• Heredity-family tendency
• Normal fetal development
• Intrauterine position
• Posturing (sitting position): cause or effect?
• Associated pathology (spasticity or DDH, for example)
• This condition does not, by itself, cause pain. If the child is in pain, look for another diagnosis.
• Function is usually good but may be associated with minor problems (i.e., intoeing with running).
• Increased femoral anteversion may be associated with other pathology, such as DDH, SCFE, or mild cerebral palsy.

• Usually excellent
• Most will correct or improve with no treatment.

• DDH
• SCFE
• Mild cerebral palsy
• Fracture or osteotomy malunion
• Leg length discrepancy
• Internal tibial torsion
• Increased femoral anteversion may be associated with any of the other conditions.

• Intoeing is usually noticed by 2 to 3 years of age as the foot turning inward.
• Often, the family also complains of the child being clumsy, with awkward, slow running.
• Birth history (first-born common), pain, limping, family history, other “packaging” conditions (metatarsus adductus, torticollis), when first noticed, getting better or worse, functional limitations (i.e., trips and falls frequently)

• If ambulatory, watch the child walk and assess for foot-progression angle (the angle formed between the axis of the foot and the axis of forward progression of gait).
• Also assess other aspects of gait (stride, heel-toe gait, cadence, limping, other abnormalities).
• Unilateral or bilateral torsion
• Look for leg length discrepancy, hip abnormalities, contractures, spasticity.

• With the child prone, the knee flexed to 90 degrees and the ankle at neutral, measure the difference between the axis of the foot and the axis of the femur.
• If the thigh–foot axis is internal, this suggests internal tibial torsion; if external, external tibial torsion.

• With the child seated and the knee flexed to 90 degrees, assess the malleolar axis in reference to the coronal plane (less reliable than TFA).
• Look for abnormalities of the feet. Metatarsus adductus or clubfoot may be a primary cause of intoeing.
• Marked calcaneovagus may be a component of outtoeing.
• Do a careful neurologic examination to see if intoeing is related to a mild neurologic abnormality (such as mild spastic diplegic cerebral palsy).
• One can also evaluate by palpating the midpoint of the lateral greater trochanter and comparing this axis with that of the distal femoral condylar axis.
• This method is less reproducible.
• Look for increased Q-angle (angle formed by axis of pull of the quadriceps and the axis of the patellar tendon)

• Foot-progression angle
• Medial hip rotation in extension
• Lateral hip rotation
• Thigh–foot angle
• Transmalleolar axis
• Configuration of the foot

• Usually not helpful

• X-ray: X-ray has been used, but in addition to not adding much, there are difficulties positioning the patient reproducibly, there is the factor of radiation exposure, and x-rays are not very reproducible. Complicated tables for analyzing data are available.
• CT: CT is an accurate way of measuring anteversion, but there is radiation exposure. The usual indication is the occasional patient who is being evaluated for surgery.
• Techniques for using MRI and ultrasound have also been described but, in general, are less accurate than CT.

• Observation and family and patient reassurance (almost always the treatment of choice)
• Devices such as casts, shoe wedges, twister cables, splints, and Denis Browne bars have no proven benefit (i.e., they will not change the natural history). They may in fact cause problems such as ligamentous damage to hip, knee, ankle, and foot.

• Observation (i.e., no treatment)
  • Physical therapy will not change natural history, but it may help with associated patellofemoral malalignment pain.
  • Devices (casts, shoe wedges, twister cables, splints, Denis Brown bars)
  • Femoral osteotomy for increased femoral anteversion:
    • Very seldom needed
      • Greater than 45 degrees above normal
      • No lateral rotation of the hip
      • Major cosmetic problem with no improvement with growth

• Not helpful

Q: How will a child with increased femoral anteversion likely sit on the floor?
A: These children often sit in a position called “w sitting,” with the hips and knees flexed and the hips internally rotated such that the legs look like a “w.”

Q: If a child has increased femoral anteversion but walks with the foot-progression angle close to normal, what compensatory situation likely exists?
A: The child likely also has compensatory external tibial torsion (i.e., an external rotation of the tibia that matches and in effect balances the internal rotation of the femur). This situation is sometimes a “setup” for patellofemoral subluxation and knee pain (increased Q-angle).

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Staheli LT. Lower positional deformity in infants and children: a review. J Pediatr Orthop 1990; 10:559.

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Staheli LT, Corbett M, Wyss C, King H. Lower extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg 1985; 67A:39.

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