Knock Knees & Pigeon Toes
Rotational and Angular
Deformities in Children
February 9th 2012
Lauren Cochran MD
To-Do
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Search PREP for more questions?
Email Myra to ensure no Mac-to-PC glitches?
Summary slide / reasons to refer
Clean up references slide
Objectives
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To review the common causes of intoeing &
outtoeing in children
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To describe the progression of normal physiologic
alignment over time & how to evaluate a child with
genu varum or genu valgum
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To describe the physical examination techniques
used in assessing rotational and angular deformities
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To review indications for imaging and/or
Orthopedics referral
4 Categories
of Lower Extremity Problems
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Rotational Deformities
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Angular Deformities
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Intoeing (“Pigeon Toes”)
Outtoeing
Genu Varum (“Bow legs”)
Genu Valgum (“Knock knees”)
Foot Deformities (e.g., clubfoot & pes planus)
Hip Disorders (e.g., DDH & SCFE)
Intoeing
Intoeing
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Often raised as concern by parents
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Sometimes associated with tripping/falling
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Possible origin:
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Foot = metatarsus adductus
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Between knee & ankle = internal tibial torsion
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Between hip & knee = medial femoral torsion
Metatarsus Adductus
Metatarsus Adductus (MTA)
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“Packaging Defect” (1st born children at higher risk)
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Tarsal & phalangeal bones angled toward midline
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+ convex lateral curvature of foot
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+ medial instep crease
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Evaluation includes:
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Degree of adduction (heel bisector)
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Degree of flexibility
Metatarsus Adductus
Heel Bisectors
Heel Bisectors
Metatarsus Adductus
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Heel bisector (quantifies degree of adduction):
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Normal: between 2nd/3rd toes
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Mild MTA: 3rd toe
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Moderate MTA: 3rd/4th toe
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Severe MTA: 4th/5th toe
Metatarsus Adductus
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Degree of Flexibility  determines need for
treatment!
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Actively correctable: tickle foot on lateral
border  no treatment required
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Passively correctable: gentle lateral
pressure to 1st metatarsal head  “stretching”
10sec per foot x5 with each diaper change 
REFER if not corrected by 4-6mo
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Rigid: REFER for possible casting/bracing
Metatarsus Adductus
Wheaton Brace
Metatarsus Adductus & DDH?
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Previously reported association between
MTA & DDH  now disputed
Still warrants careful hip exam
What Metatarsus Adductus
is NOT…
Clubfoot
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aka talipes equinovarus
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Constellation of metatarsus adductus PLUS:
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Equinus positioning = inability to dorsiflex foot
(shortening of gastroc/soleus & tendon)
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Hindfoot varus (supination)
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Inversion of the forefoot
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Warrants early referral to Orthopedist
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Famous athletes with clubfoot: Troy Aikman,
Kristi Yamaguchi, Mia Hamm
Clubfoot
Where’s the Intoeing Origin?
Internal Tibial Torsion
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Origin of intoeing between knee & ankle
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Most common intoeing etiology for children less
than 3yrs
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“Packaging defect”  present from birth but often
noticed only when child begins to stand/walk
Almost never requires treatment:
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Most cases gradually resolve by age 2-3yrs
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REFER if persists beyond age 6
Where’s the Intoeing Origin?
Medial Femoral Torsion
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Origin of intoeing between hip & knee
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aka “femoral anteversion” but to a pathologic degree
(> 60-65)
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Most common intoeing etiology for children
older than 3yrs
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Associated with “W sitting position” (unclear effect
on progression/outcome)
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“Egg beater” or “windmill” running pattern
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Almost always corrects gradually by age 10
Medial Femoral Torsion
W Sitting Position
“Kissing Patellae”
Tibial Torsion vs.
Femoral Torsion
Intoeing: H&P
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HPI: onset, progression, pain, disability, previous
evaluation/treatment
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Development: particularly gross motor milestones
including walking
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General screening exam:
• Growth parameters
• Evaluation for DDH (Ortolani/Barlow, Galeazzi, skin
fold asymmetry)
• Basic neurological exam (UE+LE reflexes, ankle
clonus, heel/toe walking)
Intoeing: “Rotational Profile”
1. Foot progression angle
2. Heel bisector
3. Thigh foot angle
4. Hip rotation
Foot Progression Angle
Foot Progression Angle
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Normal = -5 to +20
Mild intoeing: -5 to -10
Moderate intoeing: -10 to -15
Severe intoeing: > -15
Heel Bisector
The V-Finger Test
Thigh Foot Angle
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Patient prone with knees
flexed to 90 degrees + natural
foot position
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Line down center of thigh to
heel bisector
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Normal = 0 to +10-15
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Negative = internal tibial
torsion
Thigh Foot Angle
Thigh Foot Angle
Thigh Foot Angle
Hip Rotation
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Child is prone with knees flexed to 90
Assess both sides simultaneously
Normal (varies by age): ~-45 to +45
Hip Rotation
Hip Rotation
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If asymmetric  get XR (AP pelvis AP) to
evaluate for DDH or other hip problem
Increased internal rotation > 60-65 = femoral
anteversion
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> 80  = moderate
> 90  = severe
Hip Rotation
Ortho Referrals for Intoeing
Benefits of Intoeing?
