During the first year of life, children’s feet usually point outwards (out-toeing). The cause of this is a pronounced exorotation (80-90°) of the hip due to the child seeking better stability. With the hips extended, the total rotation is normally 100°.
Children with weak ligaments (joint laxity) form an exception to this observation. From the age of about four years onwards, the endorotation range of motion is virtually the same as that for exorotation (both about 50°). Persistent ‘out-toeing’ occurs in children with a neuromuscular disorder (spina bifida, muscular diseases).
However, sometimes there can be pronounced endorotation in the femur. If this rotation is more than 70°, the child will walk with the toes pointing inwards (pigeon toes or ‘in-toeing’). These children (usually aged between 3 and 7 years) tend to trip more frequently than their peers and when examined, the patellae clearly point medially.
The abnormality corrects itself spontaneously, before the age of 12 years in 80% of cases. If the abnormality does not correct itself spontaneously, a posture is usually observed in which the patallae point medially with compensatory pronounced exotorsion in the tibiae (more than 20°). As a result, the toes point forwards. In rare cases, no pronounced exorotation occurs, yet compensatory abduction of the forefoot occurs. Therefore, a pes planovalgus develops due to partial dislocation of the talocalcaneonavicular joint.
Sometimes, the child is pigeon-toed from an earlier age (1-2 years onwards). The cause of this may be pronounced endotorsion in the tibiae or a foot abnormality (metatarsus adductus or metatarsus varus). Usually, these children prefer sleeping on their stomach, with the knees drawn upwards. This sleeping posture leads to the physiological untwisting of the lower leg skeleton. Upon inspection of the child, it can be seen that the patellae point ventrally instead of medially.
The pronounced endotorsion may occur asymmetrically and usually also corrects itself before the twelfth year of age. The metatarsus adductus corrects itself in 90% of cases before the age of six months. However, sometimes in this age group, pronounced endorotation (anteversion) in the femur (even by 90°) can be the cause.
