🦵 In-Toeing Causes by Age • Infant (<2y): Metatarsus adductus (forefoot adduction) • Toddler (1-3y): Internal tibial torsion (most common cause of in-toeing overall) • Child (>3y): Increased femoral anteversion (medial femoral torsion) • These conditions are benign, self-resolving in vast majority
🦶 Out-Toeing Causes • External tibial torsion (less common) • External femoral torsion (rare, suspect SCFE if unilateral in older child) • Flat feet (pes planus) can give appearance of out-toeing
🦶 Toe-Walking • Idiopathic (habitual) toe walking: <3 years normal, normal neuro exam, passive dorsiflexion >15° • Pathologic toe walking: cerebral palsy (spastic diplegia), muscular dystrophy, tethered cord, autism • Persistent toe walking >3 years requires evaluation
📋 Rotational Profile Measurements • Foot progression angle (gait) • Thigh-foot angle (tibial torsion) • Hip rotation (femoral anteversion): internal/external rotation • Most resolve spontaneously; surgery rarely indicated (residual severe intoeing >10 years)
📌 Decision strategy: In-toeing is usually benign and resolves with growth. Measure rotational profile; reassure parents. Pathologic toe walking: cerebral palsy, tethered cord (neurologic signs).