Page 124 - ASOP ROT Study Guide

7 . 1 . 2 In-toeing
In-toeing is a frequent cause of parental anxiety. In this condition, children stand with their feet pointing
inwards ("pigeon-toed"), and this is often exaggerated when they run. Children are often referred to the
orthopaedic specialist because of clumsiness, but a careful enquiry may suggest that they are no more
prone to falling than other children. Parents also often complain bitterly because shoes tend to wear
down at the heels.

http://www.massgeneral.org/ortho/services/pediatrics/intoeing.aspx

The causes of in-toeing are:
♦ Femoral neck angle variation. During the later stages of the normal development of the fetus, the

leg rotates on the pelvis so that the acetabulum points almost backwards and the femoral head on the
neck is orientated forwards. Sometimes this rotatory process is not completed by birth and so the
femoral neck is more anteriorly orientated (i.e. it is anteverted) than normal. This means that children
born like this can internally rotate their femur a lot and externally rotate it only a little. This is reflected in
their posture and they have an in-toed gait. This delayed development will correct by itself by the age of
ten, although some are left with a little residual deformity. This is seldom, if ever, severe enough to warrant
surgery.
♦ Tibial torsion or twisting (where the bone is literally distorted or warped along its vertical axis) is a normal
variation and should be ignored.
♦ Abnormal forefeet, particularly the hooked (adducted) forefoot are commonly seen. It is dubious
whether surgery to correct this is ever justified, and it certainly should not be considered before the
age of seven. The vast majority correct spontaneously by men and any residual hooking rarely causes
functional difficulties. There is no evidence that special shoes make any difference.

7 . 1 . 3 Flat foot
Flat feet are abnormal only in the minds of the public of the western world - a flat foot is a normal variation
which very rarely causes functional abnormalities apart from uneven shoe wear. In some human races,
a flat foot is the norm.
There are two kinds of flat foot - rigid and mobile. The vast majority are mobile and entirely innocuous.
All children's feet are flat at birth and the normal arch of the foot may not form until the child is seven.
Parents must be reassured about this, and all pressure to intervene should be resisted. Referral to
hospital for mobile flat foot is not really required.