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Intoeing in Children

30
Apr
  • Guide to Intoeing
  • Guide to Intoeing
  • Guide to Intoeing
  • Guide to Intoeing
Guide to Intoeing
  • Stuart
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  • feet . Intoeing . Paediatrics . walking .

What is Intoeing?

Some children’s feet turn in when they walk. This is called intoeing and is a part of growing up for many toddlers.  It is one of the most common developmental problems in children. It is frequently is due to normal variations of development.

It is usually seen in both feet, but can occur in just one.

Intoeing is often not a serious problem and usually corrects itself with time. This is why there are not many adults with intoeing. In a few children, it doesn’t get better on its own and must be treated.

Research has shown that about 1 in 10 children between the age of 2-5 intoe.

There are different reasons why a child may walk with their feet pointing inwards.

What does Intoeing look like?

An intoeing gait or walking pattern is whereby the feet and and entire leg will point towards each other instead of functioning in a parallel aligned position.

What problems will occur?

Children who intoe tend to trip a little more at first, but later on are fine. They can be just as good at sport and are no more likely to get arthritis or back problems than anyone else. The intoeing should not get worse.  If you think your child’s intoeing is getting worse you should arrange a reassessment. Many parents worry that their child will always walk with their feet turned in, however this hardly ever happens. Once your child has been evaluated to be certain that no serious / congenital condition exists, you can expect some improvement with time.

What is the causes of Intoeing?

Intoeing can be caused by a problem in one (or a combination of) or a multiple of these areas: the foot, the knee, or at the hip. 

1. The Foot: Metatarsus Adductus

Metatarsus adductus is considered to be the most common cause. This is an increased curve in the foot. This is best seen if you look at the sole of your child’s foot,   If your child has metatarsus adductus, you may notice an increased curvature on the outside of the feet.

This is probably caused before the baby is born, when the feet are pressed into this position inside the uterus.

If the foot is flexible and can be gently pulled into the correct position, no treatment is necessary.  In 9 out of 10 children with this problem, the feet get straight as the children grow up.

Sometimes it may be necessary to do some stretches to improve the position of the foot.

Mild cases with good range of motion show improvement by 12 months and typically resolve by age 3 years.

In a very few cases strapping or plaster of Paris casting is necessary for better correction.  A strong curve can cause problems with fitting shoes, and this is the main reason for using casts.

2. The shin bone: Internal tibial torsion?

Internal tibial torsion is a twist in the tibia (the leg bone between the knee and the ankle)

Parents usually notice internal tibial torsion about the time their child begins to walk.(When the knee caps are facing straight forward, the feet point inward).

Some inward twist of the tibial bone is normal in babies. Usually this twist straightens out during the ages of 1-2years. In some children, the twist doesn’t get straight enough that their feet point straight ahead or outward and these are the children who still intoe when they begin walking.

Involvement is often both legs; in single leg (unilateral cases), the left side is more often involved. 

Leg bones usually continue to grow straighter until the child is 6 to 8 years old.

Braces and special shoes are not very helpful. One treatment that has been used is a bar with shoes on it that makes the child’s feet point out. It hasn’t been shown to work. Braces like this one are expensive, and often children don’t like to wear them. So most podiatrists don’t give any treatment for internal tibial torsion in young children. 

In a small number of children, the twist in the tibia doesn’t go away. Even if the twist remains, it hasn’t been shown to cause arthritis or problems with running and jumping.

3. The Knee: Medial Genicular Position.

This is noticed most commonly during the second year of life after the child has started walking. The feet turn inward but the kneecaps (patellae) face ahead.  The shinbone (tibia) is slightly internally rotated within the knee causing the foot to turn in. 

This usually spontaneously improves as the child develops a maturer walking style

4. The Hip: Femoral anteversion

Intoeing can be caused by a twist in the bone between the hip and the knee (Femur). This twist is normal and gradually “unwinds” during development.  Any delay to this normal “unwinding” gives the appearance of intoeing. The kneecaps turn inward as well as the feet

In 90% of cases the intoeing will slowly improve between the ages of 7 and 14. 

 

Excessive femoral anteversion usually presents as a cause of intoeing at 3 to 4 years of age. It is present at birth but is often masked .

Intoeing due to excessive femoral anteversion increases up to 5 to 6 years of age and then gradually decreases. It is more common in females.

In persistent cases there is usually a strong family history.

For the rare case that does not improve, there remains the possibility of correction by an operation. In practice, this is rarely necessary. Surgical correction is not even considered at a young age since most children show complete correction on their own.

