Introduction
An intoeing walking or running gait is a frequent childhood concern that podiatrists may be asked to verify. It is important for any clinician to recognize when observable intoeing may be expected as a part of normal development and when it is clearly abnormal, causing problems and warranting intervention.
It is equally important that the child be fully assessed, beginning as always with good elicitation and recording of the clinical history. Gait and objective evaluation should be performed, always keeping the subjective history in mind. Intoeing gait is a frequent problem in cerebral palsy, which can present quite subtly in young children and always needs to be considered as a part of the differential diagnosis.
Aetiology
Intoeing gait may originate from a single cause or multiple factors (to be discussed later in this chapter) which seem to be age related (Li & Leong 1999). Most reviews agree that primary causes of intoeing gait at different ages generally follow a developmental pattern (Fabry et al 1994, Li & Leong 1999, Lincoln & Suen 2003, Sass & Hassan 2003, Weseley et al 1981, Widhe 1997):
• Toddler (aged 2–3 years) – internal tibial torsion
• Children (aged over 3 years) – femoral torsion.
Prevalence
It has been cited that 1 in 10 children aged between 2 and 5 years has an intoeing gait (Ryan 2001). Elsewhere, some 30% of children have been observed at age 4 years, with only 4% intoeing as adults (Thackeray & Beeson 1996a).
Diagnosis
While it is agreed that intoeing gait is a commonly reported problem in children, there remains much opinion and less science about its significance as a clinical finding (Fixsen & Valman 1981, Lincoln & Suen 2003, Valmassy 1996).
Key Concepts
Key Concepts
The basic diagnosis of intoeing is easy as the child is seen to walk with an adducted angle of gait. The significance of an adducted foot progression angle has been contentious, but numerous investigations agree that intoeing generally reduces with age (see Table 10.1; Fabry et al 1994, Lincoln & Suen 2003, Ryan 2001, Thackeray & Beeson 1996a, Wenger & Leach 1986, Weseley et al 1981, Widhe 1997).
| The consensus is that intoeing is common in childhood to age 6 years and that the adducted angle of gait then reduces with increasing age. Clinicians must be alert to compensations which may occur to abduct the angle of gait in some cases, e.g. reduced knee extension, flat feet. | ||
| Date | Age | Angle of gait findings |
|---|---|---|
| 1997 | Birth – 16 years | By 6 years, 87%, and at 16 years, 95% of adductus deformities had resolved (Widhe 1997) |
| 1996 | 4–16 years | |
| 1996 | 3, 6 and 9 years | |
| 1990 | 4 years – adult | |
| 1974 | Children | |
| 1971 | Children | 13.6% intoeing gait (Ho et al 2000) |
Differential diagnosis
If intoeing gait is not developmental, consider familial, neurological and orthopaedic factors.
Developmental factors
As can be seen from Table 10.1, most forms of intoeing gait are developmental and resolve with increasing age. Intoeing gait in children which is functionally disabling, painful, increasing over time, associated with a limp or presents a very asymmetrical gait pattern requires closer attention, investigation and perhaps treatment.
Familial factors
Familial intoeing gait patterns will usually be revealed as part of a full case history and inquiry. Developmental intoeing gait seems to be more common in the early childhood years in some families.
Neurological factors
Intoeing gait is common in children with cerebral palsy where prevalence has been reported as greater than 60% (70% in quadriplegic, 66% in diplegic, 54% in hemiplegic children) (Rethlefsen et al 2006). Medial hip rotation and medial tibial torsion are the most common causes in this population, along with a varus/cavus foot type. Spasticity of the adductors and medial hamstrings influence both gait angle and torsion of the young femurs and tibiae (Tervo et al 2002).
Key Concepts
Key Concepts
In addition to an intoeing gait, cerebral palsy markers may include:
• abnormal muscle tone
• limited hip abduction
• leg length discrepancy (Li & Leong 1999)
• significant birth history (e.g. birth weight, gestational age, Apgar scores, complications) (Lincoln & Suen 2003)
• delayed walking (e.g. 16–18 months).
