1. Rotational and Angular Deformities in Children
Knock Knees & Pigeon Toes
Rotational and Angular Deformities in Children
February 9th 2012
Lauren Cochran MD

2. To-Do Search PREP for more questions?
Myra to ensure no Mac-to-PC glitches?
Summary slide / reasons to refer
Clean up references slide

3. Objectives
To review the common causes of intoeing & outtoeing in children
To describe the progression of normal physiologic alignment over time & how to evaluate a child with genu varum or genu valgum
To describe the physical examination techniques used in assessing rotational and angular deformities
To review indications for imaging and/or Orthopedics referral

4. 4 Categories of Lower Extremity Problems
Rotational Deformities
Intoeing (“Pigeon Toes”)
Outtoeing
Angular Deformities
Genu Varum (“Bow legs”)
Genu Valgum (“Knock knees”)
Foot Deformities (e.g., clubfoot & pes planus)
Hip Disorders (e.g., DDH & SCFE)

5. Intoeing

6. Intoeing Often raised as concern by parents
Sometimes associated with tripping/falling
Possible origin:
Foot = metatarsus adductus
Between knee & ankle = internal tibial torsion
Between hip & knee = medial femoral torsion

7. Metatarsus Adductus

8. Metatarsus Adductus (MTA)
“Packaging Defect” (1st born children at higher risk)
Tarsal & phalangeal bones angled toward midline
+ convex lateral curvature of foot
+ medial instep crease
Evaluation includes:
Degree of adduction (heel bisector)
Degree of flexibility

9. Metatarsus Adductus

10. Heel Bisectors

11. Heel Bisectors

12. Metatarsus Adductus Heel bisector (quantifies degree of adduction):
Normal: between 2nd/3rd toes
Mild MTA: 3rd toe
Moderate MTA: 3rd/4th toe
Severe MTA: 4th/5th toe

13. Metatarsus Adductus
Degree of Flexibility  determines need for treatment!
Actively correctable: tickle foot on lateral border  no treatment required
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
Rigid: REFER for possible casting/bracing

14. Metatarsus Adductus

15. Wheaton Brace

16. Metatarsus Adductus & DDH?
Previously reported association between MTA & DDH  now disputed
Still warrants careful hip exam

17. What Metatarsus Adductus is NOT…

18. Clubfoot aka talipes equinovarus
Constellation of metatarsus adductus PLUS:
Equinus positioning = inability to dorsiflex foot (shortening of gastroc/soleus & tendon)
Hindfoot varus (supination)
Inversion of the forefoot
Warrants early referral to Orthopedist
Famous athletes with clubfoot: Troy Aikman, Kristi Yamaguchi, Mia Hamm

19. Clubfoot

20. Where’s the Intoeing Origin?
Internal Tibial Torsion

21. Internal Tibial Torsion
Origin of intoeing between knee & ankle
Most common intoeing etiology for children less than 3yrs
“Packaging defect”  present from birth but often noticed only when child begins to stand/walk
Almost never requires treatment:
Most cases gradually resolve by age 2-3yrs
REFER if persists beyond age 6

22. Where’s the Intoeing Origin?

23. Medial Femoral Torsion
Origin of intoeing between hip & knee
aka “femoral anteversion” but to a pathologic degree (> 60-65)
Most common intoeing etiology for children older than 3yrs
Associated with “W sitting position” (unclear effect on progression/outcome)
“Egg beater” or “windmill” running pattern
Almost always corrects gradually by age 10

24. Medial Femoral Torsion

25. W Sitting Position

26. “Kissing Patellae”

27. Tibial Torsion vs. Femoral Torsion

28. Intoeing: H&P
HPI: onset, progression, pain, disability, previous evaluation/treatment
Development: particularly gross motor milestones including walking
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)

29. Intoeing: “Rotational Profile”
Foot progression angle
Heel bisector
Thigh foot angle
Hip rotation

30. Foot Progression Angle

31. Foot Progression Angle
Normal = -5 to +20
Mild intoeing: -5 to -10
Moderate intoeing: -10 to -15
Severe intoeing: > -15

32. Heel Bisector

33. The V-Finger Test

34. Thigh Foot Angle
Patient prone with knees flexed to 90 degrees + natural foot position
Line down center of thigh to heel bisector
Normal = 0 to 
Negative = internal tibial torsion

35. Thigh Foot Angle

36. Thigh Foot Angle

37. Thigh Foot Angle

38. Hip Rotation Child is prone with knees flexed to 90
Assess both sides simultaneously
Normal (varies by age): ~-45 to +45

39. Hip Rotation

40. Hip Rotation
If asymmetric  get XR (AP pelvis AP) to evaluate for DDH or other hip problem
Increased internal rotation > 60-65 = femoral anteversion
> 80  = moderate
> 90  = severe

41. Hip Rotation

42. Ortho Referrals for Intoeing

43. Benefits of Intoeing?
Some evidence that persistent intoeing is actually beneficial for some sports that require quick directional shifts:
Tennis
Basketball
Soccer
Etc.

