INDICATIONS FOR REFERRAL — Most patients with rotational variations of the lower extremity can be followed in the primary care office. In a retrospective review of 202 children (median age four years) with intoeing who were referred for orthopedic surgery consultation by primary care providers, 86 percent were discharged after their first visit. The distribution of etiologies is displayed in the graph.

Indications for referral include: 


¦Rigid metatarsus adductus, which may require serial casting (refer to pediatric orthopedic surgeon or an orthopedic surgeon with expertise in rotational problems)
¦Unilateral or asymmetric in-toeing associated with clinical findings suggestive of neurologic disorder (refer to a pediatric orthopedic surgeon, pediatric neurologist, or physical medicine and rehabilitation specialist)
¦Children =8 years with activity limiting or cosmetically unacceptable in-toeing due to internal tibial torsion (may be candidates for derotational osteotomy; refer to an orthopedic surgeon with expertise in rotational problems)
¦Children =11 years with activity limiting or cosmetically unacceptable in-toeing due to increased femoral anteversion (may be candidates for derotational osteotomy; refer to an orthopedic surgeon with expertise in rotational problems)
¦In-toeing that does not follow the expected course (eg, increased femoral anteversion that progresses after age five or six years) [16] (refer to pediatric orthopedic surgeon or an orthopedic surgeon with expertise in rotational problems)