Pigeon toe

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 and, when not the result of simple muscle weakness, 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.

Causes The cause of in-toeing can be differentiated based on the location of the misalignment. The variants are:

Curved foot (metatarsus adductus) Twisted shin (tibial torsion) Twisted thighbone (femoral anteversion)

Metatarsus adductus This is 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. The rate of metatarsus adductus is higher in twin pregnancies and preterm deliveries. Most often self-resolves by one year of age and 90% of cases will resolve spontaneously (without treatment) by age 4. Signs and Symptoms

C-shaped lateral border of foot Intoeing gait Pressure sites during shoe wear

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. It is usually bilateral (both legs) condition that typically self-resolves by 4 to 5 years of age. Signs and Symptoms

Frequent tripping and clumsiness Intoeing gait

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. As a result, all structures downstream of the hip including the thigh, knee, and foot will turn in toward mid-line. Femoral anteversion is the most common cause of in-toeing in children older than 3 years of age. It is most commonly bilateral, affects females twice as much as males, and in some families can show a hereditary pattern. This condition may progressively worsen from years 4 to 7, yet the majority of cases still spontaneously resolve by 8 years of age. Signs and Symptoms

W-sitting and inability to sit cross-legged In-toeing gait Circumduction gait (legs swing around one another) Frequent tripping and clumsiness

Diagnosis

Pigeon toe can be diagnosed by physical examination alone. This can classify the deformity into "flexible", when the foot can be straightened by hand, or otherwise "nonflexible". Still, X-rays are often done in the case of nonflexible pigeon toe. 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). Many variants of this measurement exist, but Sgarlato's angle has been found to at least have favorable correlation with other measurements. Sgarlato's angle is defined as the angle between:

A line through the longitudinal axis of the second metatarsal bone. The longitudinal axis of the lesser tarsal bones. For this purpose, one line is drawn between the lateral limits of the fourth tarsometatarsal joint and the calcaneocuboid joint, and another line is drawn between the medial limits of the talonavicular joint and the 1st tarsometatarsal joint. The transverse axis is defined as going through the middle of those lines, and hence the longitudinal axis is perpendicular to this axis. This angle is normally up to 15°, and an increased angle indicates pigeon toe. 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. Internal Tibial Torsion Internal tibial torsion is diagnosed by physical exam. The principle clinical exam is an assessment of the thigh-foot angle. The affected individual is placed in prone position with the knees flexed to 90 degrees. 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. A value greater than 10 degrees of internal rotation is considered internal tibial torsion. A thigh-foot angle less than 10 degrees internal, and up to 30 degrees of external rotation is considered normal. Femoral Anteversion Femoral anteversion is diagnosed by physical exam. The principle physical exam maneuver is an assessment of hip mobility. The child is evaluated in the prone position with knees flexed to 90 degrees. Using the tibia as a lever arm the femur is rotated both internally and externally. A positive exam demonstrates internal rotation of greater than 70 degrees and external rotation reduced to less than 20 degrees. Normal values for internal rotation are between 20 and 60 degrees and normal values for external rotation are between 30 and 60 degrees.

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