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Addressing pediatric intoeing

in primary care
Abstract: Primary care providers frequently encounter children with an intoed gait.
Intoeing is most often a normal variation of development that resolves without treatment.
The well-informed primary care NP can identify the small subset who need referral
through child and/or family history, physical exam, and identification of red flags.

By Lauren Davis, DNP, RN and Donna G. Nativio, PhD, CRNP, FAAN, FAANP

oncern about intoeing in children is a com-
C mon presenting complaint in primary care.
Parents may expect this condition to re-
quire referral to and treatment with an orthopedic
specialist and/or physical therapist. However, intoe-
ing is one of the most common musculoskeletal
findings and is frequently due to normal variations
in development.
An intoeing clinic conducted by advanced prac-
tice providers (NPs, clinical nurse specialists, and
physician assistants) with an orthopedic surgeon as
consultant evaluated 926 otherwise healthy pediatric
Keywords: femoral anteversion, intoeing, metatarsus adductus, pediatric physical exam, tibial torsion
patients with intoeing and found that approximately
95% had a benign diagnosis that did not require any
treatment.1 This is consistent with other research
studies and supports that the majority of children
with intoeing can be managed in primary care.2
However, there is a small subset of patients for
whom intoeing is a sign of an underlying pathologic
condition or who will require interventions led by an
orthopedic specialist. The patient’s history and physi-
cal exam will guide the NP to determine whether the
patient can be managed in primary care or requires a
specialty care referral.

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 Addressing pediatric intoeing in primary care

The three most common causes of intoeing are also helpful to gain information regarding the onset
metatarsus adductus, internal tibial torsion, and in- and clinical course of intoeing. (See Expected clinical
creased femoral anteversion. These conditions can be course of intoeing.)
diagnosed by physical exam without the use of radio- It is important to remember that these conditions
graphical studies and can be managed by primary care can often occur in combination.2,8,9 Red flags obtained
providers.3 while acquiring the patient’s history may include uni-
lateral or asymmetric intoeing, with findings sugges-
■ Anatomy and pathophysiology tive of cerebral palsy or developmental dysplasia of the
The formation of lower extremity alignment begins at hip, delayed developmental milestones, associated pain
the seventh week of intrauterine life when the lower or limping, daily recurrent trips or falls, or a positive
limbs rotate medially and bring the great toe toward family history for disorders that can lead to intoeing
midline.4 This intrauterine positioning is hypothesized requiring treatment.7,10
to influence limb rotational deformities. Metatarsus
adductus is characterized by the medial deviation of ■ Physical exam
the metatarsals. This most often occurs bilaterally and A thorough developmental, musculoskeletal, and neu-
is thought to be a result of intrauterine positioning.3 rologic exam must be completed for the child present-
Internal tibial torsion is internal rotation of the tibia ing with intoeing. An age-appropriate assessment of
on its long axis.5 The exact etiology is unknown; how- developmental social and emotional, language and
ever, it is also thought to be a result of intrauterine po- communication, cognitive, and gross and fine motor
sitioning.6 A newborn normally has approximately 40 milestones should be documented.7 If the patient is
degrees of femoral anteversion at birth, which decreases ambulatory, he or she should be assessed while stand-
to 15 to 20 degrees by the age of 8 to 10 years.4 Some ing, walking, and running while observing for sym-
believe that increased femoral anteversion is a result of metry, limping, and foot or patellar progression an-
persistent infantile anteversion, whereas others believe gles.2,3,7 Specific physical exam techniques are used to
it is acquired secondary to abnormal sitting habits (W determine the origin of intoeing (see Physical exam
leg position) or the prone sleeping position.4 techniques to identify intoeing).2,3,11-14
When a patient’s presentation is consistent with one
■ History of these three diagnoses and there is a lack of red flags
The clinician should elicit a complete birth and medical or significant physical exam findings indicative of an-
history, including developmental milestones, presence other diagnosis, the NP can properly educate the family
of chronic illnesses, and any associated complaints.6,7 about the condition and manage the patient in primary
A family history of intoeing may suggest a genetic care. (See Physical exam findings of intoeing.)
variation and/or may be used to reassure parents that
these conditions frequently resolve with growth.7,8 It is ■ Differential diagnosis
Pathologic conditions associated with the presence of
Expected clinical course of intoeing7-9 red flags discussed in the history of intoeing include
neuromuscular diseases (cerebral palsy), developmen-
Condition Onset Course
tal dysplasia of the hip, lower leg deformities such as
club foot and skewfoot, infection, and bone tumor or
Metatarsus Apparent at Mild cases with good
adductus birth or early in range of motion show lesion.8,10 It is also key to differentiate intoeing from
infancy improvement by 12 genu varum (bowleg). Genu varum is most often physi-
months and resolve ologic and a normal variation seen in 1- to 3-year-olds.
by age 3 years
Similar to internal tibial torsion, it is often first noticed
Internal Between ages Improves by
tibial torsion 1 and 2 years age 6-8 years
once the child begins ambulation. On physical exam,
(when the child there is typically a waddling gait with symmetrical and
begins walking) diffuse lower extremity bowing and an increased dis-
Increased After the age Gradual improvement, tance between the knees when standing.
femoral of 2 years resolves around age There is no casting, bracing, or surgery indicated
anteversion 10-12 years
for physiologic bowing.3 If genu varum continues to