Orthopaedic factors
Hip dysplasia should be suspected if hip range of motion is altered or asymmetrical, or if a limp or limb length difference is evident in addition to an intoeing gait pattern.
Achondroplasia has been found to be associated with lower limb abnormalities, including reduced (lateral) tibial torsion and increased femoral (medial) torsion (Song et al 2006).
Clubfoot (talipes equinovarus) or metatarsus adductus can result in a ‘C’-shaped foot and contribute to an intoeing gait pattern. It is clearly important to correctly diagnose the foot type, as both prognosis and management issues are very different (see Chs 8 and 9; Morcuende & Ponseti 1996, Morcuende et al 2004).
Typical clinical picture
Classically the child presents with an intoeing gait pattern and worried parents. While most cases of intoeing gait will be developmental, it is important to take a full and thorough history and to examine the musculoskeletal system so that any underlying disorders are detected (or at least suspected and referred for further medical evaluation) before presuming to focus on the benign rotational problem and reassure the parents (Fabry et al 1994, Li & Leong 1999, Lincoln & Suen 2003, Ryan 2001).
History
Some simple, but revealing questions may include:
• When did the parent first notice the intoe?
• Were they aware of any inward rotation of the legs or feet at birth?
• How big was the baby at birth?
• Were the hips examined and were they stable?
Check the child’s milestones to get an indication of development:
• At what age did the child sit, crawl, stand and walk? Significantly delayed walking may suggest a neuromuscular disorder, e.g. cerebral palsy, hypotonia (Cusick 1990).
• Is the intoe getting better or worse over time or has it stayed the same?
• What positions does the child sit in, sleep in? Both sitting and sleeping postures have been thought to be of great importance to both the aetiology and management of children with intoeing gait. Perhaps a better interpretation is that these postures may act to prevent resolution of the problem as opposed to being singular causes (Redmond 2000). While it has been shown that chronic sleeping postures can deform limbs in neonates and affect later gait (Katz et al 1991), caution is advised in deeming postures as causative of intoeing gaits.
• Is there a family history of this condition?
• How are older members now with respect to pain and function?
• How much of a problem is it?
• Is it of mild aesthetic concern or is it severe and limiting the child’s ability to walk and run?
Spend adequate time taking the history as this will usually guide both your examination and the management plans.
Examination
There are probably many ways of dealing with assessment of this condition. My own approach to the child presenting with an intoed gait is to run through an organized physical examination, which is focused by prior history details and gait observation.
Starting proximally (simply my preference – it does not matter where you begin):
Hips
Medial and lateral rotations with respect to the age of the child:
• Lateral range is usually greater than medial range initially.
• Usually symmetrical by about 2 years of age.
• Be sure to test in hip extended and then flexed positions to check for soft tissue versus bony factors (Table 10.2)
| Infants and young children usually have greater lateral than medial hip range of motion, until age 2–3 years. From there on the hip range generally equalizes and the total range of motion reduces slightly with age. The clinician needs to be suspicious when the medial range exceeds the lateral and in particular if there is asymmetrical hip range of motion. | ||
| Position | Structure | |
|---|---|---|
| Ligaments | Lateral femoral position | Tight ischiofemoral ligament |
| Medial femoral position | Tight pubofemoral ligament Tight iliofemoral ligament | |
| Muscles | Lateral femoral position | Gluteus maximus Obturator externus Obturator internus Gemelli Quadratus femoris Piriformis Sartorius Adductor magnus Adductor longus Adductor brevis |
| Medial femoral position | Iliopsoas Tensor fasciae latae Gluteus medius Gluteus minimus |
Femur
Femoral torsion (twist within the shaft of the femur) should be reducing from birth. Clinically this can be assessed by a modified Ryder’s test. This is a useful test to perform as it can clinically delineate the relative contributions of hip position and range from femoral torsion in children who display an intoeing gait.