Weakness in the structures of the hip notably the ‘lateral’ structure (on the outside part of the hip) and overpower of the other surrounding structures can pull the leg and foot to adapt to an intoed aligned position.

Tightness of the hamstrings can also cause an intoed gait with the kneecaps turned inward.  Growth spurts often make the intoe seem much worse.

Usually a set of stretching exercises, performed regularly, will be enough to improve this.

Sitting in the 'W' position

Families were previously advised to discourage their children with increased femoral anteversion from sitting in the “W” position. (Sitting on their bottom with knees bent in the front centre and the legs splayed out toward the back of each side).  

Recent research has shown this is not detrimental to normal development.

The reason is that children with low resting muscle tone and/or hypermobility tend to choose the ‘W’ position when-sitting it has a wide “base of support” making it a very stable shape.

Here is a well written link to “What’s wrong with the ‘w’ position.

Treatment options:

Evaluation  and assessment of the child and watching them walk to determine the cause of intoeing and developmental milestones.

Treatment involves monitoring the child and reassurance to the parents.

Activities that may assist include ballet and dancing, martial arts and swimming with breast stroke legs.

Stretching of tight muscles especially the hamstrings following periods of rapid growth.

Footwear with  an inflexible or firm sole has been shown to reduce the angle of  intoeing.

Here is a link to our guide on childrens footwear.

Insole and orthoses (gait plates) may be of benefit in children with in-toeing gait caused by excessive femoral anteversion. The evidence is limited and lacking. However, gait plates have been reported to reduce frequency of tripping and reported parental satisfaction was high. 

Summary:

Intoeing should not affect your childs abilities to walk and run. It is considered within the literature that a mild degree of intoeing may actually be beneficial. It is possible that mild intoeing facilitates running by placing the toes in an optimal position.

Falling is a part of the learning to walk process and is not exclusively caused by intoeing.

 95% of paediatric patients have a benign diagnosis that requires no intervention.

References:

Li, Y. H., & Leong, J. C. Y. (1999). Intoeing gait in children.

Redmond, A. C. (1998). An evaluation of the use of gait plate inlays in the short-term management of the intoeing child. Foot & ankle international19(3), 144-148.

Redmond, A.C. (1998).The effectiveness of gait plates in controlling in-toeing symptoms in young children. Journal of the American Podiatric Medical Association 2000 90:270-76

Davis, L., & Nativio, D. G. (2018). Addressing pediatric intoeing in primary care. The Nurse Practitioner43(7), 31-35.

Fabry, G., Cheng, L. X., & Molenaers, G. (1994). Normal and abnormal torsional development in childrenClinical Orthopaedics and Related Research®302, 22-26.

Sass, P., & Hassan, G. (2003). Lower extremity abnormalities in children. American family physician68(3), 461-468.

Ganjehie, S., Saeedi, H., Farahmand, B., & Curran, S. (2017). The efficiency of gait plate insole for children with in-toeing gait due to femoral antetorsion. Prosthetics and Orthotics International, 41(1), 51–57. https://doi.org/10.1177/0309364616631349.

APA Staheli, L T; Corbett, M; Wyss, C; King, H Lower-extremity rotational problems in children. Normal values to guide management., JBJS: Jan 1985 – Volume 67 – Issue 1 – p 39-47.

Uden H, Kumar S. Non-surgical management of a pediatric “intoed” gait pattern – a systematic review of the current best evidence. J Multidiscip Healthc. 2012;5:27‐35. doi:10.2147/JMDH.S28669

 

Frequently Asked Questions

Most frequent questions and answers

Can Intoeing be corrected?

About 95% of children who intoe have a benign diagnosis that requires no intervention.

Treatment it typically based around monitoring their development and letting your child be active.

What ages should Intoeing correct itself?

The age that intoeing typically resolves is based on the underlying cause:

The foot (metatarsus adductus)- usually by the age of 3.

The shin bone (internal tibial rotation) up to age 8.

The hip (femoral anteversion) up to age 14.

Do insoles or Orthoses help?

nsole and orthoses (gait plates) may be of benefit in children with in-toeing gait caused by excessive femoral anteversion. The evidence is limted and lacking. However, gait plates have been reported to reduce frequency of tripping and reported parental satisfaction was high. 

 

Is Intoeing genetic?

Often the causes of intoeing tend to run in families. A parent or grandparent who intoes as a child can pass this along.

If concerned please get in contact.

To contact us or make an Appointment 0208 962 0635

Please click the link below or complete the contact form
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