Pigeon toe

Last updated • 6 min readFrom Wikipedia, The Free Encyclopedia
Pigeon toe
Other namesMetatarsus varus, metatarsus adductus, in-toe gait, intoeing, false clubfoot
In-toeing.jpg
Specialty Pediatrics, orthopedics

Pigeon toe, also known as in-toeing, is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of age [1] and, when not the result of simple muscle weakness, [2] normally arises from underlying conditions, such as a twisted shin bone or an excessive anteversion (femoral head is more than 15° from the angle of torsion) resulting in the twisting of the thigh bone when the front part of a person's foot is turned in.

Contents

Causes

The cause of in-toeing can be differentiated based on the location of the misalignment. The variants are: [3] [4]

Metatarsus adductus

The most common form of being pigeon toed, when the feet bend inward from the middle part of the foot to the toes. This is the most common congenital foot abnormality, occurring every 1 in 5,000 births. [5] [6] The rate of metatarsus adductus is higher in twin pregnancies and preterm deliveries. [5] Most often self-resolves by one year of age and 90% of cases will resolve spontaneously (without treatment) by age 4. [7]

Signs and Symptoms [5]

Tibial torsion

The tibia or lower leg slightly or severely twists inward when walking or standing. Usually seen in 1-3 year olds, internal tibial torsion is the most common cause of intoeing in toddlers. [5]   It is usually bilateral (both legs) condition that typically self-resolves by 4 to 5 years of age. [6] [5]

Signs and Symptoms [5]

Femoral anteversion

The neck of the femur is angled forward compared to the rest of the bone, causing a compensatory internal rotation of the leg. [8] As a result, all structures downstream of the hip including the thigh, knee, and foot will turn in toward mid-line. [8] Femoral anteversion is the most common cause of in toeing in children older than 3 years of age. [5] [6] It is most commonly bilateral, affects females twice as much as males, and in some families can show a hereditary pattern. [5] This condition may progressively worsen from years 4 to 7, yet the majority of cases still spontaneously resolve by 8 years of age. [6]

Signs and Symptoms [5] [6]

Diagnosis

A Sgarlato's angle of more than 15deg indicates pigeon toe. Sgarlato's angle of metatarsus adductus.jpg
A Sgarlato's angle of more than 15° indicates pigeon toe.

Pigeon toe can be diagnosed by physical examination alone. [10] This can classify the deformity into "flexible", when the foot can be straightened by hand, or otherwise "nonflexible". [10] Still, X-rays are often done in the case of nonflexible pigeon toe. [10] On X-ray, the severity of the condition can be measured with a "metatarsus adductus angle", which is the angle between the directions of the metatarsal bones, as compared to the lesser tarsus (the cuneiforms, the cuboid and the navicular bone). [11] Many variants of this measurement exist, but Sgarlato's angle has been found to at least have favorable correlation with other measurements. [12] Sgarlato's angle is defined as the angle between: [9] [13]

This angle is normally up to 15°, and an increased angle indicates pigeon toe. [9] Yet, it becomes more difficult to infer the locations of the joints in younger children due to incomplete ossification of the bones, especially when younger than 3–4 years.[ citation needed ]

Internal Tibial Torsion

Internal tibial torsion is diagnosed by physical exam. [6] The principle clinical exam is an assessment of the thigh-foot angle. [6]   The affected individual is placed in prone position with the knees flexed to 90 degrees. [6]   An imaginary line is drawn along the longitudinal axis of the thigh, and of the sole of the foot from a birds-eye view and the angle at the intersection of these two lines is measured. [6]   A value greater than 10 degrees of internal rotation is considered internal tibial torsion. [6]   A thigh-foot angle less than 10 degrees internal, and up to 30 degrees of external rotation is considered normal. [6]

Femoral Anteversion

Femoral anteversion is diagnosed by physical exam. [6]   The principle physical exam maneuver is an assessment of hip mobility. [6] The child is evaluated in the prone position with knees flexed to 90 degrees. [6] Using the tibia as a lever arm the femur is rotated both internally and externally. [6]   A positive exam demonstrates internal rotation of greater than 70 degrees and external rotation reduced to less than 20 degrees. [6] Normal values for internal rotation are between 20 and 60 degrees and normal values for external rotation are between 30 and 60 degrees. [6]  

Treatment

In those less than eight years old with simple in-toeing and minor symptoms, no specific treatment is needed. [14]