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Some evidence that persistent intoeing is actually
beneficial for some sports that require quick
directional shifts:
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Tennis
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Basketball
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Soccer
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Etc.
Outtoeing
Outtoeing
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Much less common than intoeing
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Origin:
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Foot: Calcaneovalgus deformity
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Between knee & ankle: External tibial torsion
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Between hip & knee: Femoral retroversion
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Hip: External rotation contracture
Most cases resolve within first 1-2yrs of
ambulation
Calcaneovalgus Foot
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Hyperdorsiflexion of foot
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Abduction of forefoot
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Forefoot often rests on anterior surface of leg
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REFER for casting if foot cannot be plantarflexed below neutral
Calcaneovalgus Foot
Calcaneovalgus Foot
External Tibial Torsion
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Thigh foot angle > +20
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Possible compensation for
femoral anteversion
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REFER for severe cases
(> 40)
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REFER if persistent > age
6yrs
External Tibial Torsion
Femoral Retroversion
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Rare cause of outtoeing
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Characterized by increased external rotation
(and decreased internal rotation) at the hip
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Associated with obesity
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Possibly associated with osteoarthritis, stress
fractures, and SCFE
External Rotation Contracture
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Normal intrauterine position = flexed and
externally rotated hips
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May result in external rotation contracture
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Usually resolves spontaneously by 12
months of age (or when child begins to walk)
Angular Deformities
Genu Varum
Genu Valgum
Mnemonics
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Varus = “vAIRus” (more air between the legs)
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Valgus Gum (knees stick together)
Normal Progression
Normal Progression
Normal Progression
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Birth: genu varum  improves by age 2
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Age 3: genu valgum  improves by age 6-7
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Can monitor over time with distance between
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knees w/ ankles together (genu varum)
ankles w/ knees together (genu valgum)
Monitoring Varus/Valgus
Deformities
Measurement: Genu _____
When to Work Up
and/or Refer?
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Asymmetry (or Unilateral)
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Associated with pain
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Associated with short stature
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Associated with poor nutrition
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Progression defers from expected
NOT Physiologic Genu Varum…
Blount Disease
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Pathologic varus deformity due to disruption of normal
cartilage at the proximal tibial physis (medial aspect)
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Infantile & adolescent types
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Differentiate from physiologic genu varum based on:
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Atypical age/progression
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Asymmetry
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“Lateral thrust” with ambulation
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Focal angulation at proximal tibia
Risk factors: early walking, obesity, African American
heritage, + family history
If any doubt  get an x-ray!
Blount Disease
Blount Disease
NOT Physiologic Genu Valgum…
Rickets
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Deficient growth plate mineralization associated
with insufficient Ca/Phos
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Differentiate from physiologic genu valgum or
genu varum based on:
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Atypical age/progression
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Short stature (<10%ile for age)
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Poor nutrition
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Associated findings like frontal bossing, craniotabes,
costochondral swelling (aka rachitic rosary), wrist
widening
PREP Question #1
You are seeing a child born at home for the first time
at his 2-week health supervision visit. The mother’s
primary concern is the shape of her son’s foot. The
best maneuver to differentiate metatarsus adductus
from clubfoot is to:
a)
b)
c)
d)
e)
Abduct the forefoot
Compare the appearance of the feet
Dorsiflex the ankle
Look for a transverse crease on the plantar surface
Tickle along the lateral aspect of the foot
PREP Question #1
You are seeing a child born at home for the first time
at his 2-week health supervision visit. The mother’s
primary concern is the shape of her son’s foot. The
best maneuver to differentiate metatarsus adductus
from clubfoot is to:
a)
b)
c)
d)
e)
Abduct the forefoot
Compare the appearance of the feet
Dorsiflex the ankle
Look for a transverse crease on the plantar surface
Tickle along the lateral aspect of the foot
PREP Question #2
A 5-year-old girl continues to “intoe,” although this has
no impact on her level of activity or function and she is
otherwise healthy. The most likely cause for this
condition is:
a)
b)
c)
d)
e)
Femoral anteversion
Malignant malalignment syndrome
Metatarsus adductus
Talipes equinovarus
Tibial torsion
PREP Question #2
A 5-year-old girl continues to “intoe,” although this has
no impact on her level of activity or function and she is
otherwise healthy. The most likely cause for this
condition is:
a)
b)
c)
d)
e)
Femoral anteversion
Malignant malalignment syndrome
Metatarsus adductus
Talipes equinovarus
Tibial torsion
PREP Question #3
A 3-year old girl is “bowlegged,” and because her
mother is certain that it is getting worse, she requests
an immediate radiograph. The finding that would best
support the parent’s request is:
a)
b)
c)
d)
e)
A “bowlegged” appearance at birth
A normal sequence of achieving motor milestones
A symmetric appearance to the lower extremities
The absence of pain in the lower extremities
The natural history of angular deformities in the lower
extremities
PREP Question #3
A 3-year old girl is “bowlegged,” and because her
mother is certain that it is getting worse, she requests
an immediate radiograph. The finding that would best
support the parent’s request is:
a)
b)
c)
d)
e)
A “bowlegged” appearance at birth
A normal sequence of achieving motor milestones
A symmetric appearance to the lower extremities
The absence of pain in the lower extremities
The natural history of angular deformities in the lower
extremities
PREP Question #4
Which of the following is a characteristic of metatarsus
adductus?
