Epidemiology

Large clinical series of healthy children reveal that lower-limb rotational alignment varies widely throughout childhood.[2][3][4][5] In the absence of neuromuscular disease, femoral anteversion and tibial torsion are within normal values in 84% to 98% of the population, regardless of age or sex.[5] Although most torsional problems are normal variations, they cause concern in parents and are among the most common reasons for a pediatric orthopedic referral from a primary care pediatric provider.[6] Taking into account the various methods to measure limb rotation through physical examination (primarily the rotational profile) and subtle population differences, torsional deformities by definition fall outside 2 standard deviations from the mean of normative values of the torsional profile, thereby including about 5% of the population.[1][2][5][7][8][9] That is not to imply that these patients have some degree of disability, or that patients with borderline values do not. Torsional problems are common in infants and toddlers, and rare in adolescents.

Common abnormalities include: 1) normal femoral anteversion and internal tibial torsion - seen in 2% to 9% from a mean 3 to 8 years old; and 2) increased femoral anteversion and normal tibial torsion - seen in 1% to 9% of children from a mean 6 to 9 years old, and higher in females at any age.

Overall, intoeing is more common than out-toeing. In early infancy, inward rotation of the feet is most likely due to metatarsus adductus or, less commonly, hallux varus. In the toddler, intoeing is commonly due to medial tibial torsion. Intoeing in early childhood and adolescence (especially in girls) is usually due to medial femoral torsion. Torsional deformities are frequent and more often severe in patients with neuromuscular conditions.[10][11][12][13][14][15]

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