In toeing is where when walking, the feet turn inwards. It often appears in early childhood and is outgrown in most cases however can result in frequent tripping, or look awkward when running. Your podiatrist will do several assessments to manage this effectively assessing the level at which the in toeing is occurring as it may occur between the foot and hip and at each different level the management is different and work with you to discern if the in toeing requires active or passive treatment.
The three common causes of in towing are internal femoral torsion (thigh bone), internal tibial torsion (the shin bone) or metatarsus adductus (the foot). Internal tibial rotation is when the thigh bone turns inward between the hip and the knee which is normal in young children and will usually correct itself without active treatment, however avoiding ‘W sitting’ is to be advised. Internal tibial torsion is when the shin bone turns inwards between the knee and the ankle, which is very common in infancy and early childhood, usually correcting itself in early primary school. Metatarsus adductus is where the rearfoot is straight however the front of the foot curves inwards occurring in babies and often correcting when they become toddlers, however exercises, shoe inserts or casting may help straighten the feet. Sometimes in toeing can also be because of a combination of these factors.
When you see your podiatrist they will take a thorough history including a birth history, family history, pain/tripping/shoe history to exclude conditions such as cerebral palsy, hip dysplasia and endocrine and metabolic diseases such as rickets. Your podiatrist will then observe you walking and running and assess your joint range and quality of motion. Depending on the nature of the in toeing and where it is coming from treatment options will vary from observing and monitoring, as the natural progression is in most cases to improve, or active treatment such as the following:
- Changing sitting and sleeping positions
- Exercises as games
- Penguin walking
- Soldier walking
- Tightrope waking
- Serial casting
- Gait Plates
- De-rotation splinting
- In shoe padding to reduce pronation
Treatment can be justified if your child is tripping repeatedly and falling or is having associated pain in their condition or if it does not reduce with age. Surgery is only indicated for really problematic in toeing in children older then 10 years of age with a neurological in nature and if this occurs, your podiatrist will work closely with orthopedic surgeons and pediatricians for ongoing care and rehabilitation.
Metatarsus adductus is a deformity in the forefoot where the front of the foot becomes adducted or facing inwards in relation to the rearfoot coming from the tarsometatarsal joint (metatarsal cuneiforms and cuboid bones- also known as the Lisfranc Joint) making the foot look like a banana. It occurs at birth especially in multiple births and is associated with developmental dysplasia of the hips and is reported to be the most common congenital foot deformity in newborns. Most cases of metatarsus adductus self resolve. This deformity is a solely forefoot deformity which differs it from other congenital foot deformities such as talipes equinovarus (club foot) and skew foot which involve rearfoot deformity.
Metatarsus adductus is grouped into four types of classification. The first is developmental metatarsus adductus (MTA Type 1) which is the most common type and will usually spontaneously result. It is positional in nature due to tightness in one of the muscles in your midfoot (abductor hallucis) which occurs either congenitally or intrauterine position and is seen only when weight is put through the foot whilst mobilising. Metatarsus adductus Type 2 (MTA Type 2) also known as true metatarsus adductus is where the long bones in the front of your foot- the metatarsals- move towards the midline of your body making a C shape or banana shape, however the heel doesn’t have any change, remaining neutral. Metatarsus (aducto) varus, MTA Type 3, is where the midfoot essentially twists, with the heel bone (calcaneus) everts (twists outwards) and the forefoot inverts (twists inwards) in addition to the C or banana shaping of the metatarsals. This type of metatarsus adductus becomes more entrenched with time, thus required accurate identification and effective treatment earlier. The final type is known as Skew foot (MTA Type 4) is more complicated. It is where even more twist is noted through the midfoot with the rearfoot everting at multiple points and forefoot has the same C or banana shaping.
When you attend your podiatrist, they will assess the foot with a range of different methods, grading it from normal to severe metatarsus adductus or in some cases refer for X-ray. They will take a full history inclusive of birth history. They will also assess the flexibility of the foot, to classify if the deformity is flexible, semi flexible or rigid. This will determine the treatment direction taken. If the deformity is rigid your podiatrist will refer for surgical opinion and work in a team with your orthopedic surgeons to ensure that the best treatment is given. If the deformity is flexible, depending on the history, at times a hands off approach will be taken as deformities can spontaneously resolve, however sometimes your podiatrist can recommend stretching, monitoring sleeping and sitting positions or give footwear recommendations. If the deformity is semi-flexible, splints, casting or braces can help resolve the deformity. All treatment options will be discussed thoroughly with you and your family depending on the nature of the deformity and your podiatrist will work with you to achieve the best outcome for your child.