What is the Differential Diagnosis of Intoeing and Outtoeing?

Patient Presentation
A 2-month-old male came to clinic for his 2-month health supervision visit.
His parents have no concerns other than his feet seem to turn in looking like a “C”.
This has been present since birth and they think that perhaps it is slightly improving over time but they are not sure.
The past medical history shows that he was the product of a 38 1/2 weeks gestation with spontaneous vaginal delivery birth with vertex presentation.
There were no complications and he has not had health care visits other than routine care. Past medical records do not mention any physical abnormalities.
The family history is negative for any orthopaedic problems.
The pertinent physical exam shows a happy male infant with normal developmental milestones and growth parameters in the 50-75%.
On inspection, both forefeet appear to turn inward with a curved lateral border. With the hindfoot stabilized, the forefoot can be brought to a normal neutral position with little effort and did not cause discomfort. There is no stiffness with motion of any of the toes, forefeet, ankle, knees or hips.
The medial malleoli were anterior to the lateral malleoli. The hips had normal ab- and ad- duction and a negative Barlow and Ortolani test bilaterally.
The diagnosis of bilateral metatarsus adductus was made. The parents were told that this is a common problem in infancy thought to be due to intrauterine positioning. They were instructed and shown how to do forefoot stretching exercise that could be done with each diaper change and they demonstrated the proper technique.
They were also told that this generally corrects as the child begins to put more weight on his feet.

Discussion
Intoeing or outtoeing are common complaints by parents. For most children, it is a normal variant or developmental problem that often resolves with a tincture of time.
In general, referral should be made to an orthopaedist if the body part cannot be brought back to a neutral position or if doing so involves pain or discomfort. If there is any stiffness or an incomplete range of motion is felt then patients should also be referred.
Patients with other abnormalities that may indicate that the in- or outtoeing may be part of a syndrome or neuromuscular problem should be referred too. Parents generally will complain about the in- or outtoeing if it is obvious (as in the patient above), the child seems to trip more often, there is excessive shoe wear, or other parents, teachers or family members have noticed the same problems.

Intoeing is complained about much more often than outtoeing because the children tend to trip more with intoeing. Outtoeing is common when children begin to bear weight and the outtoeing helps with balance. The outtoeing improves usually over the next several months as strength, coordination and balance are improved.
A normal gait has a slight outtoeing (i.e.10-15° external rotation).

Learning Point

The differential diagnosis of intoeing includes:

  • Metatarsus adductus
    • Cause: Intrauterine positioning deformity, i.e. a “packaging” problem.
    • Age: Infants
    • Diagnosis: Hold the hindfoot in one hand to stabilize and use other hand to attempt to bring toes back to midline. If this can be easily done without stiffness of the foot, then this is metatarsus adductus. There is also a tranverse midline crease on the plantar surface.
    • Prognosis: is excellent and it spontaneously corrects especially with weight bearing
  • Internal tibial torsion
    • Cause: Normal in newborns. Caused by the effects of gravity and dominant tone in ankle plantar flexor muscles and foot invertors
    • Age: Toddler – often seen when child begins walking and is generally better by age 2 and almost all are corrected by age 4.
    • Diagnosis:
      • Intermalleolar axis – The medial malleoli lies approximately 10 – 15% anterior to the lateral malleoli normally. With tibial torsion, they lie in the same plane.
      • Thigh foot angle – With child prone on table, flex the knee. Draw an imaginary line through the axis of the femur and another imaginary line between the midpoint of the heel and toes. Normally the angle between these two lines is 10-30° with the foot turned outward. Refer to orthopaedics if the angle is > 20°.
    • Prognosis: is excellent, generally no treatment is necessary, rarely requires surgery only if persistent
  • Femoral anteversion
    • Cause: Angular difference between the axis of the neck of the femur and the transcondylar axis of the knee. Normally reaches the adult angle of 10 – 20° in 5 – 8 year olds.
    • Age: School age children can often sit in “W” position without any problems (this position does not exacerbate the condition)
    • Diagnosis: Check the internal and external rotation of the hips. Internal rotation > 70° and limited external rotation are suggestive of femoral anteversion.
    • Prognosis: Improves but is often slow to do so. Once external rotation increases to 10 – 20° then intoeing generally is resolved.
  • Cerebral palsy
  • Clubfoot – is rigid deformity with plantar flexion and medial deviation at the ankle
  • Hip dysplasia

The differential diagnosis of outtoeing includes:

  • Normal gait when first learning to walk
  • Femoral retroversion
  • External tibial torsion – usually seen as a compensatory mechanism to femoral anteversion

Questions for Further Discussion
1. What causes knock-knees and bowlegs?
2. What causes flat feet?
3. What causes leg length discrepancies?
4. When would radiographs be indicated for intoeing or outtoeing?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check Foot Injuries and Disorders

and at Pediatric Common Questions, Quick Answers for this topic: Intoeing and Outtoeing

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Mier RJ, Brower TD. Pediatric Orthopedics A Guide for the Primary Care Physician. Planum Medical Book Company, New York NY. 1994:95-102.

Lincoln TL,
Suen PW.
External rotation contracture of the extended hip. A Journal of the American Academy of Orthopaedic Surgeons. 2003;11(5);312-20.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    May 28, 2007