History and exam

Key diagnostic factors

common

convex lateral border of the sole of the foot

Lateral border with the patient prone is normally straight. Convex lateral border indicates forefoot adductus.

asymmetric hip range of motion

Increased external rotation and decreased internal rotation compared with the other side may indicate slipped capital femoral epiphysis.

Other diagnostic factors

uncommon

foot progression angle >2 standard deviations outside the mean for age

Positive values indicate out-toeing. Negative values indicate in-toeing. Infant: <-20°. By age 8 years, >30° or <-20° indicates significant deformity.[2]

hip medial rotation >2 standard deviations outside the mean for age

In an infant >60° and adolescent >70° indicates increased femoral anteversion.[2]

hip lateral rotation >2 standard deviations outside the mean for age

In an adolescent >70° indicates increased femoral retroversion.[2]

thigh-foot axis >2 standard deviations outside the mean for age

Average in infants is 5° internal (range -30° to +20°). By age 8 years, >30° indicates lateral tibial torsion, and <-10° indicates medial tibial torsion.[2]

transmalleolar axis >2 standard deviations outside the mean for age

Averages about -4° in newborns. By age 7 to 8 years >40° indicates lateral tibial torsion.[2]

heel-bisector line

A line projecting lateral to the second web space suggests forefoot adduction. A line passing more medially suggests forefoot abduction.

sitting in the W position

Children with medial femoral torsion tend to sit with the legs medially rotated because lateral rotation of the hips is limited and may be uncomfortable.

medial-facing patella (squinting or cross-eyed patella)

Seen in children with medial femoral anteversion during stance and gait.

lateral knee thrust

Knee abruptly translates laterally as weight is placed on the leg during stance phase of gait.

Risk factors

strong

neuromuscular disease

Developmental torsional deformities are common in children with cerebral palsy, myelomeningocele, and polio.[13][45]

intrauterine position abnormalities

Abnormal shaping of structures caused by mechanical forces leading to torsional deformities.

weak

family history of rotational problems

Mothers of patients with medial femoral torsion often recall a history of femoral torsion when they were children and have a similar or less pronounced rotational profile pattern as adults.[1]

female sex

Regardless of age, females have greater hip medial rotation and a greater total arc of hip range of motion than males, which may predispose them to in-toeing.[22][24]

short stature or disproportionate body-limb ratio

May be associated in cases of skeletal dysplasia.

Nemours Foundation: skeletal dysplasia Opens in new window

ligamentous laxity

Associated with torsional deformities by increasing intra-articular joint motion. Patient is asked to touch the thumb to the volar surface of the forearm, hyperextend the little finger metacarpophalangeal joint >90°, hyperextend the elbows, hyperextend the knees, and place the palms of the hands on the floor with forward bending.

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