feet, turning in

First, let's subdivide this by age: newborn, toddlers, and pre-schooler/school age. The causes are different.

Infants' feet turn in because of the cramped position in utero. The bones of the fetus are rather soft and pliable; they can take a "set" if subjected to twisting force or cramping. Both the legs (especially the larger lower leg bone - the tibia) and the bones of the feet are affected by the cramping. More about the leg bones in a moment - they are actually twisted.

As for the bones of the feet, they remain pretty straight, but the much softer and stretchier ligaments of the foot easily take a set pointing and curving inward. Usually, this isn't severe enough to worry about. Storke the bottom of the baby's foot and produce the Babinski response. If the foot straightens out in response to this, it is quite flexible and will straighten by itself. Your doctor may give you some foot stretching exercises to do if the ligaments seem tight or if the curvature of the foot is severe. Every once in a while the orthopedist will cast the baby's feet to hurry up the straightening process. Occasionally, reverse last shoes are used as well, but this isn't very often needed.

Toddlers' feet commonly point in for several months to a year after they begin to walk on their own. This is usually caused by the persistent twist in the tibias (shin bones) caused by the cramped positioning in utero (tibial torsion). It is nothing to worry about. Nature will straighten this twist, because bones are living tissue, not inert rocks. They are constantly broken down and rebuilt along the proper lines of stress bearing and will thus naturally straighten. There is no shoe that helps this, period. We used to see a lot of bars used for tibial torsion, but they have largely fallen out of favor. There's no good evidence they work any faster than Mother Nature, and they tend to annoy the toddler.

Pre-school/early school age children generally toe in because of a twist in the thigh bone, the femur. This is naturally called femoral torsion, or femoral anteversion ("knock knee"). It is likewise outgrown, and if it isn't (rare) there isn't much to do except learn to live with it. The surgical cure would be to cut the thigh bones, rotate and pin them, and let them heal. Not something very many people would choose to do, even if they were knock-kneed. Three studies have looked at outcomes for corrective surgery. There was a 15% rate of major complications in all the studies. A few authors have alluded to long term arthritic complications of femoral torsion, but this was not confirmed by autopsy studies1. The majority opinion in orthopedic circles is that there is not enough evidence for this to justify a rather radical and somewhat risky corrective procedure.

1 220 cadavers were dissected and the degree of osteoarthritis of the hip compared with the degree of femoral anteversion. No relationship was found. The conclusion was that surgery would be unnecessary to correct this condition. Journal of Bone and Joint Surgery, August, 1989.

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