Initial pre-referral workup

Clinical history

Common causes:

• infant – metatarsus adductus
• toddler – internal tibial torsion
• school-age child – increased femoral anteversion (excessive range of internal rotation and small range of external rotation)

Physical examination

Observe the child’s gait.

Place in prone and check range for internal and external rotation of the hip, thigh-foot angle and foot posture.

GP management

Reassure parents that in-toeing in most children will improve as they grow and no treatment is required.

In-toeing can persist into adult life but rarely does this seem to cause major problems.

Refer parents to In-toeing in children (fact sheet).

Indications for specialist referral

Routine

• in-toeing exceeds normal limits for age
• asymmetrical deformity
• tripping in a school-age child that affects participation in activities
• progressive in-toeing
• associated patella pain
• hypertonicity