Metatarsus Adductus

Nonoperative management: Non operative treatment of metatarsus adductus is dictated by the flexibility of the forefoot. [6]   If the child can actively correct the forefoot to midline no treatment is indicated. [6]   If the adduction cannot be corrected actively but is flexible in passive correction by an examiner, at-home stretching that mimics this maneuver can be performed by parents. [6] In the case of a rigid deformity serial casting can straighten the foot. [6]

Surgical Management: Most cases of metatarsus adductus that does not resolve is asymptomatic in adulthood and does not require surgery. [6] Occasionally, persistent rigid metatarsus adductus can produce difficulty and significant pain associated with inability to find accommodating footwear. [5] Surgical options include tasometatarsal capsulotomy with tendontransfers or tarsal osteotomies. [5] Due to the high failure rate of capsulotomy and tendon transfer it is generally avoided. [6] [5] Osteotomy (cutting of bone) and realignment of the medial cuneiform, cuboid, or second through fourth metatarsal the safer and most effective surgery in patients over the age of 3 years old with residual rigid metatarsus adductus. [5]

Internal Tibial Torsion

Nonoperative management: There are no bracing, casting, or orthotic techniques that have been shown to impact resolution of tibial torsion. [5] [6]   This rotational limb variant does not increase risk for functional disability or higher rates of arthritis if unresolved. [6] Management involves parental education and observational visits to monitor for failure to resolve. [15]

Surgical management: Indications for surgical correction are a thigh foot angle greater than 15 degrees in a child greater than 8 years of age that is experiencing functional limitations because of their condition. [6] Surgical correction is achieved most commonly through a tibial derotational osteotomy. This procedure involves the cutting (osteotomy) and straightening (derotation) of the tibia, followed by internal fixation to allow the bone to heal in place. [15]

Femoral Anteversion

Nonoperative management: Nonoperative treatment includes observation and parental education. Treatment modalities such as bracing, physical therapy, and sitting restrictions have not demonstrated any significant impact on the natural history of femoral anteversion. [6]

Surgical management: Operative treatment is reserved for children with significant functional or cosmetic difficulties due to residual femoral anteversion greater than 50 degrees or internal hip rotation greater than 80 degrees after age 8. [5] [6] Surgical correction is achieved though a femoral derotation osteotomy. [8] This procedure involves the cutting (osteotomy) and straightening (derotation) of the femur, followed by internal fixation and to allow the bone to heal in place.[ citation needed ]

See also

Related Research Articles

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Human leg</span> Lower extremity or limb of the human body (foot, lower leg, thigh and hip)

The human leg is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or buttock region. The major bones of the leg are the femur, tibia, and adjacent fibula. The thigh is between the hip and knee, while the calf (rear) and shin (front) are between the knee and foot.

<span class="mw-page-title-main">Bunion</span> Deformity characterized by lateral deviation of the big toe

A bunion, also known as hallux valgus, is a deformity of the joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is typically gradual. Complications may include bursitis or arthritis.

<span class="mw-page-title-main">Ankle</span> Region where the foot and the leg meet

The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

<span class="mw-page-title-main">Coxa vara</span> Deformity of the hip

Coxa vara is a deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees. This results in the leg being shortened and the development of a limp. It may be congenital and is commonly caused by injury, such as a fracture. It can also occur when the bone tissue in the neck of the femur is softer than normal, causing it to bend under the weight of the body. This may either be congenital or the result of a bone disorder. The most common cause of coxa vara is either congenital or developmental. Other common causes include metabolic bone diseases, post-Perthes deformity, osteomyelitis, and post traumatic. Shepherd's Crook deformity is a severe form of coxa vara where the proximal femur is severely deformed with a reduction in the neck shaft angle beyond 90 degrees. It is most commonly a sequela of osteogenesis imperfecta, Paget's disease, osteomyelitis, tumour and tumour-like conditions.

<span class="mw-page-title-main">Genu valgum</span> Medical condition known as knock-knee

Genu valgum, commonly called "knock-knee", is a condition in which the knees angle in and touch each other when the legs are straightened. Individuals with severe valgus deformities are typically unable to touch their feet together while simultaneously straightening the legs. The term originates from the Latin genu, 'knee', and valgus which means "bent outwards", but is also used to describe the distal portion of the knee joint which bends outwards and thus the proximal portion seems to be bent inwards.

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References

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