Which cases of in-toeing require referral?

Primary care physicians can manage the vast majority of children with in-toeing disorders. Only a few require casting or surgery, but be careful because about 15% actually have another diagnosis, according to a recent study.

At a session of the American Academy of Pediatrics annual meeting held last week in Orlando, Florida, researchers presented findings from a retrospective study involving 143 consecutive children referred to orthopedists for evaluation of in-toeing.

The investigators found that 85% of the referred cases did, in fact, have an in-toeing problem, but that 95% required no care beyond that provided by their pediatricians. Most cases resolved spontaneously without treatment. None required casting or surgery.

Of the referred cases, almost half (43%) demonstrated internal tibial torsion (TT); 16% demonstrated internal femoral torsion (FT); 8% had metatarsus adductus (MTA); and 17% had a combination of TT, FA, or MTA. Three-quarters were discharged from care after an initial consultation, and 18% were discharged after the first follow-up visit. Only 8% required more than 2 office visits.

Fifteen percent of the referrals didn’t have in-toeing at all. Other diagnoses included flexible flat feet (8%), physiologic genu varum (1%), and tight heel cords and cerebral palsy (2%). Three percent were completely normal.

The average age of the patient referred was 4 years, but the children ranged in age from 2 months to 13 years. More of the children were girls (59%) than boys (41%).

According to the American Academy of Orthopaedic Surgeons, the vast majority of in-toeing in children aged younger than 8 years will correct itself without the use of casts, braces, surgery, or any other special treatment. Referral to an orthopedic surgeon is generally only necessary when pain, swelling, or a limp accompanies in-toeing.

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