Intoeing–Tibial/Femoral Torsion

Description

• Intoeing, as a presumptive diagnosis, results in numerous orthopedic consultations.
• Causes of intoeing are most frequently one or more of the following: metatarsus adductus, internal tibial torsion, and femoral anteversion.
• Definitions:
  • Version: normal variation in axial alignment
  • Torsion: any variation beyond two standard deviations of normal
• Clear explanation of the difference between physiologic variations and pathologic anatomy will allow the treating physician to effectively manage expectations.

Epidemiology

Very common; one of the most common reasons for a “well child” to visit an orthopedist

Risk Factors

Pathophysiology

• Most are self-limiting issues but when paired together, can cause significant issues.
• Excessive femoral anteversion and external tibial torsion can result in the so-called “miserable malalignment,” known to cause significant patellofemoral issues.

Etiology

• In utero, fetuses are subjected to forces that mold feet and tibiae into adductus and internal torsion, respectively.
• Most children are born with a relatively increased femoral anteversion (approximately 45 degrees).
  • Tends to resolve and “unwind” as the child develops
  • Usually resolves by age 8 to 10 years to the normal adult anteversion of 10 to 20 degrees

Commonly Associated Conditions

May be more common in first-born children (especially metatarsus adductus) as part of the “packaging disorders” such as developmental dysplasia of the hip and torticollis