a)
b)
c)
d)
e)
Hindfoot equinus deformity
Hindfoot varus deformity
Hindfoot valgus deformity
Lateral deviation of the forefoot
Medial crease of the instep
PREP Question #4
Which of the following is a characteristic of metatarsus
adductus?
a)
b)
c)
d)
e)
Hindfoot equinus deformity
Hindfoot varus deformity
Hindfoot valgus deformity
Lateral deviation of the forefoot
Medial crease of the instep
PREP Question #5
A 7-year-old girl is brought to your clinic for in-toeing that has
persisted since she was about 3 years of age. She frequently
sits in a “W” pattern on the floor while watching television.
Physical examination reveals markedly increased internal
rotation of the hips while prone. Which of the following
statements regarding his girl’s condition is true?
a)
b)
c)
d)
e)
Computed tomography scan is indicated to confirm the diagnosis
She is at high risk of developing osteoarthritis of the hips later in life
She likely will be able to participate in spots without difficulty
She should begin wearing medial pads in her shoes to correct the
in-toeing
The in-toeing likely is due to a dietary deficiency
PREP Question #5
A 7-year-old girl is brought to your clinic for intoeing that has
persisted since she was about 3 years of age. She frequently
sits in a “W” pattern on the floor while watching television.
Physical examination reveals markedly increased internal
rotation of the hips while prone. Which of the following
statements regarding his girl’s condition is true?
a)
b)
c)
d)
e)
Computed tomography scan is indicated to confirm the diagnosis
She is at high risk of developing osteoarthritis of the hips later in life
She likely will be able to participate in spots without difficulty
She should begin wearing medial pads in her shoes to correct the
in-toeing
The in-toeing likely is due to a dietary deficiency
PREP Question #6
You are evaluating an 18-month-old boy whose mother thinks he is
“pigeon-toed”. He began walking at 12 months and walks well, but
in-toeing is noted on examination. Range of motion at the hips,
knees, and ankles is normal. Which of the following is the most
likely cause of his gait disturbance?
a)
b)
c)
d)
e)
Blount disease
Femoral anteversion
Internal tibial torsion
Metatarsus adductus
Pes planus
PREP Question #6
You are evaluating an 18-month-old boy whose mother thinks he is
“pigeon-toed”. He began walking at 12 months and walks well, but
in-toeing is noted on examination. Range of motion at the hips,
knees, and ankles is normal. Which of the following is the most
likely cause of his gait disturbance?
a)
b)
c)
d)
e)
Blount disease
Femoral anteversion
Internal tibial torsion
Metatarsus adductus
Pes planus
Summary?
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Most intoeing, outtoeing, knock knees, and
bow legs are NORMAL & require only
reassurance and observation
BUT… don’t want to miss clubfoot, DDH, CP,
rickets, Blount disease
Systemic approach to exam
Reasons to Refer
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Rigid metatarsus adductus, which may require serial casting (refer to pediatric
orthopedic surgeon or an orthopedic surgeon with expertise in rotational
problems)
Unilateral or asymmetric in-toeing associated with clinical findings suggestive
of neurologic disorder (refer to a pediatric orthopedic surgeon, pediatric
neurologist, or physical medicine and rehabilitation specialist)
Children ≥8 years with activity limiting or cosmetically unacceptable in-toeing
due to internal tibial torsion (may be candidates for derotational osteotomy; refer
to an orthopedic surgeon with expertise in rotational problems)
Children ≥11 years with activity limiting or cosmetically unacceptable in-toeing
due to increased femoral anteversion (may be candidates for derotational
osteotomy; refer to an orthopedic surgeon with expertise in rotational problems)
In-toeing that does not follow the expected course (eg, increased femoral
anteversion that progresses after age five or six years) [16] (refer to pediatric
orthopedic surgeon or an orthopedic surgeon with expertise in rotational
problems)
References
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Scherl SA. Common lower extremity problems in
children. Pediatr Rev. 2004;25(2):52-62.
Smith BG. Lower extremity disorders in children and
adolescents. Pediatr Rev. 2009;30(8):287-301.
Grottkau BE. Intoeing, outtoeing, and limping:
making sense of common pediatric gait
abnormalities.
UpToDate: Lower extremity positional deformations;
Approach to the child with in-toeing; Approach to the
child with outtoeing; Approach to the child with bow
legs
Thank You!