Rotational Deformities

Rotational deformities in children include internal femoral torsion, internal tibial torsion and metatarsus adductus, the common causes of in-toeing. Most resolve with growth, so assessment with the Staheli rotational profile and reassurance are the mainstay, and derotation osteotomy is reserved for severe persistent deformity.

Aetiology

1. Physiological
2. Non Physiological
   • Congenital
   • Acquired

Definition

• Torsion
  • Rotation 2 SD <> mean
• Femoral Version
  • Angular difference between Transcervical & Transcondylar Axes
• Tibial Version
  • Angular difference between transcondylar Axis of Knee & TMA
    

Normal Development

• Lower limb bud develops during 4/52
• Great Toe points lateral
• During 7th week bud internally rotates
  • Brings hallux into midline
• For remainder of intrauterine period & childhood limb is externally rotated
  • femoral anteversion decreases
  • tibial external rotation Increased
• Neonates have external rotation hip contracture that masks the femoral Anteversion
• Femoral Anteversion decreases with age
  • 40° Neonate
  • 15° Adult
• Tibia Increased external rotation
  • 5° Neonate
  • 15° Adult
• Internal Rotation In-toe toddlers become external rotation in adults

Classification

• Toeing In
  • Internal Femoral Torsion IFT
  • Internal Tibial Torsion ITT
  • Metatarsus Adductus
• Toeing Out
  • Physiological
  • External Tibial Torsion ETT
  • Pronation / Abduction of the Feet

Assessment

• Initiator of referral
• Reason for presenting
• History
  • Age of onset
  • Severity
  • Disability
  • Previous Management
  • Age first walked
    • If delayed consider CP
  • Family History of In / Out Toeing
• Examination
  • General screening
    • Assess Height percentile
    • Check Spine for Scoliosis
    • Check Hips
    • Examine Feet
• Consider
  • CP (In-toeing)
  • CDH (Limb Asymmetry)
  • SUFE (Out-Toeing)
  • Genu Varum (In-toeing)

• Staheli’s Torsional Profile
  1. Foot Progression Angle
     • Assessed on gait
     • Usually 10° out (0°-30°)
     • (5+/- 10)
  2. Hip Internal Rotation
     • Child prone
     • Usually < 65°
     • > 70° = FAV
     • (45+/-15)
  3. Hip external rotation
     • Usually 40° (20-60°)
     • (45+/- 15)
     • Greater in young child
     • Note Internal Rotation + external rotation should = 90°
  4. Thigh- Foot Angle TFA
     • Child prone & knees flexed
     • Reconstruct foot
     • Usually 15° (0°-30°) external rotation
     • (15 +/-15)
  5. Transmalleolar Axis (TMA)
     • Prone & knees flexed
     • Usually 0 -30° ER
  6. Foot
     • Shape of foot
     • Metatarsus ADD or Everted foot affects FPA
• Normal Examination Figures
  • Foot Progression angle = 5° +/- 10°
  • Thigh Foot angle = 15° +/- 15°
  • ER & Internal Rotation hip = 45° +/- 15°
  • Transmalleolar Axis (TMA) = 0 -30° ER

Investigation

• Required if:
  • Problem complex
  • Intervention planned
• AP Pelvis
  • Acetabular Version
  • DDH
  • SUFE
  • AP & lateral Hip allows calculation of version using tables by Magilligan Tech which converts measurements of neck length into an FAV angle
• CT Scan
  • Direct measurement of femoral & tibial version

Management

• General Principles
  1. Trying to control the sleeping, walking, or sitting of infants & children is impossible
  2. surgery correction effective but carries significant risk
  3. surgery only justified in the child with sev defects that has failed to resolve with time
  4. skewfoot,
     • ITT <-10°
     • ETT>40°
     • FAV>50°
  5. Splints not benefit & interfere with child
  6. Observational Management >99% – only 1 in 1000 need surgery
  7. at least > 8 yrs prior to surgery

Presentations by Age

• 1st Year of Life
  • Feet turn in = MT Adductus
  • One foot external rotation = Metatarsus Adductus Contralateral
  • Both feet turn out = lateral rotation pattern of infants’ hips
• 2nd Year of Life
  • Feet turn in = ITT
• After 3rd Year of Life
  • Feet turn in = FAV
  • Foot turns in = ITT
  • Foot turns out = ETT

TOEING IN

• Most common causes are:
  • femoral Internal Torsion
  • Internal Tibial Torsion
  • MT ADD
  • Talar neck deviation
• Neonate usually 2° MT ADD
• 2 yo usually 2° Internal tibial Torsion
• > 3yo usually 2° FAV
• Mild in-toe helpful for runners

Metatarsus Adductus

• Commonest congenital foot deformity
• Packaging disorder
• Natural History
  • Flexible & resolves Spontaneously in >90%
    • no long term disability if untreated
    • cosmetic only
• Treatment
  • only after 6-9m old (usually resolves prior)
  • POP successful up to 4-5 yo old
    • Above knee cast with knee flexed
    • change casts bi-weekly
  • achieve correction in 2-3 weeks in most
  • if recurs then repeat cast & follow with night splint for 3m
• Operative treatment
  • nearly all correct Spontaneously but if not then at 6-9yo do abductor Hallucis release & MT osteotomy (ie level of deformity)

Metatarsus Varus

• Rigid, plantar crease
• Deforms medial cuneiform
• Often persists & needs treatment
• Cast from age of 3m as above

