summary Internal Tibial Torsion is a common condition in children less than age 4 which typically presents with internal rotation of the tibia and an in-toeing gait. Diagnosis is made clinically with a thigh-foot angle > 10 degrees of internal rotation in a patient with an in-toeing gait. Treatment is observation in most cases as the condition usually resolves spontaneously by age 4. Surgical management is indicated in children > 6-8 years of age with functional problems and thigh-foot angle >15 degrees. Epidemiology Incidence most common cause of in-toeing in toddlers Demographics usually seen in 1-3 year olds Anatomic location often bilateral Etiology Pathophysiology exact etiology unknown believed to be caused by intra-uterine positioning and molding Presentation History commonly noticed once child begins walking parents report that the legs are "turning in" increased tripping and/or falling Symptoms usually asymptomatic Physical exam Rotational profile assessment foot progression angle hip internal rotation to identify increased femoral anteversion thigh foot angle to quantify tibial torsion heel bisector to identify metatarsus adductus Foot progression angle directed internal product of hip rotation, tibial torsion and shape of foot. measure angle between foot position and imaginary straight line while walking normal is -5 to +20 degrees thigh-foot angle directed internal technique login to view 2 more bullets normal values login to view 2 more bullets thigh-foot angle > 10 degrees internal is generally considered as intoeing transmalleolar axis > 15 degrees internal technique login to view 1 more bullet normal login to view 2 more bullets Imaging Radiographs usually not indicated unless other conditions present (see above) Advanced imaging CT or MRI can be utlized for surgical planning (in the few cases that require surgery) Differential Causes of Intoeing Condition Key findings Metatarsus Adductus Medial deviation of the forefoot (abnormal heel bisector), normal hindfoot Tibial Torsion Thigh-foot angle > 10 degrees internal Femoral Anteversion Internal rotation >70 degrees and < 20 degrees of external rotation In-toeing associated with the following necessitates further work-up pain limb length discrepancy progressive deformity family history positive for rickets/skeletal dysplasias/mucopolysaccharidoses limb rotational profiles 2 standard deviations outside of normal Treatment Nonoperative observation and parental education indications login to view 1 more bullet outcomes login to view 2 more bullets Operative derotational supramalleolar tibial osteotomy vs. proximal osteotomy indications login to view 2 more bullets technique login to view 3 more bullets Prognosis Usually resolves spontaneously by age 4