In-toe gait

This condition may originate in the foot - metatarsus varus - in the tibia - tibial torsion - or in the femora - persistent anteversion of the femoral neck.

• metatarsus varus (metatarsus adductus)
  • this presents as a twisting inwards of the forefoot occurring in the first few months of life
  • medial border of the forefoot is curved inwards - believed to be a result of overactivity in abductor hallucis
  • management - advise against prone nursing and sleeping, observation; about 85% of cases show spontaneous resolution. If a persistent intoeing occurs then splintage may be beneficial. If after the child reaches the age of 5 years the intoeing is still evident then surgical intervention may be necessary
  • this condition is associated with developmental dysplasia of the hips so this should also be checked for when a child presents with metatarsus varus
• tibial torsion (internal tibial torsion)
  • this condition generally presents in toddlers aged between one and three years
  • most cases resolve spontaneously
  • in a tiny proportion of cases a derotational osteotomy may be indicated
• internal femoral torsion (persistent anteversion of the femoral neck)
  • generally presents in children aged three to ten years
  • a result of an abnormal anteversion of the femoral neck
  • the degree of anteversion of the femoral neck varies from about 40 degrees (when a baby is born) to the degree present in an adult (about 15 degrees). Thus there is a gradual transition from the angle of anteversion a child is born with towards the adult position. If there is a slow transition of this degree of anteversion and the greater degree of anteversion persists into childhood, then the child generally presents with an abnormal gait and symmetrical intoeing
    • the child wil have absent or reduced external rotation of the hip
  • in most cases there will be spontaneous resolution. However if there is complete absence of external rotation then this a poor prognostic sign and increases the likelihood for need for surgical intervention
  • in a small minority of cases a rotational osteotomy will be needed when the child is in his/her teens
  • note that some children will self-compensate via development of external rotation of the tibia so resulting in the child's feet pointing forward normally. In this situation there is a pointing intwards of the patellae (known as the squinting patella syndrome). This condition may be considered cosmetically unattractive but would necessitate extensive osteotomies to correct and may be considered that should not be treated

Reference:

1. GP (April 15th 2005), 67.