In-Toeing: A Primary Care Problem Referred to Pediatric Orthopaedic Clinic?
Methods 143 consecutive patients referred with a new consult noted as “in-toeing” were studied. Active treatment was defined as casting for rigid metatarsus adductus and osteotomy for rotational abnormalities. Each patient underwent a history and physical exam to exclude neurologic disorders, osseous malformations, or inflammatory conditions. A rotational profile was documented. An explanation of the natural history of the disorder and a handout about the disorder were provided at each visit. For some parents/grandparents displaying overabundant anxiety, a follow up evaluation was arranged for family reassurance and to minimize detrimental patient satisfaction scores.
Results 143 patients were referred for ‘in-toeing.’ After the pediatric orthopaedic evaluation, 121 of 143 (85%) patients were confirmed with an ‘in-toeing diagnosis’. 61 (43%) patients demonstrated internal tibial torsion, 23 (16%) internal femoral torsion, 12 (8%) metatarsus adductus and 25 (17%) had a combination of TT, FA, or MTA. No patient was indicated for casting or surgery. 74% of patients with in-toeing were discharged from care after the initial consultation and 18% after the first follow up visit. 8% of patients had more than 2 visits. 22 additional patients who presented with ‘in-toeing’ on the consult were diagnosed with another condition. For example, 12 (8%) had flexible flat feet, 2 (1%) physiologic genu varum, 3 (2%) tight heel cords and cerebral palsy, and 4 (3%) normal exams. 126 (88%) patients were referred from a primary care physician, 9 (6%) from a general orthopaedic surgeon, and 8 (6%) were self-referred. The ave age was 4 years (range 2 mo to 13 years). 85 (59%) were female and 58 (41%) were male.
Conclusion Casting or surgery for in-toeing disorders in childhood is rarely indicated. 25% of patients with received serial clinic visits in order to reassure the parents. 15% of patients actually had another diagnosis including 2% with a subtle neurologic diagnosis. More than 95 % of patients could be readily managed by a primary care physician. The finding of this study have implications for pediatric musculoskeletal education, pediatric orthopaedic reimbursement under the Affordable Care Act, and pediatric orthopaedic workforce needs.