In-Toe Assessment

In-toeing in children is common, and of great concern to parents. In-toeing originates at one or more of three sources: the proximal femur (femoral anteversion), the tibia (internal tibial torsion), or the forefoot (forefoot adductus, also called metatarsus adductus). Femoral anteversion at the hip may be hereditary, while intrauterine position may create internal tibial torsion and metatarsus adductus. Progressive derotation of the limbs occur during normal growth, and certain sitting and sleeping positions may interfere with this process.


Examination involves watching the child walk barefoot, and then prone on a table with the feet just over the end (Staheli method). Children in-toe and
trip when they are most tired near the end of the day.

Femoral anteversion:

is assessed by com-paring the amount of internal versus external hip rotation (Craig’s Test), the normal range being equal, approximately 70 degrees each way. In the examining position, the knee is flexed to 90 degrees, then holding the right ankle and swinging it out and down to the right, the femur will internally rotate. Femoral anteversion usually exists when the maximum I.R. is greater than the normal 70 degrees, or when there is a predominance of internal versus external rotation. The abscence of tibial and forefoot torsions on examination may help confirm the more common source at the hip.

Internal tibial torsion
exists when a bisected line through the heel, compared to a line bisecting the thigh, is less than 0 degrees. This thigh-foot angle is also measured with the knee flexed to 90 degrees in the examination position. Normal thigh-foot angle is from 0 to 30 degrees of external rotatation.

Forefoot adductus
is similarly measured by comparing bisection lines through the heel and the forefoot. Normally a line bisecting the heel should continue on to pass close to the medial aspect of the 3rd toe. Adductus is present when this line passes lateral to the 3rd toe. The lateral border of the foot may be convex in appearance, and the 5th metatarsal head may be prominent.


Treatment of femoral anteversion is generally passive since the limbs generally derotate up to about age 12. This is frustrating to parents since it does not appear to be proactive. It is impossible to predict if residual toe-in will be excessive until normal derotation occurs. Noting that Wayne Gretzky is toed-in is reassuring to both child and parent. After age 4, the child may develop external tibial torsion to compensate. Avoid sleeping and sitting positions that slow derotaation, and sports that encourage it like skating, ballet and gymnastics. In-toe in the older child is usually persistent femoral anteversion. Bracing has not been found to be effective. Mild residual adult toe-in does not usually result in any functional restrictions from sports participation.

Internal tibial rotation
is usually noted when the child begins to walk and usually resolves spontataneously at 18 months. The rapid period of growth following this time may be assisted by night splints (Dennis-Browne, Langer Counter derotational splints) which discourage rotation. Forefoot adductus is noted shortly after birth and most cases spontaneously resolve in the first few months. Continued deformity is controversial, including serial casting, reversed or straight lasted shoes, surgery or continued observation.

** The above information is not intended to replace a physicians advice. Seek a physicians advice first.

Author Derek Gilmer

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