Conservative Management of Intoeing in young children. A review of the evidence
Joan Glover
Lynn Purves
As we looked at common questions about best practice in our field, The Early
Intervention physiotherapists put forward the topic of conservative management of
intoeing including clarification of best assessment, and treatment. We often receive
referrals of preschool children who intoe, with or without other mild developmental
gross motor problems. We excluded children with cerebral palsy from this search, as
intoeing, in that case, may be related to a specific muscle imbalance and motor
pathology
The search Several search engines were used: Pub Med, CINAHL, OVID, and
Cochrane. Search topics included:
 Intoeing
 Femoral anteversion
 Tibial torsion
 Hip rotation
 Forefoot adduction
 Physiotherapy
 Conservative management
With a variety of combinations of search topics there were over 900 article
titles found. Many were repetitions.
Inclusion criteria; The abstracts were reviewed for content:
 article related to intoeing in children
 includes information re assessment of above
 includes information re causes/incidence natural history of above
 includes information re conservative management of above
 limited to publications from 1990 or later
Exclusion criteria: The abstracts were reviewed for content. The following
were excluded:
 Article predominantly related to children with a specific pathology;
cerebral palsy, spina bifida, slipped capital epiphysis, Legge Perthes
disease
 Surgical intervention
 Related to assessment of newborn (There is a large body of literature
related to newborn foot anomalies and their assessment and treatment
which would require a whole EBP study)
DATES: The search was conducted between Oct 22 2008 and March 19 2009
1990 or later
Two therapists chose the more recent review articles that seemed relevant to
our large question of conservative management. They were mostly in the field of
orthopedics. Two were in physiotherapy, No comprehensive reviews were found
however there were several recent summary articles that included a large reference
list of most of the articles we had found and some referred to the levels of evidence
as weak fair or strong, as well as differences in findings or in expert opinion.
Reference lists from these key references were hand searched
These articles were reviewed, some by two physiotherapists. Main initial findings were
presented/discussed at EIP PT meeting in Nov 2008 and some further questions raised
especially around femoral torsion ,nomenclature, and its measurement.
The following information was summarized from those chosen reviews.
OVERVIEW: THE CHILD WHO INTOES:
INCIDENCE;
Many publications refer to the huge number of referrals of children who intoe
to orthopaedic clinics or doctors with only a small number requiring treatment (1,2,3,7).
For example Karol (3) reports 720 referrals to an orthopedic clinic re intoeing, only one
child required surgical intervention during that time period)
A recent Turkish study by Altinel (5) found that 5.9% of their population (1000
children aged 3 to 6) intoed. 63% of the children who intoed preferred to w-sit. The
girl/boy ratio was 2.4/1. In 75% the intoeing was from femoral origin, in 25% from
tibial origin. Gulan reports that 30% of 4 year olds intoe compared to 4% of adults.
ASSESSMENT
Observe /ask about sitting position: especially W-sitting, reverse tailor sitting or
sitting on feet, sleep posture
Birth history
Family history
Pain, tripping, shoe wear
Need to rule out:
 CP,
 slipped capital femoral epiphysis -usually preadolescent hip/groin or knee pain



hip dysplasia ;Karol describes that dysplasia presents with asymmetrical
adduction/ rotation, and a tendency to external rotation but this can be
difficult to assess if bilateral
endocrine, metabolic disease (vitamin D resistant rickets)
There are a lot of references (1,2,3,7) to the fact that referrals of children
who intoe to orthopaedic specialists is a very expensive use of resources for a
group of children who, in most cases, are expected to grow out of it
However it is critical that no child who intoes due to the above slips through
untreated
OBSERVATION
Patella position
 Patella will be facing medially if excessive femoral anteversion
(torsion) exists
 You will likely see “eggbeater run” and W sitting
Staheli’s rotational profile is the most commonly referred to standard of
assessment for children who intoe. It is designed to differentiate between medial
femoral torsion and tibial torsion See Figure 2 (1,3,4,5,6,9)
COMPONENTS OF STAHELI’S ROTATIONAL PROFILE:
Foot Progression Angle (FPA) during gait
The angular difference between the long axis
of the foot and the line of progression
In toeing is given a minus sign, out-toeing a
plus sign
Normal FPA is +10 (range from -3 to +20)
Mild in-toeing = 0 to –10, moderate = -10 to -20, severe greater than
Hip internal/external Rotation Measurement
Flex both knees to 90 and let the legs fall into IR or ER concurrently by
gravity
Hip rotation should be symmetrical. Asymmetrical rotation may be indicative of a
disorder of the hip
Normally medial rotation is less than 70 for girls and about 60 for boys. Higher
values indicate medial femoral torsion:
70 –80 mild
80-90 moderate
more than 90 –severe( Lincoln, Staheli, Cusick)
Thigh-foot angle
To test for Internal/External Tibial Torsion
Measures the angular difference between the axis of the foot
and the axis of the thigh.
