Toeing the Line on Your Baby’s Feet

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Maybe it’s because baby footprints are one of the first things done after birth. Maybe it’s because what makes us relatively unique in the animal kingdom is our getting around on our two feet. Maybe it’s the first thing we see when we look down at a child. Whatever the reason, there are few external features in an infant or young child that parents notice—and worry about—as much as feet.

I have most recently practiced in an area that is over 100 miles from the nearest pediatric orthopedic surgeon—the specialist that most often deals with leg and foot abnormalities in young children. Many parents request a referral, most commonly for inward turning feet. Many conditions that cause feet to appear to turn inward are normal variants, and many get better on their own. It breaks my heart to see a family drive that long distance for reassurance regarding benign, self-resolving conditions. Yet for many, it’s the only option to achieve peace of mind.

On the other hand, there are infant foot abnormalities that really do need treatment, sometimes urgently. In deciding which babies and children will need to be treated, it’s helpful to know that an inward turning foot can be caused by a deviation anywhere from the foot all the way up to the thigh bone. While every case is different, particularly in children with other abnormalities, for most children there is a helpful rule of thumb:

  • The further the abnormality is down toward the foot (and away from the hip; in other words, the more distal),
  • The earlier it tends to show up, and
  • The more likely it will need some treatment.

As we talk about some issues we see in infants and children, this rule of thumb will become clearer. Let’s start at the foot and work our way up.

Clubfoot

Clubfoot, also known as talipes equinovarus, is present in 1 in 1000 live births, and can often be diagnosed on prenatal ultrasound. The best way to describe clubfoot is to turn one foot so that your sole is facing your opposite ankle. The heel bone is involved along with the rest of the foot, and the foot can’t be flexed upward toward the ankle (known as an equinus deformity).

This condition always needs treatment. Usually the orthopedist will use a series of casts, which should be started by a few weeks of age. (I have heard that in days past, an orthopedist would even be paged emergently to the nursery for a newborn with a clubfoot. This doesn’t appear to happen nowadays, but treatment should be started early.) Also often part of the regimen are special shoes, bracing, and surgery on the tendon.

Metatarsus Adductus

Like clubfoot, this condition, which is present in 1 of every 1000-1500 babies, tends to show up early. In the newborn period, it can look a lot like clubfoot. The heel bone, however, is not involved. Generally, by a few days of age, you can see the characteristic curved border of the side of the foot, and a crease on the inner edge of the sole.

This, too, is treated, although the treatment in this case consists mostly of stretching exercises. Occasionally, casting or special shoes are needed. Rarely does a case require surgery.

Internal Tibial Torsion

Technically, internal tibial torsion isn’t a foot problem. Rather, it occurs when the lower leg bone known as the tibia is twisted. The twisting, or torsion, of this bone makes the feet turn inward and is usually most obvious when the little one begins to walk. There may appear to be bowlegs as well, especially in early walkers. (There also exists a condition known as external tibial torsion, where the feet appear to turn outward; this is less common.)

While children with internal tibial torsion used to receive treatment, usually with a special bar, nowadays it’s a rare child that receives any therapy for it. The condition either gets better on its own or is sufficiently mild that it in no way interferes with activity.

Femoral Anteversion

Femoral anteversion isn’t a foot problem, either. Rather, it occurs when the femur, or thigh bone, is bent past the normal angle. Infants have some femoral anteversion normally, and it generally self-corrects over time. However, in some children it persists, leading to intoeing which becomes most noticeable in preschool or early school age. Another clue to femoral anteversion is a child sitting in the “W” position.

Femoral anteversion rarely causes problems, and the treatment involves surgically severing the femurs and reforming them. For this reason, it’s treated only in the most extreme circumstances.

Some Final Thoughts

Back in the day, much faith was placed in a variety of treatments, some of which are noted above, to develop the ideal foot and/or the ideal gait. An entire children’s shoe industry was developed behind the thinking that certain shoes were necessary for the development of healthy children’s feet.

As we’ve seen, only a couple of conditions need treatment regularly. Your pediatric provider is trained to evaluate your child for conditions that might be contributing to her intoeing and discuss the need for treatment (or lack of it). For most kids, shoes just function to protect feet from the environment. In fact, going barefoot has been shown to produce better mobility and foot development. If you have clean, warm and safe surfaces in your household, it’s likely that “barefoot is best” for your youngest walker!

Reference:

Smith B. Lower Extremity Disorders in Children and Adolescents. Pediatr Rev 2009 Aug;30(8):287-294.

Stan Sack
Dr. Stan Sack has 29 years’ experience as a primary care pediatrician in Massachusetts and Florida. A medical writer since 2015, he enjoys blogging on topics that are on parents’ minds but are covered less often in books and on websites. He lives in the Florida Keys with his family and enjoys healthy cooking, fitness activities and singing in his spare time.

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