Internal Tibial Torsion & Femoral Torsion & Metatarsus Adductus

Internal Tibial Torsion (ITT)

What is it?

Internal Tibial Torsion (ITT) is a condition in early childhood in which the tibia (leg bone) is twisted inwards axially, causing the child to intoe as he walks. This is a very common condition, and considered normal unless it does not resolve beyond 3 to 4 years of age. ITT is universal in infants and toddlers, and when the child takes his first steps, intoeing is the norm. With walking, the ITT usually resolves, and disappears by 3 or 4 years of age.

What causes it?

ITT is a normal phase of skeletal development in the first 2 years of life. The tibia derotates itself over time, and the intoeing improves. During this phase, walking causes the ITT to correct itself. In a small proportion of children, however, the ITT does not resolve completely, or improves partially only. Even in these cases, the ITT can still improve spontaneously beyond age 2.

What are the symptoms?

The child intoes, and keeps intoeing beyond 18 to 24 months of age. In the more severe cases, the child trips frequently, much more than his peer, to the consternation of his parents.

What does your doctor do about it?

The doctor makes the diagnosis by checking the Thigh-Foot angle (TF angle). In a child 18 months of age, it should be between -10 degrees to +10 degrees. A value more than -10 degrees warrants the diagnosis of ITT, but not necessarily treatment. Clinically, intoeing is not significant unless the TF angle is worse than -45 degrees, so treatment should be limited to these children only.

The doctor will also check to see if the child has associated Metatarsus adductus (or varus) or Femoral Torsion.
Denis-Browne bar

Treatment for ITT traditionally consist of using a Denis-Browne bar at night for about 6-12 months. This is a very punishing treatment for the child, and parents have lost sleep nights because of this. A recent improvement is an articulated bar that allows some movement of the legs. This has made it more tolerable, but is still very tough on the child. Moreover, recent research found that the amount of corrective force on the tibial torsion using the bar has been negligible. Because the knees are in the extended position, most of the torque goes to the hips, rather than the tibia.  The vast majority of cases of ITT resolve spontaneously. There are some physicians who feel that all cases of ITT correct spontaneously, and preach that no treatment is ever needed for ITT.  Since the brace doesn’t provide any corrective force and Itt almost always correct on its’ own, no treatment is necessary.  Even in the rare case that ITT persists, those patients have no functional complaints and almost always choose to live with what is at most a minor cosmetic deformity.  A short, well tolerated operation is available to those who for a variety of reasons may benefit.

Femoral Torsion(anteversion)

What is it?

The upper end of the femur consists of the neck and head (the ball) articulating with the acetabulum (or cup) at the hip joint. The neck and head of the femur is pointed inwards with a slight forward inclination. This slight forward inclination is called femoral neck anteversion.

The amount of femoral neck anteversion is 40 degrees at birth, and decreases with age to about 15 degrees at maturity. This is the normal evolutionary process of growth in most people. In some instances, the femoral neck anteversion present at birth does not decrease, but stays excessive compared to age, giving rise to the condtion of excessive femoral neck anteversion, or femoral torsion.

What are the symptoms?

The typical presentation is a child between age 3 to 8 brought in by parents because of concerns about intoeing. He or she may even have had treatment for metatarsus adductus or tibial torsion in the past, and parents may think that there has been a recurrence of the old problem.

Typically the child stands or walks with the knee caps and toes pointing in.

What does your doctor do about it?

Femoral torsion was in the past treated by use of twister cables- twisted strands that connect a waist belt to shoes that tend to twist the feet outwards. Kids wore them for years, and they do improve the position of the feet on standing and walking.

However, recent research consisting of longitudinal studies of thousands of children confirmed that most children with femoral torsion resolve spontaneously by age 10. Even in those cases that did not resolve completely, it improves sufficiently to be of no functional significance.

There are still instances where twister cables may be needed. But this is usually in neuromuscular impaired kids, where normal muscle function is not present to effect the evolutionary corrective process.

Fig: The W-position and kneeling position which should be discouraged. The cross-legged or Indian position should be encouraged.