Tested in prone with the knee bent to 90. Subtalar and mid
tarsal joints should be neutral viewed from above.
Transmalleollar axis-thigh angle
This axis is between a line perpendicular to a line from the medial to
the lateral malleolus and the axis of the thigh See diagram in
Staheli’s rotational profile
This also tests internal/external tibial torsion but can help to clarify
whether the rotation involves the foot rather than the tibia
Newborns typically have internal tibial torsion. By skeletal maturity, external tibial
torsion of 15 is average.( )
Evaluate the shape of the sole of the foot
Staheli suggests one assesses the projection
of the midline axis of the hindfoot forward to
quantitate forefoot adduction:
 normal between second
and third toe
 mild- along third toe
 moderate-between third
 severe-between fourth
and fifth toes
Lincoln suggests forefoot
adduction may be best
categorized by flexibility as it
correlates better to treatment and prognosis
 flexible forefoot can be abducted beyond heel midline
bisector
 partially flexible-can be abducted to midline
 rigid-cannot be abducted to midline
In-toeing and Development
Metatarusus adductus is commonly seen at birth due to positioning in utero. It
usually resolves by 2 months of age. Sleeping position can contribute to metatarsus
adductus (1)
At age 1-2, in toeing is more often caused by internal tibial torsion. After age 3,
it is usually due to medial femoral torsion
Out-toeing is normal in infancy due to external rotation contractures. In the older
child it is usually due to external tibial torsion and occasionally lateral femoral
torsion. Lateral femoral torsion is more common in children who are obese or with
slipped capital epiphysis
Follow up studies that indicate 80 to 95%resolution of intoeing may include many
children who develop compensations elsewhere, especially in the knee or foot. Many
authors mention “miserable malalignment syndrome” which may cause more
functional problems or knee pain, later in life than femoral or tibial torsion. (1,6,7)
FEMORAL ANTETORSION (ANTEVERSION)
(diagram from Gulan)
Terminology: Femoral antetorsion or
anteversion?
Version and torsion are not identical although they
may occur together. Version describes a position in
space relative to a plane. Torsion describes a twist
in structure.( Cusick 1992)
Terminology is different in different studies and
countries. If the axis of the femoral neck inclines
forward (anterior to transcondylar plane), the angle
of torsion is called anteversion, ante torsion ante
rotation.( Gulan )
Anteversion is normal:
newborns average 30 to 40
5 year old average 26
9 year old average 21
16 yearold average 15
adults about 15 to 20 
If femoral neck angle (FNA) inclines backwards it is
called retroversion. There can be confusion as many
people mistakenly use the term retroversion to describe anteversion below the normal
range.
Gulan reports that the Pediatric Orthopedic Society of North America call a femoral
neck angle above 2 SD of mean for age, medial torsion of the femur .
Cusick suggests that we use the word antetorsion to mean an increased femoral neck
angle(more than normal) and retrotorsion to mean a decreased FNA though it may still
be anteverted.
Many authors use antetorsion, anteversion, medial torsion, medial torsion, increased
femoral neck angle meaning the same thing and will use different words in the same
paragraph (eg Lincoln page 317) You need to read the article carefully to be clear if
the author is discussing anteversion that is outside of normal range (medial torsion).