Skew Foot

• Rare
• Valgus heel, plantar flexed talus, abducted midfoot
• Flexible
• Diagnosis confirmed with AP & lateral XR
  • AP XR – Z due to abd at mid-tarsal jnts & add at MTs
  • Lateral XR – flexion of talus
• Treatment
  • Nonoperative
    • is not helpful
  • Operative
    • Surgery at >/= 6yo
    • opening wedge osteotomy of calcaneus
    • correct midtarsal abduction & to elevate sustentaculum tali under neck of talus to correct talus flexion
    • opening wedge osteotomy of 1st cuneiform to correct forefoot adductus

Dynamic Hallux Adductus

• Searching toe
• No treatment necessary
• Natural History
  • resolves

Internal Tibial Torsion

• Angular difference between Transcondylar Axis of Knee & TMA
• No 1 cause of intoeing in 2 yo
• does not occur in preterm infants
• Natural History – 10% < 2 yrs ITT
  • 2/3 bilateral (ie 1/3 unilateral of these usually left side)
  • associated with MT ADD in 1/3
  • TMA (transmalleolar Axis) Increased 0-5° from age 1 to 2 yrs
  • Tibial external rotation usually continues through childhood
  • presents on walking
  • patella normal position
  • kids tend to trip & appear clumsy
  • Most cases of ITT resolve by 2yo
    • few resolve > 8 yo
  • Resolution not universal
  • +ve FamHistory = Poor prognosis
  • Consider Neuromuscular Disease if:
    • Unilateral
    • Asymmetrical
    • Progressive
  • associated with tibial vara, polio, tibial fractures
• Aetiology
  • ? Packaging defect
  • Prone sleeping with limbs Internal Rotation may delay Spontaneous recovery
• Clinical
  • TFA usually Medial
  • Usually little final deficit
  • May be compensatory pronation & ABD of foot
  • most runners apparently intoe
    • ? advantage
• Treatment
  • almost never required
  • Nonoperative treatment
    • of any sort does not work
    • Splints shown not to work
  • Surgery
    • rarely indicated
    • Supramalleolar Osteotomy
      • Indications
        • 1 TMA > 3 SD (< -10° or > 40°)
        • 2 Age 10+ years
        • 3 Severe disability

Internal Femoral Torsion

• Transverse plane rotation of the femoral neck axis anteriorly relative to the transcondylar axis
• F:M = 2:1
• Bilateral, symmetrical
• Familial
• Aetiology
  • Unknown
• Natural History
  • Resolves in 95%
  • Compensatory ETT may develop after 5 yo
  • Little final disability
  • >50% of patients with persistent femoral Antetorsion achieve normal gait
  • Doesn’t predispose to OA
• Presentation – Intoeing in early childhood
  • Starts 3 yo
  • Max 4-6 yo
• Examination
  • Squinting patellae
  • Sit in W
  • run like egg beaters & trip over
  • Degree estimated by noting the position of the patella with the GT in the direct lateral position
  • Prone Rotation test – find position where greater trochanter most prominent from neutral
  • Increased Internal Rotation = decreases external rotation = 90°
  • abnormal if Internal Rotation > 70°
  • If severe, no external rotation possible
  • If unilateral or progression of in-toeing then Rule out DDH / CP
• Treatment
  • Nonoperative
    • No evidence for orthoses
    • May produce:
      • Lig problems at Knee & Ankle joints
      • Genu Valgum
      • Severe ETT
        
  • Operative
    • Very severe functional gait disturbance
    • age > 10
    • Rotational criteria
      • 1 Internal Rotation >85°
      • 2 external rotation <10°
      • 3 Measured Anteversion > 50°
    • Cosmesis
• Imaging
  • X-ray
    • AP & lateral Hip allows calculation of version using tables by Magilligan Tech which converts measurements of neck length into an FAV angle
  • CT Scan
    • Direct measurement of femoral & tibial version
• Principles
  • leave at least >8-10 because many resolve
  • not needed if 10° external rotation present
  • Derotation osteotomy > 8yo, Better > 12 yo
  • Proximal Intertrochanteric osteotomy best
    • No knee stiffness
    • Cosmesis
    • Better union & fixation
    • Malunion is less obvious
    • Aim Internal Rotation = external rotation

Management Toeing Out

• Normal in neonates
• Due to external rotation hip contractures
• During childhood 2° ETT

External Tibial Torsion

• Presents in late childhood
• Often unilateral
• More often Right side
• Natural History
  • tends to increase
    • rarely a problem until late childhood
    • associated with patellofemoral instability & pain
• Aetiology
  • May occur 2° to IFT; CP; Orthoses for IFT
• Treatment
  • Nonoperative Management
    • useless
  • Operative
    • Osteotomy
      • indicated if TFA > 40°
    • Certain cases of CTEV & NMD

External Femoral Torsion

• associated with OA, Increased stress fracture in LL, SUFE

Torsional Malalignment Syndrome

• “Miserable Malalignment syndrome “
• IFT with compensatory ETT
• Knee Internal Rotation to axis of progression
• Management
  • generally observation only
• Most deformities show
  • Lack of disability
  • Lack of long-term problems
  • Ineffectiveness of Nonoperative Management
• Disability producing defects persist in 1/ 1000

Acetabular Version

• Remains relatively constant through life at 15°
• Not a source of rotational problems
  

Normal Examination Findings

Staheli rotational profile, normal values

Measure	Normal
Foot progression angle	5° ± 10°
Thigh foot angle	15° ± 15°
Hip internal and external rotation	45° ± 15° each
Transmalleolar axis	0 to 30° external rotation

Original publication Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985;67(1):39-47.

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.