Intoeing is a lower extremity rotational abnormality. It is one of the most common reasons why children are referred to an orthopedic surgeon. Concerned parents perceive that their child will have lasting structural, cosmetic, and/or functional issues. Concomitantly, many pediatricians feel ill-equipped to deal with or address orthopedic issues. The pediatric practitioner can effectively address intoeing by knowing the normal lower extremity developmental process, normal variations, key historical red flags, and a few basic physical examination maneuvers. The vast majority of cases of intoeing resolve with time. It is only a minority of cases that will necessitate referral and/or surgical intervention.

Intoeing is the manifestation of one of three likely underlying processes: metatarsus adductus, internal tibial torsion, or femoral anteversion. Rotational variation is a more concise term to describe these processes. As a result of intrauterine crowding, many infants are born with varying degrees of femoral anteversion, internal tibial torsion, or angulation of the feet. The normal maturational process of the lower extremity involves external rotation of the tibia and femur as the child grows. The foot also rotates to assume the normal position. Thus, these counteracting forces result in the resolution of most cases of intoeing as the child grows.

• It is essential to obtain a thorough birth history, including prenatal complications, Apgar scores, gestational age, and the nursery or NICU course. Cerebral palsy should be part of the differential diagnosis for complicated births.

• Multiple gestation births, due to intrauterine crowding, have higher rates of rotational issues.

• Genetic disorders such as achondroplasia and vitamin D resistant rickets predispose children to lower extremity rotational and structural issues.

• Clubfoot is associated with syndromes such as arthrogryposis, Down syndrome, and myelodysplasia. Children with these syndromes will likely require corrective surgery.

• Pain, progression, and worsening of the disorder warrant further evaluation.

• Children with neuromuscular and/or developmental disorders warrant a more in-depth and encompassing assessment.

• Ascertain if there is a family history of lower extremity rotational disorders. There are familial and ethnic tendencies for rotational issues.

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