32 The Nurse Practitioner • Vol. 43, No. 7 www.tnpj.com

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 Addressing pediatric intoeing in primary care

Physical exam techniques to identify intoeing2,3,7,8

Exam technique Explanation Findings Picture

Determined while viewing Foot and/or patellar angle

Foot/patellar
the foot and patella as the may be described as inter-
progression angle
patient walks forward nal, neutral, or external

Knee caps point a

straight ahead
With the patient sit-
Normally, lateral mal-
ting and patella facing Normal Internal
leolus is posterior to the tibial tibial
View of lateral and straight forward, view the torsion torsion
medial malleolus (0 to -10
medial malleolus relationship of the lateral
degrees internal rotation is
malleolus to the medial
average)
malleolus

With the patient prone,

Normally, the line crosses
view a line through the
Heel bisector line the forefoot between the
axis of the heel to the
second and third toes
forefoot

With the patient prone,

Normal mean in infants is
knee flexed, and foot
5 degrees internal angle
flexed, an angle is formed
Thigh-foot angle
by drawing a line that is
Normal mean by age 8 is
bisecting the thigh and a
10 degrees external
line bisecting the foot

.
External Internal c
With the patient prone: rotation rotation
Normal internal during
Internal (legs rotated 0˚
childhood is 40 to 50
away from center of the
degrees 40˚
body) 45˚
Hip internal/
external rotation

External (legs rotated to- Normal external is 40 to 70

ward center of the body) degrees

These angles are often measured subjectively, but a geniometer can be used to determine a more precise objective measurement.
a
Reproduced with permission from Merens TA. The toddler gait—normal or not. Pediatric Annals. 2015;44(5)187-190.
b
Reproduced with permission from Rosenfeld SB. Approach to the child with in-toeing. In: UpToDate, Post TW, eds. Waltham, MA: UpToDate. Copyright ©2018
UpToDate, Inc.
c
Reproduced with permission from Beetham WP, Polley HF, Slocumb CH, Weaver WF. Physical Examination of the Joints. Philadelphia, PA: Saunders; 1965.

www.tnpj.com The Nurse Practitioner • July 2018 33

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 Addressing pediatric intoeing in primary care
worsen or is seen beyond the age of 3 or 4 years, a
referral to an orthopedist for additional investigation
is warranted. Pathologic causes of genu varum include
rickets, epiphyseal dysplasia, dwarfism, and other
metabolic abnormalities or growth disturbances.3
■ Management
Routine radiographs are not recommended for chil-
dren with intoeing and are typically only indicated if
there are complaints of pain to rule out hip dysplasia
after an abnormal hip exam or if there are additional
Physical exam findings of intoeing2,3,7,8
Metatarsus adductus
• Internal, neutral, or external foot and patella
progression angle
• Mild deformity (heel bisector crosses third toe)
• Moderate deformity (heel bisector crosses between
third and fourth toes)
• Severe deformity (heel bisector crosses between
fourth and fifth toes)
Internal tibial torsion
• Internal, neutral, or external foot and patella
progression angle
• Thigh-foot angle >10 degrees internal
• With patella forward, lateral malleolus is parallel
or anterior to medial malleolus
Increased femoral anteversion
• Internal foot and patella progression angle
• Increased hip internal rotation (may be up to 90
degrees [legs rotate flat against exam table])
• Preference to sit in “W” position
Indications for orthopedic referral7,8
Metatarsus adductus
• Cannot passively bring foot into neutral position
(may indicate club foot)
• Severe deformity (heel bisector crosses between
fourth and fifth toes)
Tibial torsion
• Child older than 8 years with severe intoeing causing
functional or cosmetic deformity
Increased femoral anteversion
• Child is >8 years old and complains of severe function-
al or cosmetic deformity with:
femoral anteversion >50 degrees (measured
radiographically)
internal hip rotation >80 degrees
Any diagnosis of intoeing that does not follow an ex-
pected clinical course
34 The Nurse Practitioner • Vol. 43, No. 7
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
risk factors present for a pathologic condition. Fur-
thermore, surgical management is not necessary for
these conditions most of the time.1,7,8 Orthotics (braces
and splints) do not change the natural history or ad-
vance resolution.7
For patients with metatarsus adductus, providers
can encourage families to massage and lightly stretch
the inside of the foot into a neutral position; however,
no research consistently supports the use of specific
stretching or exercise to resolve intoeing quicker than
the child’s natural growth and development.8
Families were previously educated to discourage
their children with increased femoral anteversion from
sitting in the “W” position (sitting on the bottom with
knees bent in the front center and legs splayed out
toward the back of each side); however, research has
shown this is unlikely to change the natural history as
well.6,7 The “W” position is comfortable for the child
and this sitting position is not detrimental to normal
development. The child will stop sitting in this posi-
tion once they can sit cross-legged more comfortably
as natural improvement occurs.6
One of the most important aspects to the man-
agement of intoeing is family reassurance. If the
child’s parents or guardians choose not to seek fur-
ther workup treatment after obtaining the patient’s
history and performing a physical exam, families
should be educated on the prevalence of these condi-
tions and their expected resolutions.
For long-term prognosis, these rotational deformi-
ties do not lead to an increased risk of hip or knee
arthritis.7,15 Children with metatarsus adductus, inter-
nal tibial torsion, and increased femoral anteversion
do not require activity restrictions or additional pre-
cautions. These conditions are common developmen-
tal variations that often resolve without treatment as
the child grows.7
■ When to refer
Any of the red flags discussed in the history section
indicate a need for referral to an orthopedic specialist.
Physical exam findings of limb length discrepancy and
deformity progression should be referred as well.6 (See
Indications for orthopedic referral.)
■ Implications for practice
Intoeing can be distressing to pediatric patients and
families, especially as patients get older and begin
school and activities. NPs can reassure patients and
www.tnpj.com
 Addressing pediatric intoeing in primary care