In most of these articles they are clarifying this though there does not seem to be
consistency, even in new articles
ASSESSMENT OF ANTEVERSION
Anteversion is composed of three components:
-axis of femur,
-axis of femoral neck,
-axis of knee
For accurate measurement of all 3 one would probably need 3 images by CT scan
(as described by Murphy later Mulligan)
There have been many studies correlating measurement of internal and external
rotation with anteversion and it is generally felt to have a high correlation to femoral
neck angle (FNA) with a good degree of accuracy, except in the first 2 to 3 years of
life when there is a hip abduction contracture or if one is measuring in preparation for
an osteotomy when greater accuracy between the 3 components is necessary (i.e. CT
images necessary) (Gulan Cusick))
Hip internal and external rotation
To test for Femoral Anteversion-most authors flex both knees to 90 and let the
legs fall in to internal or external rotation by gravity, applying no overpressure

Infants average 40IR and 70ER (ER contracture)

In children greater than 3 years old there is a strong positive correlation
between measurement of internal rotation and anteversion confirmed in many
studies (4)
Trochanteric Prominence Angle Test (TPAT), Craig test, Ryder’s Test for medial
femoral anteversion
In prone, feel for the greater trochanter and put it in the most lateral
position. Measure the angle of hip internal rotation at
this position (i.e. the line of the tibia against the
vertical). This angle equals the amount of femoral
anteversion.
This is similar to Ryder’s test, which is done in supine as
recommended by Cusick. (6)
Reliability of TPAT has either been not assessed or not reported in reported
studies. There are studies that find TPAT performs well and also studies that
find it performs poorly in predicting femoral neck angle and also that there
was considerable variability in children with CP Cibulka concludes that
”Because physiotherapists do not need a precise FNA angle measurement, I
believe either the TPAT or hip rotation values can be used to help predict
FNA.” (Cibulka)
Treatment of Femoral Anteversion:
Cibulka reported studies (1980 and older) that suggest that habitual sleeping
and sitting positions in which the hip is held at or near the end of medial or lateral
rotation, may produce changes in the FNA .He states that maintaining an extreme hip
posture also produces changes in soft connective tissue, shortening the capsule and
muscle on one side, which will likely create uneven torsional forces on the femur.
He also describes animal studies that may indicate some of the forces that can cause
the femur to twist:
-Muscle forces-resecting rotator muscles can change FNA (animal study)
-Positioning- when animal hind legs held in lat rotation, FNA decreased. If held
in med. Rot. FNA increased
There is a large body of information related to bony change and growth related
to forces placed on the bone. This “thread” was not followed in this study
Almost all articles concur that treatment is unnecessary as the natural history
is that medial torsion increases to age 5, and then resolves by age 8. There is no
evidence that bracing, splints or shoes change the natural history of increased femoral
medial torsion. Several also stress that that twister cables or stresses (Elastic) over
the knee should not be used as they can cause excessive tibiofibular torsion or
(miserable malalignment syndrome)
According to Li and Leong “Intoeing due to excessive femoral anteversion and internal
tibial torsion should not be treated with night splints, twister cables, orthotics, or
special shoes. These methods will not alter the natural course of these conditions.”(2)
Many studies have shown that such interventions have no demonstrable effect on the
natural history.(1)
Cusick published the only review article relating to paediatric physiotherapy for
intoeing. She concluded “No radiological or anatomical studies have documented the
effects of twister cables, antirotation braces, exercises, orthoses, splints or shoes on
the existing degree of femoral or tibial torsion.” Until research proves that exercise
positioning and orthosis offer no benefit, we base our management recommendations on
the principal that the application of correct forces is required for optimum skeletal
modeling before the skeleton ossifies”:
 -Multiple daily repetitions of resisted hip extension and lateral rotation
 -Reduction of hip and knee flexion and hip medial rotation posture in stance and
gait
 -Improvement of lateral and posterior weight shift over the feet
 Use of appropriate foot splints or orthotics, serial casting to reduce effects (if
any) of abnormal pronation
 Does not recommend twister cables because of stresses on the knee
Cibulka suggests that there are studies to suggest that habitual sitting and sleeping
postures in which the hip is held at or near the end of rotation, may produce changes in
femoral neck angle He also reports animal studies in which changes in muscle balance
and capsule cause changes in FNA. He also references studies in children with
hemiplegia that support the notion that asymmetrical position of limbs influences
torsion. (Cibulka)
Staheli suggests that it is “unlikely” that correcting w-sitting will change the course of
the deformity of femoral torsion . Although he offers studies to support that bracing
and shoe wedges have not been shown to be effective, his statement about w-sitting is
offered as his (expert) opinion. (7)
Clinical studies have found no association between medial femoral torsion and
degenerative joint disease. Karol reports it is not linked with arthritis and that in fact
retroversion is more linked to later arthritic changes.(3)
There may be some association with knee pain, in children with concurrent
lateral tibial torsion (miserable malalignment)( 1,2,7)
Surgical intervention may be considered when a child is over 8 with a marked
cosmetic or functional deformity (anteversion>50 internal rotation>80) Waiting allows
the family and Doctors to see if the anteversion decreases naturally which occurs in 80
to 99% of case (1,2,7)
Internal Tibial Torsion
Newborns typically have internal tibial torsion. By skeletal maturity,
external tibial torsion of 15 is average.
