Published in Panoram
One and a half year old Reema, much to her mother’s horror, was walking pigeon-toed! That is, little Reema was walking with both her feet turned inwards. Intoeing, as the condition is called, leaves many parents concerned and worried, that all is not well with their toddler’s feet!
To allay fears, Dr.Salman Hameed, Specialist Orthopedic Surgeon, Welcare Hospital explains, “Simply put, Intoeing refers to a malalignment somewhere between the hip and the toes. This may be the case with most children when they start walking, to walk with one or both feet turned inwards. Normally, when a person walks, the feet should be straight, or facing slightly outwards. If you draw a straight line on the floor and walk on it, the foot should be about 5 degrees inwards, to about 10 – 15 degrees outwards. If it is more than 15 degrees outwards, it is called out-toeing; if it is facing more than 5 degrees inwards, it is called intoeing of the feet. Most of these are normal phenomena, simply a sign of developing posture and balance and in about 90% of these kids, by the time they reach 10 years of age, will have the problem resolved, naturally, without any medical intervention.”
What causes Intoeing? There is a hereditary factor in Intoeing, besides other causes, including congenital abnormalities, explains Dr.Salman. There may be a twist in the femur or the thigh bone, called Internal Femural Torsion – somewhere between the hip and the knee. This is often seen in a child who likes to sit in an abnormal posture called the “W” position, though there is no evidence that sitting in this posture aggravates Internal Femural Torsion.”
Dr.Salman continues on the causes of Intoeing, “There may be a twist in the shin bone between the knee and the ankle. This Internal Tibial Torsion may be present at birth and is commonly associated with increased bowing of the shins. A third cause of Intoeing is at the mid foot area, Metatarsus adductus where there is an inward curving of the foot causing the big toes to point somewhat towards each other.”
Usually, the most common cause of Intoeing in children below one year is Metatarsus adductus; children of about two have the problem caused below the knee level and in the above 3 year old, the most common cause of Intoeing is at the hip level or thigh bone level. And in 90% cases, all these three conditions usually resolve by the age of 10 years, reveals Dr.Salman. “The remaining ones that have not resolved, it depends on the severity of the condition, if it is causing abnormal foot wear, when the child is tripping and falling while running because the feet are both intoed. But these conditions again, are very much treatable.”
Intoeing due to Metatarsus Adductus, may be associated with certain other birth defects like hip dislocation and also cerebral palsy. So it is very vital for the doctor to assess the child clinically to make sure that these problems are ruled out. We would have to wait and watch, once we rule out these other conditions that are associated with intoeing.
In the vast majority of children with intoeing, no specific treatment other than reassurance, observation at yearly interval and attention to proper sitting positions is required, explains Dr.Salman. “Intoeing does not normally cause any pain nor does it interfere with the way the child learns to walk. In a small number of children who do need treatment, it is usually mild and benign with good results. If the condition persists over 10 years of age and is so severe as to cause problems in gait, foot wear or there is some pathology, the problem should be addressed. For instance, if the problem is present at the hip level, than an osteotomy of the thigh bone can be done. This involves cutting the mal-aligned bone and correcting the twist, aligning it normally with the help of plate and screws. The plate can be removed after one year of surgery. The same can be done at the lower leg level. The correction can be done depending on where the problem lies. Sometimes, if the condition is very severe, the problem is at two levels – for example, at the leg and hip levels.”
The surgery can be done even on the foot though treatment of the foot is best begun by gentle manipulations. If these do not succeed, we then do the plaster treatment and change casts every week, reveals Dr.Salman. “Most of the foot problems do resolve with this. In very rare cases, surgery may be required. Surgery if needed, should be done after the age of 10, preferably around 12-13 years. The risk of surgery itself is minimal and includes infection and slow healing, though this is very rare. Some kids may not become completely normal after surgery. It is difficult to say how each child will respond to surgery. But one thing should be borne in mind: surgery should not be done for cosmetic reasons; it should be done for functional improvement and improvement of footwear.””
Prior to the age of 10, when intoeing is present in children, can they participate in normal sporting activities? Dr.Salman is reassuring: “Yes, they can indulge in every possible activity that a child without Intoeing does. In fact, some of these children actually run faster ! The only thing of concern is that if the intoeing is very severe, it can lead to the child tripping and falling, while running. Usually, different wedges or footwear, do not affect the natural history of the disease and do not correct the problem; it just gives a sense of security to the parents. The long-term outlook for a majority of children with intoeing is to go on to perfectly normal life activities regardless of whether or not the overall alignment improves.”
Dr.Salman dispels certain misconceptions regarding the condition. “It is a misnomer that sitting in a “W” position can cause increase of the problem at the hip areas. This is not true. But it is advisable for parents to discourage their children sitting in that position. One very important thing to keep in mind when the child has intoeing, is to make sure the child does not have dislocation of the hips at birth.”