Epidemiology

Large clinical series of healthy children reveal that lower-limb rotational alignment varies widely throughout childhood.[2][3][4][5]​ In the absence of neuromuscular disease, femoral anteversion and tibial torsion are within normal values in 84% to 98% of the population, regardless of age or sex.[5] Although most torsional problems are normal variations, they cause concern in parents and are among the most common reasons for a paediatric orthopaedic referral from a primary care paediatric provider.[6] Considering the various methods to measure limb rotation through physical examination (primarily the rotational profile) and subtle population differences, torsional 'deformities' by definition fall outside 2 standard deviations from the mean of normative values of the torsional profile, thereby including approximately 5% of the population.[1][2][5][7][8][9]​ However, this does not imply that these patients have some degree of disability or that patients with borderline values do not. Torsional variations are common in infants and toddlers and rare in adolescents due to physiological bone remodelling during growth.

Common rotational variations include: 1) physiological femoral anteversion and internal tibial torsion (seen in 2% to 9% from a mean age of 3-8 years); and 2) increased femoral anteversion and normal tibial torsion (seen in 1% to 9% of children from a mean age of 6-9 years, and higher in females at any age).

Overall, in-toeing is more common than out-toeing. In early infancy, inward rotation of the feet is most likely due to metatarsus adductus or, less commonly, hallux varus. In toddlers, in-toeing is commonly due to internal (medial) tibial torsion. In-toeing in early childhood and adolescence (especially in girls) is usually due to internal (medial) femoral torsion (anteversion). Torsional deformities are more frequent and more often severe in patients with neuromuscular conditions.[10][11][12][13][14][15]

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