Corrective devices and shoe modifications are expensive and generally ineffective.

Toeing-in is the most common rotational deformity seen in the growing child. This problem most often arises from femoral anteversion (twist in the thigh); internal tibial torsion (turned in lower leg), metatarsus adductus (curved foot), or a combination of these conditions. Therefore, to manage this problem, is necessary to localize the level of deformity to hip, leg, or foot.

It is also important to be aware of the natural history and normal variations of these conditions as there is a major tendency toward spontaneous correction with growth. In the past, treatment with shoe modification splints, twister cables, etc. has been popular, but there is no objective evidence that any of the above produce a result different from the normally expected spontaneous improvement. These devices are becoming increasingly expensive. Treating the parents' concerns would be better handled by education rather than subjecting the child to cost and ineffective "treatment" devices. Evaluation should determine whether the deformity is fixed or dynamic, whether the child is frequently in positions which oppose spontaneous derotation, whether there is a family history of similar problems, and should rule out other pathologic conditions (such as cerebral palsy, myelodysplasia, etc.) t can produce torsional deformities.

Metatarsus varus (adductus) describes the condition in which the forefoot is pulled inward at the tarso-metatarsal joints as viewed in the transverse plane. The heel is in neutral position. Viewing the foot with the child prone, the lateral border is normally straight. The varus foot shows a convex lateral border with prominence of the base of the fifth metatarsal. The severity of this deformity is variable and is measured by the amount of passive forefoot correctability found on clinical ex, The heel bisector should pass between toes two and three. (See Figure) In general, this condition is usually present at birth, although often overlooked until 3-4 months of age. It is usually bilateral and more often seen in males. The natural history of metatarsus varus reveals t it is probably the result of position in utero and spontaneously resolve 85% of the time. Factors mitigating against spontaneous resolution a sleeping in the prone position with the feet tucked up under the pelvis and sitting on the feet for long periods. There is no certain way of determining prospectively which feet will correct and which will not.

Most authors recommend treatment in infancy. If the deformity is mild and flexible, observation alone, straight last shoes, or stretching of the mid-foot by the parents should suffice. If there is more severe deformity, serial manipulation and casts are usually effective. The end point of casting occurs when the foot can be passively over corrected. In general, casting is more effective in infants under eight months of age, but can succeed up to age 2 years. If the deformity persists or recurs, operative correction may become necessary because of the rigid deformity of the feet. This is accomplished by metatarsal osteotomies under age seven years and midfoot osteotomies in the older child.

Internal tibial torsion refers to an inward or medial torque of the tibial shaft producing an inward rotation of the ankle joint relative to the knee joint. Normally the transmalleolar axis of the tibia is externally rotated 5 degrees during the first year of life, 10 degrees during mid childhood and 15-20 degrees in older children and adults. This assessment is best made by having the child sit on the edge of a table with the knees flexed 90 degrees. The transmalleolar axis is determined by palpating the tips of the medial and lateral malleoli and this axis is compared to the long axis of the tibia. Another method is to assess the thigh-foot angle with the child prone and knees flexed 90 degrees. (See Figure 2.)

A more precise determination of the torsion can be obtained with a C.T. scan. This problem is usually discovered when the child begins to walk. It is often associated with lateral bowing of the tibia and bow legs. The natural history of internal tibial torsion is that it spontaneously corrects in most cases. A mild persistence causes no functional handicap. Once again, some sleeping and sitting postures might tend to impede spontaneous derotation. Dennis Browne splints have been used to treat this problem and they are useful in interrupting an internally rotated sleeping position. Excessive rotation in the splint should be avoided and the splint is contraindicated if femoral anteversion is present. In the extremely rare instances of severe internal tibial torsion causing gait problems, a supra-malleolar derotational osteotomy of the tibia would be considered in the older child.

Femoral anteversion is the most common cause of in-toeing in children 3-12 years old. Anteversion is defined as the anterior angulation or rotation of the femoral neck relative to the transcondylar axis of the knee.

A newborn has femoral anteversion of approximately 45 degrees which diminishes to about 32 degrees at age 1, and gradually diminishes to the normal adult anteversion of 15 degrees by age 16 years. Increased femoral anteversion is caused by the lack of normal derotation. This condition occurs more often in females, usually presents at age 3-6 years, and is often associated with external tibial torsion.

Physical exam reveals that internal rotation of the hips is increased, external rotation quite limited, and the knees point inward during gait ("kissing patellae"). With the knee in neutral rotation, the greater trochanter can be palpated posteriorally rather than in its normal lateral presentation. The anteversion can be documented by physical exam, biplane x-ray studies, or C.T. scan. The natural history of femoral anteversion is of gradual improvement. Females with ligamentous laxity tend to have slower resolution of their femoral anteversion (and in-toeing).

Problems associated with anteversion are primarily cosmetic. There may be an increased incidence of patello-femoral pain in females, but there is no evidence of hip or back problems or functional deficit in adults. Correction can be obtained only by femoral osteotomy. Orthotic devices are contraindicated because they will produce an external tibial torsion rather than derotating the femur. Indications for femoral osteotomy would be cosmetic improvement or intractable knee pain in a patient with documented x-ray evidence of anteversion of greater than 40 degrees, with internal rotation of the hip greater than 80 degrees and external rotation less than 20 degrees. Parents should weigh the benefits of the correction versus the morbidity of the surgical procedure.

In summary, toeing-in may arise from the hip, tibia, foot or a combination of these areas. The overwhelming majority of these problems will resolve spontaneously. Corrective devices and shoe modifications are expensive and generally ineffective. Parental reassurance is a major part of the treatment process. Corrective casts for metatarsus varus and, occasionally, Dennis Browne splints for internal tibial torsion are the only effective therapeutic modalities in early childhood. Derotational osteotomy would be considered for the rare cases of persistent severe anteversion or torsion. (See Table 1)

TABLE 1: Comparison of clinical parameters of conditions causing "toeing-in."