The child is evaluated in the prone position with knees flexed to 90 degrees. Using the tibia as a lever arm the femur is rotated both internally and externally. A positive exam demonstrates internal rotation of greater than 70 degrees and external rotation reduced to less than 20 degrees. Normal values for internal rotation are between 20 and 60 degrees and normal values for external rotation are between 30 and 60 degrees. Treatment
In those less than eight years old with simple in-toeing and minor symptoms, no specific treatment is needed.Metatarsus Adductus
Nonoperative management:  Non operative treatment of metatarsus adductus is dictated by the flexibility of the forefoot. If the child can actively correct the forefoot to midline no treatment is indicated. If the adduction cannot be corrected actively but is flexible in passive correction by an examiner, at-home stretching that mimics this maneuver can be performed by parents. In the case of a rigid deformity serial casting can straighten the foot.Surgical Management:  Most cases of metatarsus adductus that does not resolve is asymptomatic in adulthood and does not require surgery. Occasionally, persistent rigid metatarsus adductus can produce difficulty and significant pain associated with inability to find accommodating footwear. Surgical options include tasometatarsal capsulotomy with tendontransfers or tarsal osteotomies. Due to the high failure rate of capsulotomy and tendon transfer it is generally avoided.
Sgarlatos angle is defined as the angle between:
A line through the longitudinal axis of the second metatarsal bone. The longitudinal axis of the lesser tarsal bones. For this purpose, one line is drawn between the lateral limits of the fourth tarsometatarsal joint and the calcaneocuboid joint, and another line is drawn between the medial limits of the talonavicular joint and the 1st tarsometatarsal joint. The transverse axis is defined as going through the middle of those lines, and hence the longitudinal axis is perpendicular to this axis.This angle is normally up to 15°, and an increased angle indicates pigeon toe. Yet, it becomes more difficult to infer the locations of the joints in younger children due to incomplete ossification of the bones, especially when younger than 3–4 years. Internal Tibial Torsion
Internal tibial torsion is diagnosed by physical exam. The principle clinical exam is an assessment of the thigh-foot angle. The affected individual is placed in prone position with the knees flexed to 90 degrees. An imaginary line is drawn along the longitudinal axis of the thigh, and of the sole of the foot from a birds-eye view and the angle at the intersection of these two lines is measured. A value greater than 10 degrees of internal rotation is considered internal tibial torsion. A thigh-foot angle less than 10 degrees internal, and up to 30 degrees of external rotation is considered normal.Femoral Anteversion
Femoral anteversion is diagnosed by physical exam. The principle physical exam maneuver is an assessment of hip mobility.