Metatarsus Adductus

Newborn M with h/o prematurity presents with bilateral intoeing. Parents report twin sibling diagnosed with metatarsus adductus. Bilateral intoeing with kidney-shaped foot and deviated heel-bisector line on exam; forefoot abducts to neutral when heel placed in neutral position.

• Treatment

  • Parents informed that imaging and treatment are generally not indicated

  • Severe metatarsus adductus in a child who is not walking; refer to pediatric orthopedics for adjustable shoes vs. serial casting x 6-8 weeks

• Parents reassured that 85-90% of cases resolve by 1 year of age

Notes

• More common in males, twins, and premature infants

• Differential diagnosis

  • 2% of cases are associated with developmental dysplasia of the hip

  • In metatarsus varus (rare), the forefoot does not abduct to neutral when heel is in neutral position

• Severity determined by heel bisector line (normal = 2nd toe)

  • Mild = 3rd toe

  • Moderate = between 3rd/4th toes or on 4th toe

  • Severe = between 4th and 5th toes

• Adjustable shoes are effective and less expensive than casting in pre-walking patients with motivated parents

• Surgical correction is contraindicated due to high failure and complication rates

Internal Tibial Torsion

3 y/o pt with h/o frequent falls presents with bilateral intoeing. Forward facing patellae with feet pointing inward on exam.

• No suspicion for rickets, Blount disease, or skeletal dysplasia; do not refer for imaging

• Consider surgery if thigh-foot angle is greater than 15 degrees at age 8 years

• Parents informed that braces and orthotics are ineffective

• Parents reassured that most cases resolve by age 5 years and 90% resolve by age 8 years

Notes

• Most common cause of intoeing overall

• Most common between ages 2-4 years

Femoral Anteversion

5 y/o F with h/o sitting in W position, clumsy gait presents with bilateral intoeing. Parents report family h/o femoral anteversion. Increased internal hip rotation (60 to 90 degrees) with reduced external hip rotation (10 to 15 degrees), inward pointing feet/patellae, bilateral intoeing, and circumduction gait on exam.

• Consider surgery at age 8 years for severe functional or cosmetic abnormality

• Parents informed that radiography in not recommended and that braces/orthotics are ineffective

• Parents reassured that 80% improve/resolve by 10 years of age

Notes

• Most common cause of intoeing in school aged children

• Diagnosed based on increased internal hip rotation and decreased external hip rotation