern. In-toeing and out-toeing are the most common disorders. Excessive turning in or turning out is more common in infants and children but rare in adolescents.

This condition often causes concern for parents and sometimes causes minor functional problems in children. The child must be evaluated carefully and an accurate diagnosis must be established.

Conditions in the womb can also cause in-toeing, such as the legs being in a confined position which affects the torsional alignment of the long bones, especially the thighs, legs and feet.

Normal full-term newborns have 20 degree to 30 degree hip and knee flexion contractures. These positions will resolve by four to six months of age.

Children commonly toe in when they start to walk at one year of age and are usually walking with their feet straight ahead by the age of eight years and walk with them turned slightly outwards by puberty.

There are three pathologic causes of in-toeing that your doctor will assess: femoral torsion, tibial torsion, and hooked foot (metatarsus adductus).

At birth, the most common reason for in-toeing is metatarsus adductus. This is when the feet are "C" or bean-shaped. The foot normally has a straight outside border. If the outside edge is curved, it is called a hooked foot or metatarsus adductus.

A severely hooked foot can make the whole limb appear to turn in when the child is walking. Casting is the treatment of choice in the first year of life but some spontaneous correction also occurs with growth.

As children begin to walk, the most common reason for in- toeing is an inward twist of the shin bone, or tibia. This condition is referred to as tibial torsion. The inward torsion is a variation of normal anatomy, and is caused partially by the child's position in the uterus and that the legs didn't rotate into the turned out position after birth.

Frequently the internal twist of the bone is associated with bowing of the tibia bone, The leg bone also has a natural twist between the knee and ankle. This rotation can be estimated by the orientation of the ankle joint with the knee pointing forward. The ankle normally faces slightly outward.

If the ankle faces very far outward or inward, it is called tibial torsion which gives the child an appearance of being bowlegged. It is normally corrected with growth over time.

In children from about six years and older, the most common reason to notice in-toeing is from a twist in the thighbone, the femur. The hip joint is more flexible in children and has greater rotation. The thigh bone itself has a natural twist between the hip joint and the knee called femoral version.

Anteversion in children is much greater than in adults causing the entire limb to rotate inward when they walk. Retroversion of the thigh bone causes the entire limb to rotate outward. When the rotation of the thigh bone is very severe, it is called femoral torsion.

Children with an extreme twist in the femur tend to have more difficulty running efficiently and tip more frequently. When walking more slowly, the deformity is less noticeable. In most instances, no treatment is required.

In severe cases, occasionally surgery is warranted to create more normal bone structure. Surgery is rarely necessary for physiologic in-toeing or out-toeing. The child should be given sufficient time to correct the rotational problem naturally.

The final adult position is normally reached by eight to 10 years of age.

The facts you should know are: in-toeing usually does not cause your child pain, in-toeing usually does not interfere with the way your child learns to walk and in-toeing has not been linked to degenerative arthritis in adulthood. In-toeing in children under age eight usually corrects itself on its own without casts, braces or surgery.