MEASURE, REASSURE AND REVIEW - BRACES AND SPECIAL SHOES ARE NOT NEEDED
Intoeing - StatPearls (NCBI Bookshelf NBK499993) - https://www.ncbi.nlm.nih.gov/books/NBK499993/
Almost all of this corrects itself, and the harm in clinic is spending a family's money on shoes and braces that the evidence does not support. There is no medicine, so no dose is printed. The card carries the timelines to quote to a worried parent and the short list of findings that are not a normal variant.
- OBSERVATION IS THE TREATMENT - most of these children are managed by watching, and by reassuring the parents. Special shoes, orthotics, braces and physiotherapy are held back for the cases that will not settle. Said plainly to families: reassure them about how the lower limb normally develops, and note that none of those interventions is advised where the finding is benign.
- DISPEL THE TWO MYTHS BY NAME - the myths to put down are that sleeping face-down with the hips and knees bent, or sitting in the W position, makes the deformity worse. Parents are told the opposite constantly; say it explicitly.
- THE TIMELINES TO QUOTE - metatarsus adductus is the first to go, some 90% of it resolved by the age of 1 year. Internal tibial torsion usually settles somewhere between 4 and 7 years. Femoral anteversion is the slowest: from roughly 30° at birth it falls away by degrees to the adult range of about 10° to 15°, reached between 8 and 10 years, and whatever deformity is left at that point is permanent. Where the metatarsus adductus is flexible, expect it gone by the age of 2 years; if it does persist it usually causes no symptoms.
- WHAT ACTUALLY EARNS A REFERRAL - refer where any one of these is present: a measurement lying more than 2 standard deviations outside the reference range, pain, or function that is abnormal. Pain in a child's foot, or a limp that limits play, is never a normal rotational variant. A metatarsus adductus that is rigid and severe, with no flexibility left in it, is referred for serial casting.
- IMAGING IS ALMOST NEVER NEEDED - the diagnosis is a clinical one, and where the problem is expected to improve with growth there is little call for imaging. X-rays earn their place only where surgery is in prospect for a severe metatarsus adductus, or where a tibial or femoral condition is suspected and has to be confirmed.
- THE HIP IS THE MISS - keep developmental dysplasia of the hip (DDH) in the differential, above all in an infant carrying the risk factors: a family history, a breech presentation, and being female. What separates them is that DDH disturbs how the hip sits and how stable it is, whereas the femoral causes of intoeing are a matter of rotational alignment alone and leave stability intact. DDH can accompany a metatarsus adductus, and it can equally turn up on its own.
- THINGS THAT TRAVEL TOGETHER - metatarsus adductus is put down to how the baby lay in the womb, and the other conditions that come of the same cause are developmental dysplasia of the hip - usually on both sides - and torticollis. A baby with a twisted foot deserves a look at the neck and the hips.
- CLUBFOOT IS A DIFFERENT ANIMAL - it is a deformity of several parts at once, taking in plantarflexion (cavus), a metatarsus adductus with the forefoot in valgus, a hindfoot in varus, and equinus at the foot and ankle - the mnemonic is CAVE. It is rigid and it needs orthopaedics from birth, not review in a year.
- AND SO ARE THE NEUROLOGICAL CAUSES - where something else underlies it, the causes named are skew foot, an overactive abductor hallucis, a coalition, stroke, cerebral palsy and the neuromuscular diseases. Asymmetry, spasticity, or a child who was walking normally and changed, is not a developmental variant.
- WHAT TO TELL THEM ABOUT THE FEET STRAIGHTENING - with tibial torsion, reassure the family that internal angles run large while the child is still developing. By 4 years of age most children have come to neutral, or to external rotation.
- REVIEW IS THE FOLLOW-UP, AND IT IS ACTIVE - what carries the treatment is seeing the child regularly in primary care, to observe and to reassure the family, and the advice given to the parents is backed up by measuring clinically at each visit. Writing the measurement down every time is what makes the next reassurance believable.
- FLAT FEET: FIND OUT WHETHER THE ARCH COMES BACK - a flexible pes planus has an arch when the foot is off the ground, which flattens out as soon as it takes weight, and testing the range of movement is what tells the flexible foot from the rigid one. Look from behind as well: from there you may see the too many toes sign, and the heel in valgus. (Pes Planus, NBK430802.)
- FLAT FEET RARELY NEED ANYTHING, AND INSOLES ARE FOR PAIN - a child seldom comes to surgery for pes planus. Where the flat foot hurts, an orthotic is usually what is tried first, whether the pain is in the foot alone or reaches the leg, the knee and the back as well. So an insole treats a symptom; it does not reshape the foot. The rigid foot is the one that goes on: surgery may be called for in a rigid pes planus, in tarsal coalition, and in a pes planus that is getting worse and causing symptoms. (Pes Planus, NBK430802.)
- KNOCK KNEES: THE AGE AND THE ANGLE DECIDE - most of these children are brought in between the ages of 3 and 5, which is when the knock-kneed look starts to worry parents. Observation is what is called for in a physiological genu valgum, or where the tibiofemoral angle is under 15 degrees in a child under 6 years. Bracing is generally not indicated for genu valgum at all. Physiological genu valgum, and Cozen's phenomenon, nearly always right themselves. (Genu Valgum, NBK559244.)
- KNOCK KNEES THAT ARE NOT PHYSIOLOGICAL - one-sided is the loud one: a genu valgum on one side alone most often follows injury to the physis or the metaphysis. Two-sided but pathological is the quiet one: valgus on both sides can also arise from a skeletal dysplasia, spondyloepiphyseal or chondroectodermal (Ellis van Creveld syndrome); from a metabolic bone disease such as rickets, whether of renal osteodystrophy or hypophosphataemic; or from a lysosomal storage disease such as Morquio syndrome. In Cairo that puts nutritional rickets high on the list - see that entry. (Genu Valgum, NBK559244.)
- THE FAMILY HAS ALREADY READ THE INTERNET - the musculoskeletal complaints, intoeing, genu varum and clubfoot among them, were among the topics looked up online most of all before an orthopaedic appointment. And the family may well know the treatments once used for intoeing: bracing, orthotics, alterations to the shoe, and splinting at night. Expect to argue against a brace someone has already promised them.