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In-toeing Deformity by Sean-Patrick Lewis BSc(Hons), MChS

Head & Short Podiatry Inservice Trainining

Sean Lewis

on 13 January 2013

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Transcript of In-toeing Deformity by Sean-Patrick Lewis BSc(Hons), MChS

In-Toeing Deformity Inservice Training Clinical Definition Intoeing is defined as an abnormal angle of gait with the toes pointed excessively inward, which commonly occurs in children of various ages. The rotational (transverse plane) pathology producing this deformity can occur at the level of the hip, knee, tibia or foot . What Causes In-toeing ? Pathology Clinical Presentation Assessing Femoral Anteversion Rotate the hip internally and externally until the greater trochanter is most prominent laterally Assessing Femoral Anteversion Assessing Internal Tibial Torsion Clinical Testing for Tibial Torsion Femoral Anteversion Femoral Anteversion is characterised by the femoral neck leaning forward with respect to the rest of the femur. This causes the lower extremity on the affected side to rotate internally.

Femoral anteversion at birth is about 30 to 40°.

Early adolescent development should see this value reduce to 10 to 15°. Medial Tibial Torsion Medial tibial torsion is a condition in which the tibia is rotated internally along its long axis. The internal rotation of the tibia also causes the foot and ankle to be internally rotated. Metatarsus Adductus Metatarsus adductus is a relatively common foot deformity of infancy or childhood where there is inward deviation of the forefoot relative to the rear-foot. Intrauterine positioning is the main contributing factor.

Can be compounded by ligamentous laxity, at the anterior capsular ligaments. Which should produce an external pull, and so externally rotating the femoral neck.

Can appear asymmetrical

Most common cause at the infant stage is metatarsus adductus.

At 2+ years old, internal tibial torsion is the underlying reason.

If still present after 6 years of age, a combination causes may be likely.

Normal adolescent development should see this process complete between the ages of 8 and 10 years old. Trochanteric Prominence Angle Test or Craig's Test Lye the patient prone and with the knee flexed to 90° Measure angle of anteversion The patient will prefer sitting in the 'W' Position Does the patella internally rotate when standing or during gait. Gait Analysis Rearfoot Adduction, Forefoot Abduction and Excessive Pronation Internally rotated pattella at mid-stance Abductory Twist at Toe-off Lye the patient in a supine position

Palpate the femoral condyles, ensuring the patella is parallel to the couch.

Place the foot in Subtalar neutral and draw along the transmalleolar axis.

Using a gornimeter measure the angle made by the line draw and the couch.

Adolescents should have approx. 15° of external rotation by the age of 8 - 10 years old. The forefoot is adducted and the lateral border may appear convex.

Draw a bisector line along the plantar surface of the foot.

Check if the calcaneal bisectors distal edge points lateral of the 3rd toe. Assessing Metatarsus Adductus Treatments Differential Diagnoses Metatarsus Adductus
Femoral Anteversion
Internal Tibial Torsion
Cerebal Palsy Anti-pronatory orthoses can reduce tripping and prevent compensatory damage to the feet.

Gait plates (orthoses designed to limit transverse plane abnormalities) resulted in a significant reduction in the amount of intoeing and reduced the frequency of tripping.

Exercise - Strengthen Internal Rotators of the Hip

Spiral Thigh Brace Conservative Options: Orthotic Prescription Recommendations Polypropylene Shel: Semirigid with gait plate extension
The shell of the orthosis extends past the 4th and 5th metatarsal heads, making it necessary for the child to externally rotate their lower extremity and abduct their feet in order to propel forward.

Standard Heel Cup: If the RCSP is everted, prescribe a deep heel cup to control rearfoot eversion

Wide Width: A wider width through the arch increases the surface area under the arch to provide additional support of the mid-foot.

Neutral Rear-foot Post: The rearfoot post stabilizes the orthosis inside the shoe Is Surgery Necessary? No harm done in waiting!

Importance of distinguishing between what is abnormal and what is not average!

Procedures Available:
Femoral Derotational Osteotomy
Muscle Tendon Lengthening QUESTION? References: Bibliography: The Spiral Thigh Brace Clamshell Exercise Redmond AC. The effectiveness of gait plates in controlling in-toeing symptoms in young children. J Am Podiatr Med Assoc. Feb;90(2):70-6, 2000

Li YH and Leong JCY. Intoeing gait in children. HKML. Dec; Volume 5(4); 360-6, 1999

Gelberman RH, Cohen MS, Desai SS, Griffin PP, Salmon PB and TM O'Brien. Femoral anteversion. A clinical assessment of idiopathic intoeing gait in children. The Bone & Joint Journal. January 1987 vol. 69-B(1); 75-9.

Braten M, Terjesen T and I Rossvoll. Torsional Deformity After intramedullary nailing of femoral shaft fractures. J Bone Joint Surgery Br. September 1993, vol 75-B(5); 799-803.

Eyadah A and M Ivanova. Methods for Measurement of Tibial Torsion. The Kuwait Medical Journal, March 2001, 33(10; 3-6.

Wheeless C, MD. Metatarsus Adductus. Duke Orthopaedics presents Wheeless' Textbook of Orthopaedics. Last Updated 04/25/12 at 15:45. Accessed January 2nd 2013 at 19:50. Website URL: http://www.wheelessonline.com/ortho/metatarsus_adductus

Souder C. Femoral Anteversion. Last Updated:07/24/12 at 21:45. Accessed January 3rd 2013 at 19:47.
Website URL: http://www.orthobullets.com/pediatrics/4059/femoral-anteversion

Pathology Specific Orthoses. Prolab Orthotics Evidence Based Medicine. Accessed January 3rd 2013 at 20:36.
Website URL: http://www.prolaborthotics.com/Products/PathologySpecificOrthoses/IntoeingGait/tabid/174/Default.aspx C Thompson. A guide for HIP Surgery in children with Cerebral Palsy. Department of Orthopaedic Surgery. 2010. Accessed January 4th 2013 at 20:00.
Website URL: http://childrenshospital.org/clinicalservices/Site1166/Documents/CP.LE.Book.web2.pdf

Images sourced from Google images, between Jan 2nd - 6th 2013.

Videos courtesy of YouTube, accessed Jan 2nd - 6th 2013. Physiology - Internal vs External Rotators External Rotators of the Femur at the Hip Gluteus Maximus
Gemellus Superior & Inferior
Obturator Internus & Externus
Quad. Femoris
Ischiofemoral Ligaments Tensor Fascia Latae
Gluteus Medius & Minimus
Iliofemoral Ligaments
Pubofemoral Ligament
Iliofemoral Ligaments Internal Rotators of the Femur at the Hip
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