For most regular kids, the most common cause of persistent femoral torsion is habitual kneeling or sitting in the W-position or television position. These positions perpetuate femoral torsion because they keep the hips in the internally rotated position. It is therefore important that all children, when sitting on the floor to play, learn to sit cross-legged Indian-style. This position places the hips in the externally rotated position and encourages the normal modeling process.

Parents sometimes buy their children heavy corrective shoes, hoping that they will improve the child’s walking. On the contrary, children with femoral torsion walk worse with heavy leather shoes. Since the “problem” is in the thigh, any treatment directed at the feet is not expected to help.

What can be expected in the future?

Intoeing from femoral torsion is a universal condition that resolves spontaneously by age 10. Resolution, however, is usually partial.  the mild intoeing that persists is not a functional problem and is usually compensated for by the patient.  In the exceptional case, usually associated with neuromuscular impairment, surgery is available and provides complete correction. In most instances, understanding of the natural history on the part of parents will help to avoid unnecessary treatment.

Metatarsus Adductus (Varus)

What is it?

Metatarsus adductus (MTA) or varus is a condition that is commonly seen in newborns and young infants, where the forefoot is twisted inwards relative to the hindfoot (or heel). Metatarsus adductus and Metatarsus varus are terms used interchangeably, and some doctors call the condition Metatarsus adductovarus. Some purists argue that there are subtle differences, but most doctors from a practical standpoint cannot and do not find a need to distinguish between them clinically.

In MTA, the forefoot is turned inwards, while the hindfoot (or heel) is normal. If the hindfoot is involved, it becomes a more serious problem. If the forefoot adductus or varus is associated with hindfoot valgus, it is called a skewfoot. If the forefoot adductus is associated with hindfoot varus and ankle equinus where the foot points downwards, the problem is a clubfoot.

What causes MTA?

MTA is very common in the newborn, and is usually due to the feet being “packed” in the womb in that position. The forefoot adduction at this stage is very flexible, and with freedom of movement, this postural condition of MTA often improves over the next 6 to 12 weeks.

In about 15% of cases, the adducted position of the forefoot does not improve. In fact, the deformity becomes less flexible. A crease starts to appear on the medial border of the foot and a bony “bump” on the lateral border of the foot, right at the junction of the forefoot and hindfoot. This is the classic MTA that may require treatment.

The picture left shows slight adductus at birth which usually corrects spontaneously after 2 to 3 months (indicated by horizontal arrow). In some cases, instead of correcting, it persists or gets worse, forming the typical deformity of metatarsus adductus (indicated by downward arrow).

What does your doctor do about it?

MTA that is diagnosed at birth does not require treatment. It is usually postural, and with growth, the MTA resolves spontaneously over a period of 6 to 12 weeks. If the forefoot adductus is severe, your doctor may prescribe stretching exercises which he will teach you to perform at home on the baby. X-rays are usually not necessary, unless the doctor suspects something else.

After about 3 to 4 months of observation and stretching exercises, if the forefoot adductus does not improve, treatment may be necessary. The treatment options are as follows:

1. Corrective shoes
2. Serial castings
3. Corrective bracing

Fig: The Wheaton Brace in use. Notice how the brace corrects the forefoot adductus.

1. Corrective shoes (outflare shoes) are appropriate for the very mild and flexible cases only. They are not often used at this time because, if the forefoot adductus is very mild and very flexible, why treat it?
2. Serial castings are reserved for the very severe and rigid cases, and consists of castings every one or two weeks until correction is obtained (which is usually 3 to 4 sets of casts), followed by corrective shoes to hold the correction for about 3 months. This is very time consuming, expensive and inconvenient for the baby and parent.
3. More recently corrective bracing has become very popular, because it addresses the problems associated with castings. The Wheaton Brace is a ready-made thermoplastic brace that allows correction of the majority of cases of MTA (except for the most severe). The doctor teaches the parent in the use of the brace, which can be removed twice a day, if necessary. It is convenient, less expensive than castings, and very effective. Correction is usually obtained in 4 to 6 weeks, after which the brace is used at night only for about 3 months to hold the correction.

What can be expected with treatment?

As stated above, without treatment, 85% of MTA’s resolve spontaneously. There remains 15% that requires treatment. Your doctor will decide with you in terms of the timing and mode of correction, whether by corrective casting or bracing. Once correction has been obtained, recurrence is unlikely.