Some clinicians claim success with Dennis Browne boots, but
there has been no scientific proof of effectiveness.
Most orthopedic review articles indicate that treatment of
tibial torsion by splinting, shoe modifications, exercise and
bracing has been proven to be ineffective. (1,2,7)
The natural history favours spontaneous resolution by age four.
Long term disability is rare, and some evidence even suggests
that internal tibial torsion can improve a person’s sprinting ability(7)
Surgical treatment (supramalleolar or or proximal tibial rotational osteotomy) is
reserved for children older than eight, with a marked functional or cosmetic
deformity (1)
External Tibial Torsion
Out toeing due to excessive external tibial torsion tends to increase with age and may
cause disability such as patello-femoral pain or instability. It is more likely to be
unilateral with the right side affected. (Lincoln)
Metatarsus Adductus
Metatarusus adductus is commonly seen at birth due to positioning in utero. It
usually resolves by 2 months of age. Sleeping position can contribute to metatarsus
adductus (1)
There is a huge body of literature re the assessment treatment of infant foot
deformities. There is a need to differentiate between metatarsus adductus rigid
metatarsus adductus (metatarsus varus) metatarsus primus varus, hallux abductus
and skewfoot. These are often treated, in infancy by casting, bracing, splinting and
or surgery. This could be a whole EBP search .
REFERENCES
1 Lincoln and Suen, Common Rotational Variations in Children, Journal of
American Academy of Orthopaedic Surgeons, Vol. 11, No.5, 2003 (A review
article, well referenced and refers to clinical trials as weak, medium or strong.
Reports issues where there are different opinions)
2
Li, Y, Leong, J: Intoeing Gait in Children; Hong Kong Medical Journal:5, 360-6:
1999 (A review article, well referenced. Presents same conclusions generally as
Lincoln, Staheli)
3
Karol, Rotational Deformities in the Lower Extremity, Current Opinions in
Pediatrics; 9 77-80 (summary of some review articles, simple overview that
agrees with more complex reviews)
Gulan, Matovinic, Nemic, Rubinic, Javlic-Gulan: Femoral Neck Anteversion:
Values, Development, Measurement, Common Problems. DColl. Antropol. 24 2:
521-527: 2000. (Well-referenced review paper particularly detailed re
assessment nomenclature. Reports controversy and clinical trials but with no
reference to levels of evidence)
Altinel, L, Kose C, Arskoy Y, Cengiz I, Ergan, V, Ozdemeir, A; Hip rotation
degrees, intoeing problem, and sitting habits in nursery school children: an
analysis of 1134 cases, Acta Orthopaedica et Traumatalogica Turcica 41 (3) pp
190-194 2007
Cusick, B, Stulberg W,: Assessment of Lower-Extremity Alignment in the
Transverse Plane: Implications for Management of Children with Neuromotor
Dysfunction: Physical Therapy Volume 72, Number1, Jan 1992 (Only article
found re physiotherapy in children)
Dietz, F Intoeing-Fact Fiction and Opinion: American Family Physician;Volume
30, Number 6Nov 1994 (reports levels of evidence descriptively,
disagreements, RCTs, though references are a bit older)
4
5
6
7
8
9
Cibulka M, Determination and Significance of Femoral Neck Anteversion:
Physical Therapy, Volume 84, Number 6, June 2004, pp550-558 (A
comprehensive physiotherapy review of femoral anteversion, not specific to
pediatric practice. Summarizes animal research that may suggest than hip
muscle weakness and range and positioning may influence femoral rotation)
StaheliL T: Rotational Problems in Children: Bone Joint Surg Am: 75:939-949;
1993 (Thoroughly referenced, discusses weak, medium, strong evidence and
discrepant expert opinions)