Published: 17-08-2010, 17:16

Out-toeing

Nearly 90 percent of all adults who have been clinically measured will have zero to ten degrees of out-toeing as a part of their normal gait pattern. So common is this complaint seen by primary care physicians and pediatric orthopedists, that I have devoted a separate discussion to the topic. At birth, nearly all children have 70–90 degrees of passive and active external rotation of the hip, regardless of the degree of hip flexion contracture. The normal crowded intrauterine position does not allow the infant to “stand up,” or to internally rotate the lower limbs. Consequently, external rotation at the hip level is the “norm” and this contracture deformation persists until it is no longer needed. There is little need for internal rotation of the hip until children begin to crawl and particularly until they begin to stand. Lower limbs that are externally rotated and abducted are helpful for initially achieving appropriate standing balance and stability.
Considering the needs that our body has for the age that we are, it is amazing that we are “lined up and ready to go” when we achieve that next developmental milestone. Just as a mechanical engineer would design a modern sports car for stability and balance by lowering the center of gravity and widening its base, so do we humans spread our legs (widen the base), externally rotate our hips, crouch or squat (lower our center of gravity), and even pronate or “inroll” our ankles to achieve a maximally stable weight bearing surface for our feet (Figure 2.2). Nearly every grandmother will recognise this posture, as all of her “normal” grandchildren will have demonstrated it when they began to stand and walk.
Out-toeing

Figure 2.2. Normal early stance. “Crouch” and external rotation of the lower extremities and foot pronation.

Physicians need only assure themselves and the parents that the hips are well located, and that no other hip deformity exists. Developmental displacement of the hips (formerly termed congenital dislocation of the hip), congenital coxa vara, partial absence of the femur, and neurologic disorders of the lower extremity are uncommon causes of external rotation that should be considered. However, a properly conducted history and physical, and perhaps a radiograph if clearly clinically indicated, will establish the benign nature of the observation. In addition to the expense of unnecessary braces, splints, and adaptive shoe wear to treat this condition, there is a psychological impact of implanting within families’ minds the idea that their “loved one” is “diseased,” and this should provide adequate caution to all of us. There is nothing medically demeaning in simply reassuring the family, particularly when the consequences of treatment will only perpetuate the fallacy.
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iphoneicons

23 March 2012 17:16

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weperneAcuppy

10 June 2012 02:55

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