Intoeing–Tibial/Femoral Torsion



  • 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.


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

Risk Factors


No strong evidence, but in some cases, a history of “intoeing that didn’t resolve” is reported


  • 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.


  • 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

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