American Academy of Pediatrics – Section on Orthopaedics and the Pediatric Orthopaedic Society of North America

View all recommendations from this society

February 12, 2018

Do not order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait.

Mild in-toeing is usually a physiologic phenomenon reflecting ongoing maturation of the skeleton. Metatarsus adductus, femoral anteversion, and tibial torsion all contribute to in-toeing and tend to improve with growth. Simply monitoring gait for continued improvement at normal well child examination intervals is adequate until the age of 7-8 unless there is severe tripping and falling or asymmetry. It is not possible to alter the natural evolution using physical therapy, bracing or shoe inserts.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The Pediatric Orthopaedic Society of North America (POSNA) Evidence Based Medicine Committee and the Advocacy Committee worked together during 2014 and 2015 to develop five items in the practice of Pediatric Orthopaedics of tests or procedures that should not be done routinely. Approximately 20 members of these two committees participated in the process. Each surgeon, in a blinded fashion, submitted 5 items each from their practices and experience of tests or procedures that they found were commonly over-utilized. The items were tallied in order of number of times that item was listed by each surgeon. A total of 30 items were submitted. Both committees then agreed on final list of 5 items based of frequency of responses and importance of the condition. The Evidence Based Committee reviewed the appropriate literature to provide references and support for each item. The Executive Committee of the Orthopaedic Section of the American Academy of Pediatrics (AAP) reviewed the 5 listed items and provided further feedback. POSNA Board of Directors provided further feedback and voted on the final list. Various expert committees and sections of the AAP reviewed and approved the list. The AAP Executive Committee granted final approval of the list.


Fabry G, Cheng LX, Molenaers G. Normal and abnormal torsional development in children. Clinical Orthopaedics and Related Research. May 1994; (301):22-26.

Fabry G, MacEwen GD, Sharnds AR, Jr. Torsion of the femur: A follow up study in normal and abnormal conditions. J Bone Joint Surg.  Am. Dec 1973;55(8):1726-1738.

Lincoln TL. Suen PW. Common rotational variations in children. The Journal of the American Academy of Orthopaedic Surgeons. Sep-Oct 2003; 11(5):312-320.

Staheli LT. Corbett M. Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. Jan 1985;67(1):39-47.

Svenningsen S. Apalset K. Terjesen T, Anda S. Regression of femoral anteversion. A prospective study of in-toeing of children. Acta Orthopaedica Scandinavica. Apr 1989;60(2):170-173.