families that these benign conditions resolve with
growth and development and the child can participate
in activities the same as other children. Awareness of
the red flags and indications for referral can help NPs
identify patients who require additional specialty care
and allow them to manage the majority of intoeing
patients who will not need referral.
REFERENCES
1. Faulks S, Brown K, Birch JG. Spectrum of diagnosis and disposition of pa-
tients referred to a pediatric orthopaedic center for a diagnosis of intoeing. J
Pediatr Orthop. 2017;37(7):e432-e435.
2. Sielatycki JA, Hennrikus WL, Swenson RD, Fanelli MG, Reighard CJ,
Hamp JA. In-toeing is often a primary care orthopedic condition. J Pediatr.
2016;177:297-301.
3. Zitelli BJ, McIntire S, Nowalk AJ. Atlas of Pediatric Physical Diagnosis. 7th ed.
Philadelphia, PA: Elsevier; 2017.
4. Kliegman RM, Stanton B, Geme J, Schor NF. Nelson Textbook of Pediatrics.
20th ed. Philadelphia, PA: Elsevier; 2015.
5. Iannotti JP, Parker RD. Netter Collection of Medical Illustrations: Musculoskel-
etal System, Volume 6, Part II—Spine and Lower Limb. 2nd ed. Philadelphia,
PA: Saunders; 2013.
6. Mooney JF 3rd. Lower extremity rotational and angular issues in children.
Pediatr Clin North Am. 2014;61(6):1175-1183.
7. Rerucha CM, Dickison C, Baird DC. Lower extremity abnormalities in
children. Am Fam Physician. 2017;96(4):226-233.
8. Spiegel DA, Horn BD. Lippincott’s Primary Care Orthopaedics. 2nd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
9. Harris E. The intoeing child: etiology, prognosis, and current treatment
options. Clin Podiatr Med Surg. 2013;30(4):531-565.
10. Evans AM. Mitigating clinician and community concerns about children’s
flatfeet, intoeing gait, knock knees or bow legs. J Paediatr Child Health.
2017;53(11):1050-1053.
11. Carr JB 2nd, Yang S, Lather LA. Pediatric pes planus: a state-of-the-art
review. Pediatrics. 2016;137(3):e20151230.
12. Merens TA. The toddler gait—normal or not. Pediatr Ann. 2015;44(5):
187-190.
13. Rosenfeld SB. Approach to the child with in-toeing. 2017. www.Uptodate.
com.
14. William P, Polley HF, Slocumb CH, Beetham WFW. Physical Examination
of the Joints. Philadelphia, PA: Saunders; 1965.15. Weinberg DS, Park PJ,
Morris WZ, Liu RW. Femoral version and tibial torsion are not associated
with hip or knee arthritis in a large osteological collection. J Pediatr Orthop.
2017;37(2):e120-e128.
Lauren Davis is a recent DNP graduate from the University of Pittsburgh
School of Nursing, Pittsburgh, Pa.
Donna G. Nativio is an associate professor and DNP Program Director at the
University of Pittsburgh School of Nursing, Pittsburgh, Pa.
The authors and planners have disclosed no potential conflicts of interest,
financial or otherwise.
DOI-10.1097/01.NPR.0000534939.42714.d0

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