44. Outtoeing

45. Outtoeing Much less common than intoeing Origin:
Foot: Calcaneovalgus deformity
Between knee & ankle: External tibial torsion
Between hip & knee: Femoral retroversion
Hip: External rotation contracture
Most cases resolve within first 1-2yrs of ambulation

46. Calcaneovalgus Foot Hyperdorsiflexion of foot Abduction of forefoot
Forefoot often rests on anterior surface of leg
REFER for casting if foot cannot be plantar- flexed below neutral

47. Calcaneovalgus Foot

48. Calcaneovalgus Foot

49. External Tibial Torsion
Thigh foot angle > +20
Possible compensation for femoral anteversion
REFER for severe cases (> 40)
REFER if persistent > age 6yrs

50. External Tibial Torsion

51. Femoral Retroversion Rare cause of outtoeing
Characterized by increased external rotation (and decreased internal rotation) at the hip
Associated with obesity
Possibly associated with osteoarthritis, stress fractures, and SCFE

52. External Rotation Contracture
Normal intrauterine position = flexed and externally rotated hips
May result in external rotation contracture
Usually resolves spontaneously by 12 months of age (or when child begins to walk)

53. Angular Deformities

54. Genu Varum
Physiologic

55. Genu Valgum
Physiologic

56. Mnemonics Varus = “vAIRus” (more air between the legs)
Valgus Gum (knees stick together)

57. Normal Progression

58. Normal Progression

59. Normal Progression Birth: genu varum  improves by age 2
Age 3: genu valgum  improves by age 6-7
Can monitor over time with distance between
knees w/ ankles together (genu varum)
ankles w/ knees together (genu valgum)

60. Monitoring Varus/Valgus Deformities

61. Measurement: Genu _____

62. When to Work Up and/or Refer?
Asymmetry (or Unilateral)
Associated with pain
Associated with short stature
Associated with poor nutrition
Progression defers from expected

63. NOT Physiologic Genu Varum…

64. Blount Disease
Pathologic varus deformity due to disruption of normal cartilage at the proximal tibial physis (medial aspect)
Infantile & adolescent types
Differentiate from physiologic genu varum based on:
Atypical age/progression
Asymmetry
“Lateral thrust” with ambulation
Focal angulation at proximal tibia
Risk factors: early walking, obesity, African American heritage, + family history
If any doubt  get an x-ray!

65. Blount Disease

66. Blount Disease
“beak” appearance of medial tibia

67. NOT Physiologic Genu Valgum…

68. Rickets
Deficient growth plate mineralization associated with insufficient Ca/Phos
Differentiate from physiologic genu valgum or genu varum based on:
Atypical age/progression
Short stature (<10%ile for age)
Poor nutrition
Associated findings like frontal bossing, craniotabes, costochondral swelling (aka rachitic rosary), wrist widening
Age of child determines type of LE deformity associated w/ rickets (exaggeration of physiologic pattern)

69. 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:
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

70. 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:
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

71. 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:
Femoral anteversion
Malignant malalignment syndrome
Metatarsus adductus
Talipes equinovarus
Tibial torsion

72. 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:
Femoral anteversion
Malignant malalignment syndrome
Metatarsus adductus
Talipes equinovarus
Tibial torsion

73. 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 “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

74. 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 “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

75. PREP Question #4
Which of the following is a characteristic of metatarsus adductus?
Hindfoot equinus deformity
Hindfoot varus deformity
Hindfoot valgus deformity
Lateral deviation of the forefoot
Medial crease of the instep

76. PREP Question #4
Which of the following is a characteristic of metatarsus adductus?
Hindfoot equinus deformity
Hindfoot varus deformity
Hindfoot valgus deformity
Lateral deviation of the forefoot
Medial crease of the instep

77. 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?
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

78. 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?
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

79. 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?
Blount disease
Femoral anteversion
Internal tibial torsion
Metatarsus adductus
Pes planus

80. 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?
Blount disease
Femoral anteversion
Internal tibial torsion
Metatarsus adductus
Pes planus

81. Summary?
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

82. Reasons to Refer
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)

83. References
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):
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

84. Thank You!