Rotational (Twisting) Deformities in Deformities in Children

Figure 1. Clinical assessment of tibial torsion in a child: (A) prone examination with the knees flexed to 90°; (B) measurement of the thigh–foot angle (TFA); (C) assessment of the external transmalleolar (tibial) torsion angle (ETT).

Rotational deformities are common childhood differences in the way the legs and feet point while standing, walking, or running. Parents often notice intoeing (“pigeon toes”) or out-toeing (feet pointing outward). In most children these patterns are normal developmental variants that improve with growth and do not cause long-term problems. ¹^-⁵

This article explains the most common causes, what is typical by age, warning signs to watch for, and what treatments are (and are not) helpful.

What “rotational deformity” means

“Rotation” refers to twisting around the long axis of the leg bones:

• Femur (thigh bone): rotation at/near the hip (femoral version).

• Tibia (shin bone): tibial torsion.

• Foot: shape/position of the forefoot (e.g., metatarsus adductus).

These differences can change naturally as children grow, especially in the first decade of life.¹^-⁵

The most common patterns and causes

1) Intoeing (feet point inward)

The three most common causes are: metatarsus adductus, internal tibial torsion, and increased femoral anteversion. ²^-⁴

A. Metatarsus adductus (infants)

• What it is: the front half of the foot curves inward (often a “C-shaped” foot).²^-⁴

• Why it happens: commonly linked to positioning in the womb. ⁶

• Typical course: many cases are flexible and improve on their own in early childhood. ²^,⁶

• Sometimes helpful: gentle stretching for flexible cases; a small minority may need casting or orthopaedic input if rigid/persistent. ⁶

B. Internal tibial torsion (toddlers)

• What it is: the shin bone is rotated inward, making the feet point in.²^–⁴

• Typical course: usually improves with growth and walking development; management is typically reassurance and observation.²^–⁴^,⁷

C. Increased femoral anteversion (ages ~3–8)

• What it is: the femur is rotated inward, so knees and feet may turn inward.¹^–⁵

• Clues you may notice: “W-sitting” is commonly associated (it can be comfortable for children with more hip internal rotation).⁵

• Typical course: often becomes most noticeable in early school years and gradually improves over time; most children do well without treatment.¹^,²^,⁴^,⁵

2) Out-toeing (feet point outward)

Out-toeing is less common than intoeing and is more often noticed in older children.⁴Common developmental causes include:

• External tibial torsion (shin rotated outward).⁴

• Femoral retroversion (thigh rotated outward).⁴

Out-toeing can still be a normal variant, but persistent or worsening out-toeing—especially with symptoms deserves assessment.⁴^,⁷

How clinicians assess rotational differences

Diagnosis is usually made with history and physical examination, sometimes using a “torsional profile” (a set of measurements of hip rotation, thigh-foot angle, and foot shape).²^,⁴Imaging (X-ray/CT) is not routinely needed for typical developmental intoeing/out-toeing.²^,⁴

What to do at home (and what usually isn’t needed)

Reassurance and monitoring

For most children, the main treatment is:

• Reassurance

• Serial observation during routine visits (watching for improvement over time)²^,⁴

What usually does not help

For typical developmental intoeing:

• Special shoes, braces, or orthotics have not been shown to speed up normal rotational correction in most cases and are not routinely recommended in standard primary-care guidance.²^,⁴

When treatment is considered

Treatment may be considered when a rotational issue is:

• Rigid (especially in metatarsus adductus), progressive, or functionally limiting, or

• Persisting beyond expected ages with significant impairment, where specialist assessment may discuss options (rarely including surgery in carefully selected cases).¹^,²^,⁴^,⁵^,⁷

When to seek medical review urgently or sooner than routine

Arrange prompt assessment if your child has any of the following:

• Pain, limping, frequent falls beyond what seems typical, or reduced activity tolerance.⁴

• One-sided (asymmetric) rotation (one leg very different from the other).⁴^,⁷

• Worsening deformity over time rather than gradual improvement.⁴

• Stiff/rigid foot shape (cannot be gently corrected toward straight).⁶

• Concerns about underlying neurological or developmental conditions (e.g., abnormal muscle tone, delayed milestones).³^,⁴

Prognosis

Most children with common developmental rotational patterns:

• Do not develop arthritis because of mild-to-moderate intoeing alone, and

• Grow into normal or near-normal alignment and function. ¹^–⁴^,⁷

The key is distinguishing typical development from the smaller group needing targeted assessment.

References

1.     American Academy of Orthopaedic Surgeons. Intoeing. OrthoInfo. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/intoeing/

2. Talley W, Goodemote P. Managing intoeing in children. Am Fam Physician. 2011;84(8):937-44. Available from: https://www.aafp.org/pubs/afp/issues/2011/1015/p937.html

3. American Academy of Pediatrics. Intoeing and outtoeing (PDF chapter). Available from: https://publications.aap.org/books/chapter-pdf/770804/aap_9781581105698-part02-intoeing_and_outtoeing.pdf

4. Rerucha CM, Dickison C, Baird DC. Lower extremity abnormalities in children. Am Fam Physician. 2017;96(4):226-33. Available from: https://www.aafp.org/pubs/afp/issues/2017/0815/p226.html

5. National Institute for Health and Care Excellence (NICE). Common musculoskeletal presentations in children: In-toeing. NICE CKS. Available from: https://cks.nice.org.uk/topics/common-musculoskeletal-presentations-in-children/background-information/in-toeing/

6. The Royal Children’s Hospital Melbourne. Intoeing (patient information PDF). Available from: https://www.rch.org.au/uploadedFiles/Main/Content/rheumatology/intoeing.pdf

7. Children’s Health Ireland. In-toeing in children. Available from: https://www.childrenshealthireland.ie/list-of-services/orthopaedics/in-toeing-in-children/

Image: Loh B, Coates A, Woollett E. Figure 3: Measurement of tibial torsion (TFA and ETT). In: Paediatric rotational abnormalities: A primer. Aust J Gen Pract. 2021 Mar;50(3):132-135. doi:10.31128/AJGP-08-20-5561.

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