Introduction: Recognized as one of the world's greatest philanthropies Shriner's Hospital for Children is an international hospital system recognized for transforming the lives of children throughout expert care and research. And now another episode of the Shriner's Hospital for Children, Chicago Podcast Series, Pediatric Specialty Care Spotlight with Melanie Cole.

Melanie Cole: Welcome to Pediatric Specialty Care Spotlight with Shriner's Hospitals for Children in Chicago, I'm Melanie Cole. And I invite you to listen in, as we discuss in-toeing and out-toeing, normal variations in the legs of growing children. Joining me is Dr. Terry Cappello. She's a Pediatric Orthopedic Surgeon at Shriners Hospitals for Children in Chicago. Dr. Cappello, welcome to the show. I'm so glad to have you join us. This is such an interesting topic too, for so many parents as their little babies, start to crawl around and even start to walk, are there many normal variations in the legs of our growing children? Are they pretty much alike help us to understand the normal posture of the lower extremities in our children?

Dr. Cappello: Yes. There are many normal variations in the legs of growing children, not all growing feet and legs look alike, but that doesn't mean that they're still not normal. This is a period of time when the legs can look bode, and a period of time when children are knock kneed, there are even phases when it's normal for a child to toe in. So it does take an understanding that the legs change quite a bit in the first decade of life.

Host: So, you mentioned toeing in, is that normal in a child? Is it considered a disability? Does it go away? What is that?

Dr. Cappello: Well, toeing in is completely normal in a child. Now, the reason a child toes in does change as they grow from age two to age 10, but most often it's just a normal phase. Toddlers have curved shinbones and older children can have twists in their thigh bones, which is what allows these kids to sit on the floor like a w.

Host: So, we're not supposed to let them do that, or do we look at them and go, oh my God, it hurts just to look at you, do that?

Dr. Cappello: I completely understand that it does look painful. I outgrew mine. So I can't sit that way, but it's totally okay for a kid to sit on the floor, like a w. The child is just showing us, that's currently how their thigh bones are shaped. And more importantly, sitting like a w will not stop the child from outgrowing. This curvature. That's the really big misconception from grandmothers to daycare providers. And even to some pediatricians, they keep telling kids to not sit like a w, but that's just not correct. They can sit any way that's comfortable for them. I would say that's a big area of education in my clinic. Sometimes, understandably, it can be tough for parents to accept that point, but the kids are always so happy when I tell them they're normal and that they can sit anyway that makes them comfortable.

Host: Thanks for clearing up that misconception. Are there any complications from in towing or out towing, can it affect other parts of the body as they grow like their hips or their back? And you mentioned parents, is this something parents worry about, including future athletics or even the stigma of it looking a little different?

Dr. Cappello: I think many parents are concerned about that. And so I think it is comforting when I tell them that the child is normal and that by far the most common way for this to end up is that the child completely outgrows the toeing in. So the good news is the chance of any long-term problem is actually considered rare. Whether it's a young child who toes in due to the shape of their shin bones, or an older child due to the shape of their thigh bones, observation is the only thing that's needed. No special shoes, braces, or splints or therapy will have any effect on this. Just normal growth and development helps us and medical studies have been done and have been able to prove this. These are normal kids. We let them grow and we watch them. And most importantly, we don't burden them with treatments that won't actually work.

Host: So, at what age then are their legs and feet like they're going to be as an adult. Is it once they're done growing after puberty or somewhere around there? Does this change as they grow. And you mentioned that they don't always need treatment.

Dr. Cappello: I think that the age of 10 is a good age for us to look at the legs change so much in the first 10 years of life. But we believe that where the legs are at about 10 years of age is where they're going to be as an adult. And the only successful treatment in changing the shape of the bones is actually surgery. So I routinely recommend follow up with me at about the age of 10 so that the parents can tell me if they're concerned or the child can tell me about any concern and we can make a plan.

Host: Tell us about a plan that might need to be made. Is there anything that can be done to help a child outgrow toeing in or toeing out? And when should parents actually be concerned if by the age of 10, this hasn't changed, is that when they should seek out some professionals such as yourself to give a consultation and see what's going on?

Dr. Cappello: Yes, I believe that's the right age, at the age of 10, the vast majority of children have completely outgrown this. And if you haven't outgrown it, then it's a good time for us to sit down and see if I can predict what adulthood will look like. So, you know, as long as the child is comfortable and active, nothing needs to, or nothing can be done in the first 10 years of life. If the child's in pain, or if the child can't keep up with other children, that's always a reason to see a pediatric orthopedic surgeon at any age.

Host: And what are some possible treatments? Are we looking at braces or orthotics? I mean, is there anything that you do on a routine basis for these kinds of conditions that don't heal themselves?

Dr. Cappello: Well, we have looked at this and we know that special braces or shoes or inserts, or even therapy won't help. And so the only treatment is a surgery and the surgery is very effective, but it's a big treatment. So it's great news that the vast majority of kids will just naturally outgrow this on their own. But if there is a child at the age of 10, who still has problems from toeing in, then there are treatments, but the treatment is the surgery.

Host: So then tell us why families should choose Shriner's Hospitals for Children in Chicago for their child's orthopedic condition or injury. Tell us about your team.

Dr. Cappello: We do have a very complete team here at Shriner's Chicago, from pediatric orthopedic surgeons to pediatric nurses and physical therapists. I think that we provide the full gamut of specialists for kids and for their families. I've been very impressed at Shriner's Chicago at family centered medicine. And I think that's very important. It is, you know, certainly the patient is the most important thing, but the family is also very important. And I feel that we provide that family centered care here at Shriners.

Host: And Dr. Cappello, as we wrap up, please reiterate for parents that this is not a concerning condition and kind of summarize for us when it's important that they refer to the specialists at Shriner's Hospitals for Children in Chicago?

Dr. Cappello: I think if a child is comfortable and active, then it's perfectly fine to toe in. It's really treating each kid individually. If there's any concern that the kid can't keep up or the kid has pain, then that's when a pediatric orthopedic doctor is helpful.

Host: Thank you so much Dr. Cappello for coming on and really sharing your incredible expertise today. And to make an appointment, you can call 773-385-kids. That's 5437. Or you can visit our website at shrinerschicago.org for more information, and to get connected with one of our providers. And that concludes this episode of Pediatric Specialty Care Spotlight with Shriner's Hospitals for Children in Chicago. Please remember to subscribe, rate, and review this podcast and all the other Shriners Hospitals for Children's Chicago podcasts. I'm Melanie Cole. Thanks so much for listening.