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Torsional
Deformities
(Pigeon toes)
| * Explanation | * Symptoms | * Diagnosis | * Duration |
| * Prevention | * Treatment | * Call your Doctor | * Prognosis |
Torsional deformities are abnormal inward or outward rotations of the femur (the leg bone between the knee and hip) or tibia (the larger of the two bones between the knee and ankle). The condition is also referred to as "Pigeon Toes". Internal torsion (abnormal inward rotation) of these bones tends to cause in-toeing — walking with the toes pointed inward at an angle greater than 10° from the midline. External torsion (abnormal outward rotation) tends to cause out-toeing — walking with the toes pointed outward at an angle greater than 30° from the midline.
In most young children, torsional deformities appear for short periods, then ultimately disappear during the normal stages of leg development. However, in some cases the degree of torsion is greater than average, possibly because of one or more of the following factors:
Because parents often worry that in-toeing or out-toeing will permanently interfere with their child's ability to walk and run normally, torsional deformities are among the most common reasons why children are seen by pediatricians for bone-related complaints.
Torsional Deformities That Cause In-Toeing
Internal femoral torsion — In this condition, in-toeing is caused by an abnormal inward rotation of the femur. It is the most frequent cause of in-toeing in children older than 2, and it is twice as common in girls than in boys. Experts are debating the cause of internal femoral torsion. Some believe that it is an inborn problem related to a child's position in the uterus before birth, whereas others blame it on a child's poor sitting habits. Specifically, children seem to be at higher risk of this problem if they frequently sit in the "W" or "television" position, with their knees pointed forward and their legs splayed to either side.
Internal tibial torsion — In this condition, in-toeing is caused by an abnormal inward rotation of the tibia. It is the most common cause of in-toeing in toddlers younger than 2, and it is related to a child's position in the uterus before birth.
Torsional Deformities That Cause Out-Toeing
External tibial torsion — In this condition, out-toeing is caused by an abnormal outward rotation of the tibia, which is almost always related to a child's position in the uterus before birth. External tibial torsion is the most common cause of out-toeing, and it almost exclusively affects infants who haven't started to walk.
External femoral torsion (also called femoral retroversion) — In this rather uncommon condition, out-toeing is caused by an abnormal outward rotation of the femur. If it affects both legs, external femoral torsion is usually idiopathic (that is, it has no known cause). If external femoral torsion is seen in only one leg, it may be a symptom of slipped capital femoral epiphysis (SCFE). SCFE is a serious misalignment of part of the upper portion of the femur. It commonly occurs in obese adolescents, in whom it is probably related to the mechanical stress of excess weight at the hip joint.
The in-toeing of internal femoral torsion typically develops in children 3 to 6 years of age, whereas both internal tibial torsion and external tibial torsion are most commonly seen in toddlers younger than 2. Although childhood torsional deformities tend to worry parents, they are usually painless conditions that rarely interfere with a child's ability to walk, run and play normally.
What Your Doctor Looks For
The doctor will begin by reviewing your child's medical history, including pregnancy course, birth and developmental milestones. Your doctor may then ask the following:
The doctor will begin by reviewing your child's symptoms, family history, medical history and orthopedic/podiatric history. Then, the doctor will examine:
In most cases, your doctor can make a final diagnosis based on your child's age and history, together with the results of the physical examination. X-rays are not usually necessary, except to rule out SCFE in a child with external femoral torsion.
Almost all torsional deformities are short-term conditions that resolve before a child reaches adulthood. For example, internal tibial torsion usually disappears by the time a child is 3 or 4 years old, whereas internal femoral torsion resolves before age 10. External tibial torsion is a very short-term condition that improves dramatically as soon as a child learns to walk and disappears totally by the time the child is 2 or 3 years old.
Although they are commonly called deformities, most femoral and tibial torsions actually represent predictable stages during normal childhood development of the legs. For this reason, you would not need to prevent them. The one exception might be internal femoral torsion caused by your child sitting in the "W" or "television" position. In this case, your child may be able to avoid the problem by sitting in a chair while watching television.
In most cases, doctors do not treat torsional deformities, because these conditions usually disappear as children grow older. In very rare cases, surgery can be used to correct a severe torsional deformity that persists into a child's teen-age years.
Important: SCFE requires urgent referral to an orthopedic specialist. When external femoral torsion is caused by SCFE, the condition is corrected surgically.
Call your pediatrician or family doctor if you have any concerns about the way that your child walks or runs, especially if your child seems to trip or fall more often than other children of the same age.
Even if your child appears to be walking and running normally, it is wise to check with your doctor periodically about your child's foot and leg development, just to be sure that everything is progressing as expected.
Because 90 percent to 95 percent of torsional deformities resolve by the time children mature, the prognosis is excellent.