Intoeing
  1. Metatarsus Adductus- "Hooked Foot"
    1. Characterized by adduction of the forefoot in relation to the hindfoot. If associated with supination may be called metatarsus adductus varus.
    2. Equal incidence in males and females, may be unilateral
    3. Probably due to molding in utero
    4. Associated with developmental dysplasia of the hip (10%)
    5. Greater than normal interval between the 1st and 2nd toes.
    6. The treatment and course are dependent on the mobility of the forefoot.
      1. Easily bring forefoot to the neutral position and overcorrect, will not require treatment
      2. Can correct only to the neutral position and is moderately rigid. These may require special shoes and possible casting. Should refer to pediatric orthopedics
      3. Rigid and unable to reduce to neutral. Will require serial casting by orthopedist. 
    7. Treatment if necessary should be initiated by 2 months of age. Rarely will require surgical correction. 
  2. Internal Tibial Torsion
    1. Equal incidence in males and females.
    2. Secondary to intrauterine positioning
    3. Demonstrated by having the child sit with the legs over the side of a table and noticing the positions of the medial and lateral malleoli.
    4. No therapy necessary and will resolve spontaneously.
  3. Femoral Anteversion- Hip Intoeing
    1. Usually presents between 2-6 years with the complaint that the child is "pigeon toed" and clumsy.
    2. Increased internal rotation of hip joint, sometimes to 90 degrees, when the child lies supine. Also increased external rotation. 
    3. Child often prefers sitting in the "W" position. 
    4. More common in females
    5. Often associated with generalized ligamentous laxity demonstrated by hyper abduction of the thumb and hyper mobile pes planus.
    6. Treatment is parental education and reassurance and no specific therapy necessary. Improves usually by puberty.
  4. Bowed Knees
    1. Most infants are bow-legged until 36 months of age when they then become somewhat knock-knee. 
    2. Exaggeration or assymmetry should raise suspicion of some underlying disorder and evaluation may be necessary. Most common pathologcal conditions associated are rickets and Blount's disease. 
Reference
  1. Mankin, Keith. and Zimbier, Seymour. Gait and leg alignment: What's normal and what's not Contemporary Pediatrics. November 1997.
  2. Scherl S. Common Lower Extremity Problems in Children. Pedatrics in Review February 2004