Knee
Knee extension may be limited by:
Key Concepts
• tight hamstrings
• tight proximal gastrocnemius
• tight ligaments.
Key Concepts
A typical compensation for reduced knee joint extension is adduction of the limb.
This is most noticeable when the child walks; as the forefoot loads, so the knee and hip begin to extend. If inadequate knee extension is available, adduction with heel lift will often be seen along with maintained knee flexion in some (more severe or neurological) cases.
Observe the position of the patella in both stance and gait (if walking). When the child stands facing you the patellae will normally be:
| 0–2 years: | laterally rotated |
| >2 years: | straight. |
If the patellae are medially (or excessively laterally) rotated, there is at least some femoral component involved in the intoeing gait. If the patellae are straight but feet adducted, likely areas involved are:
Tibia/fibular unit
Medial torsion
According to Tachdjian (1985, 1997), medial tibial torsion is often associated with:
• metatarsus (adducto) varus
• genu varum
• tibial varum.
Remember that tibial torsion is minimal or absent at birth and then with neuromotor activity increases to 15–25° by approximately 8 years. True tibial torsion is difficult to measure and requires CT scans (usually not necessary). Clinically, malleolar position represents tibiofibular torsion and is 5° less (i.e. 10–20° lateral by 7–8 years).
Medial genicular position or bias
According to Cusick (1990), genicular position can be typically medial in the young child as a consequence of initial intrauterine confinement. This should become symmetrical by approximately 3 years of age, but may be maintained if:
• severe initially
• postures perpetuate the position
• neuromotor dysfunction impedes normal modelling.
It is important to distinguish between medial genicular position (usually in children less than 3 years of age) and medial genicular bias, which is a lack of lateral genicular rotatory range and may need treatment in addition to changing aggravating sleeping or sitting postures.
Key Concepts
Key Concepts
In gait, intoe due to medial tibial torsion is usually consistent whereas intoe due to medial genicular position tends to be more variable from step to step (Cusick 1990).
Feet
Metatarsus adductus is the most common foot condition that gives rise to an intoed gait pattern. There is association between metatarsus adductus and medial tibial torsion and also developmental dysplasia of the hip (Kumar & MacEwen 1982a, 1982b).
In an effort to function more abducted, a typical compensation at foot level in the intoed child is for the feet to excessively pronate. This reduces the adduction and looks better but at the possible expense of the feet later on. This compensation, which reduces adduction, may well be one of the reasons that intoe is often said to be ‘outgrown’ in time. Sometimes it is (e.g. reduction of medial genicular position), but at other times it causes a second alignment change which may improve cosmesis.
Muscle tone
Muscle tone is difficult to define (Illingworth 1987). It was previously thought that muscle tone was due to a constant ‘background’ neural activity, with high tone (hypertonus) indicating increased excitatory activity and low tone (hypotonus) the opposite. This concept has been disputed and tone is probably due to a combination of factors (e.g. reflex contraction, mechanical-elastic properties, such as stiffness, physical inertia) (Shepherd 1995).
As a result, the clinical assessment of muscle tone is based upon findings in a number of areas. The following factors are usually included in the assessment of muscle tone:
• observation of posture
• feel of the muscles
• resistance to passive motions
• range of motion
• reflex testing, e.g. tendon taps, plantar response, Moro and other anti-gravity responses (Illingworth 1987, Thomson 1993).
Muscle tone can and should be evaluated in several ways, taking into account each of the areas above. It takes experience to evaluate muscle tone and the clinician should always be checking for asymmetries of muscles groups, including strength and bulk.
Postures
In very basic first impression terms, hypertonic children exhibit joint extension and consistently clenched fists, normal children show a flexed posture at rest and hypotonic children appear ‘flat’ against the resting surface.
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