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In-toeing, sometimes called pigeon-toed, is a common condition in children where the feet point inwards when walking and standing.
There are three conditions that create in-toeing: metatarsus adductus, tibial torsion and femoral anteversion.
This condition is an inward curve of the outer border of the foot. It is detected in childhood, usually noticed during infancy and is typically caused by the position of the baby in the uterus. The Metatarsus is considered: mild, moderate, or severe.
In mild feet, the foot can be overcorrected passively. These feet usually resolve on their own by age 2.
In moderate feet, the foot can be passively corrected so that the lateral border is straight, but it cannot be over-corrected. These feet also usually improve on their own in the majority of cases, and occasionally may require special shoes to help the foot to permanently straighten. Both mild and moderate feet also respond well to stretching to help get the foot straighter. This is usually shown to the parents by the doctor and can be done at home at bath time.
Severe feet cannot be stretched so that the outside border of the foot is straight. These feet may be treated with a series of casts to help stretch the feet, followed by special shoes to maintain the correction. Rarely, surgery may be necessary if casting fails or if the deformity recurs during growth and the child has functional problems as a result.
Internal tibial torsion is an inward twist of the tibia or shinbone. This is usually noticed when the child begins to walk. Inward twisting is normal in many babies and often corrects by age 1. However, the inward twist is slower to correct in some children and these are the ones that usually need to see a doctor. In about 90% of patients the inward twist slowly corrects by about ages 4-6.
A child with tibial torsion will frequently trip and fall when initially walking. As the child grows and muscles develop, he or she is better able to cope with the in-toeing until it ultimately resolves in most cases. Studies have shown that bracing does not speed up the correction of inward tibial torsion, so most doctors do not prescribe any treatment other than observation. In about 10% of patients the tibial torsion does not correct, but most children function perfectly well and there is no evidence that tibial torsion causes arthritis or functional problems in the long run.
In the rare case that the torsion does not resolve by age 6 to 8 and the child does have a functional problem as a result of the torsion, the treatment is to cut the bone and rotate it outward so the feet point straight. Very few normal children without neuromuscular problems need this surgery and careful discussion with the doctor is necessary before deciding on surgery as the best treatment option.
Femoral anteversion is an excessive inward twist of the upper thigh bone at the hip region. This is usually noticed between ages 2 to 4. All children are born with some inward twist of the thigh bone and as they grow and their ligaments around the hip tighten, the anteversion resolves during the first few years of life. In some children, these ligaments never completely tighten up and when the child starts to walk they can become looser, causing the hips to rotate further inward, causing the in-toeing to be noticed between ages 2 and 4.
Most cases of femoral anteversion resolve spontaneously by the time the child is between 6 and 8 years old. Once again, it has been shown that special shoewear and braces do not improve on the natural resolution of the deformity, and may actually cause problems such as discomfort and poor self esteem. A few children will not resolve their anteversion but most function fine without any problems. In the rare case that the anteversion does not resolve by age 6 to 8 and the child does have a functional problem as a result of the torsion, the treatment is to cut the bone and rotate it outward so the feet point straight.
Out-toeing is much less common than in-toeing and often detected by age 2. Most children are born with external rotation contractures of the hips and this resolves shortly after walking begins. In those children where this does not happen quickly, out-toeing is the result when they first start walking. This will almost always resolve within a year from the onset of walking.
Out-toeing may also be caused by outward twisting of the tibia or femur bone, and is more common seen in children with neuromuscular abnormalities. As with in-toeing, bracing and shoewear are not helpful in resolving the deformity. In extreme cases, surgery may be necessary, but very infrequently.
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