What is the best imaging modality for a child with pigeon-toed (intoeing) gait?

Best Imaging for Pigeon-Toed Child

For a child with pigeon-toed (intoeing) gait, radiographs of the lower extremity area of interest are the most appropriate initial imaging modality when symptoms are localized and there is no concern for infection. 1

Understanding Intoeing

Intoeing (pigeon-toed gait) is a common developmental condition in children that can have several causes:

• Metatarsus adductus - characterized by a "C" shaped curve on the lateral aspect of the foot 2
• Internal tibial torsion - patella points forward while foot points inward 2
• Femoral anteversion - both patella and feet point inward 2

Most cases of intoeing are normal developmental variants that resolve spontaneously with growth and rarely cause disability 3, 2.

Imaging Algorithm

Initial Assessment:

1. For children up to age 5 with localized symptoms and no concern for infection:

   • Radiographs of the lower extremity area of interest are usually appropriate 1
   • Focus imaging on the specific area of concern (foot, tibia/fibula, or femur) based on clinical examination 1

2. For children up to age 5 with non-localized symptoms and no concern for infection:

   • A radiograph of the tibia/fibula is usually appropriate as initial imaging 1
   • This approach is supported by evidence showing that tibial fractures are the most common fractures found in young children presenting with limp 1

3. For children older than 5 years with suspected foot abnormality:

   • Radiographs of the foot, or weightbearing radiographs when tolerated, are appropriate 1
   • Weightbearing views can provide additional functional information about alignment 1

Advanced Imaging (if needed):

• MRI is indicated when:

  • Initial radiographs are normal but symptoms persist 1
  • There is concern for infection 1
  • Soft tissue or cartilage abnormalities are suspected 4

• Ultrasound can be useful for:

  • Evaluating soft tissue structures 1
  • Dynamic assessment of joint motion 1

Clinical Considerations

• Most cases of intoeing in children are benign developmental variants that resolve spontaneously without intervention 3, 2
• Radiographs in children with normal physical examination and acute gait disturbance are often normal (96%) and unlikely to contribute to diagnosis 5
• Treatment must be individualized based on the specific cause of intoeing 6

Important Caveats

• Radiation exposure is an important consideration in pediatric imaging - pediatric patients are at inherently higher risk due to organ sensitivity and longer life expectancy 1
• Unnecessary imaging should be avoided when clinical examination suggests a benign, self-limiting condition 5
• If initial radiographs are normal but symptoms persist or worsen, follow-up clinical reassessment and further imaging may be necessary 1
• Always rule out neuromuscular dysfunction or other serious conditions that may present with intoeing 3

In most cases, observation and parental education are the most appropriate approaches, as most cases of intoeing resolve spontaneously 2.