Intoeing

W-SITTING=FEMORAL TORSION=INTOEING

What is it?

The upper end of the femur consists of the neck and head (the ball) articulating with the acetabulum (or cup) at the hip joint. The neck and head of the femur are pointed inwards with a slight forward inclination. This slight forward inclination is called femoral neck anteversion.

The amount of femoral neck anteversion is 40 degrees at birth, and decreases with age to about 15 degrees at maturity. This is the normal developmental process of growth in most people. In some instances, the femoral neck anteversion present at birth does not decrease, but stays excessive compared to age, giving rise to the condition known at femoral torsion.

What are the symptoms?

The typical presentation is a child between ages 3 and 8 brought in by parents because of concerns about intoeing. He or she may even have had treatment for metatarsus adductus or tibial torsion in the past, and parents may think that there has been a recurrence of the old problem. Typically the child stands with the knee caps and toes pointing in.

What does your doctor do about it?

Femoral torsion was in the past treated by use of twister cables-twisted strands that connected to a waist belt and to shoes that would tend to twist the feet outwards. Kids wore them for years, and they do improve the position of the feet on standing and walking. However, longitudinal studies of thousands of children have confirmed that most children with femoral torsion resolve without any intervention by the age of 10. Even in the cases that did not resolve completely, it proved to be of no functional significance. Twister cables are still used with children with neuromuscular impairment where the normal muscle function is not present to effect the normal developmental process.

For most regular children, persistent femoral torsion is caused by habitual kneeling or sitting in the W-position or television position. These positions perpetuate femoral torsion because they keep the hips in the internally rotated position. It is therefore important that all children, when sitting on the floor to play, learn to sit cross-legged Indian –style. This position places the hips in the externally rotated position and encourages the normal modeling process of the hip joint.

What Can the Parent Do About It?

Most parents with a child that W sits, knows how difficult it is to solve this problem. Some experts say to constantly remind the child with rhymes such as “chris cross apple sauce” but most parents get as tired of reminding the child as the child is of being corrected. For children who W sit, there is a degree of comfort and stability that always calls them back to that position. When the child reaches the age of W sitting, it is suggested that a small table and chair be purchased and many of the floor activities should be done at a table which will decrease the time spent W sitting. Buying the child his or her own small chair to watch TV or videos or to look at books can also be helpful. The chair should be low to the ground and sturdy enough for the child to crawl in and turn around without falling over. A small anti-W sitting stool can be made as seen in the photo. boy in early start

The stool is small enough for the child to take it with him and to still be able to get up to shelves and stereo cabinets. The stool encourages balance and can easily be substituted with a small sturdy plastic box, or a beach towel taped into a big roll. Try to make it permanent and personalized and then the child will be more apt to use it. Having something available to slide under the rear-end just before the W-sitting occurs can also help eliminate the nagging that parents are forced to do. Making corners of a room, a play corner so the child can lean against a pillow with his legs stretched out straight in front, is also another alternative to W-sitting.

Laurie Kasa, OTR
Occupational Therapy Consultant
Sojourn-Early Start. Santa Barbara