Childhood Orthopedic Problems: Intoeing
Guest: Dr. Jennifer Hooker – Pediatric Orthopedic Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Jenny Hooker who is Assistant Professor of Pediatric Orthopedics at the Children’s Hospital here at MUSC. Dr. Hooker, let’s talk about another pediatric orthopedic problem, which is intoeing or, I guess some people refer to it as being, pigeon-toed, or toes turned in. What are some of the causes of this problem?
Dr. Jenny Hooker: There are actually several different things that can contribute to this problem. The most common thing that we see is, what we as pediatrics would refer to as, tibial torsion. Basically it’s a twisting of the shin bone, or tibia, that causes the feet to appear to be pointed inward.
Dr. Linda Austin: What are some other causes of it?
Dr. Jenny Hooker: You have to always think about it in terms of the various levels in the leg. So, not only can the problem occur from a turning of the bone below the knee, tibial torsion, it can also occur from problems in the foot, where the foot itself has a bend inward. We refer to that as metatarsus adductus. It can also occur from the hip level where patients have an increased femoral anteversion, a big doctor word which basically just means that their leg is turned inward more than average at the level of the hip joint.
Dr. Linda Austin: Is this something that always shows up right at birth, or do some children seem to grow into this problem?
Dr. Jenny Hooker: Actually, we rarely see this problem at birth. And the reason for that is that patients aren’t up and walking. We’d usually see children present with this problem at about age 12 months to 24 months. Once they get up, they start walking and the family really starts paying attention to the position of the feet as they’re beginning to ambulate.
Dr. Linda Austin: I would imagine that the treatment of this must depend upon where in the leg or foot the problem is, isn’t that right?
Dr. Jenny Hooker: That’s exactly right, yes. Generally speaking, for problems at the foot level, the metatarsus adductus that we talk about, most patients who don’t have a very severe form will actually grow out of that without requiring any treatment whatsoever. It’s generally something we can simply observe. Some patients who have a more severe form though, may need intervention such as a special shoe or even, potentially, casting. It’s the very rare patient with intoeing that comes from the foot level who would eventually end up needing any type of surgical procedure.
Dr. Linda Austin: Now, how about tibial torsion, or twisting of the lower part of the leg?
Dr. Jenny Hooker: As I mentioned before, that’s actually the most common cause of an intoeing-type presentation. And the reason for that is because of the way the tibia, or shin bone, is molded when babies are in the womb. Because of the position of the legs, the legs actually grow and develop with an internal twist to them, below the knee. As a patient grows, develops and begins walking in their young childhood, that bone actually twists back out and ends up placing the feet in more of a position where they’re turned outward. That type of progression can actually occur up until the age of about six to eight years. So that’s why when many patients come to see us, we tell the families that it just needs to be watched, because with normal growth and development through the first few years of life, most patients will see that untwisting, or gradual turning outward, of their feet.
Dr. Linda Austin: Now, is that true, also, of the problem higher up, at the level of the hip?
Dr. Jenny Hooker: It can be true up at the hip as well, although we generally don’t see as dramatic of an untwisting in this region. Fortunately, though, fewer patients have that problem, and that tends to be associated with more of a syndrome-type patient. For example, we see a lot of difficulties in patients who have cerebral palsy, with increased turning in of the legs that actually originates from the hip joint itself.
Dr. Linda Austin: So, it sounds as if even though, I’m sure, to a parent’s eye it can be kind of a worrisome thing, in reality it turns out not, generally, to be so severe. And actually, as I think about it, you don’t really, all that often, see grown ups who walk with their toes turned in. The opposite is more common, it seems.
Dr. Jenny Hooker: That’s actually exactly correct. And, surprisingly, despite the fact that some of these children just have dramatic appearing toeing-in when they’re young, they almost invariably grow out of it as they age. What we tell parents frequently is that, when they come to see us, at age one, one and a half, two, there’s really no need for any concern whatsoever until the patient reaches at least the age of four and still has significant turning in of the toes. Again, that’s just because of the normal growth and development. So, we’ll often tell parents to just watch it, which is sometimes a hard thing to hear but, certainly, the better choice rather than operating on children who wouldn’t need surgery if we just allowed them to grow normally.
Dr. Linda Austin: Dr. Hooker, thank you so much for talking to us today.
Dr. Jenny Hooker: You’re welcome.
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