Metatarsus adductus is the most common congenital foot deformity in newborns. It is characterized by medial deviation (adduction) of the forefoot at the tarsometatarsal joints while the hindfoot remains in a neutral position. The condition produces a convex lateral border of the foot and an inward curve of the forefoot, which is usually evident at birth.
How Common It Is and Who Gets It? (Epidemiology)
Metatarsus adductus occurs in approximately 1 in 1,000 live births, with equal frequency in males and females. The deformity is bilateral in about 50% of cases and is more common in first pregnancies, twin pregnancies, and cases with oligohydramnios (low amniotic fluid). Because of intrauterine crowding, MA is considered a “packaging disorder.”
It is also associated with other congenital musculoskeletal abnormalities, including:
- Developmental dysplasia of the hip (DDH): seen in 15–20% of infants with MA.
- Congenital muscular torticollis.
Why It Happens – Causes (Etiology and Pathophysiology)
The exact cause of MA is unknown, but it is believed to result from intrauterine compression that forces the forefoot into an adducted position.
Other possible contributing factors include:
- Abnormal muscle attachments (such as a tight abductor hallucis).
- Osseous abnormalities of the tarsometatarsal joints.
- Genetic predisposition in some families.
MA affects only the forefoot, unlike clubfoot (talipes equinovarus) or skewfoot, which also involve hindfoot deformities.
How the Body Part Normally Works? (Relevant Anatomy)
The tarsometatarsal joint complex connects the metatarsals to the midfoot bones (cuneiforms and cuboid). In a normal foot, the forefoot aligns with the hindfoot along a straight lateral border. In MA, this relationship is altered, and the forefoot is medially deviated, while the hindfoot and subtalar motion remain normal.
What You Might See or Feel – Symptoms (Clinical Presentation)
- The forefoot curves inward, and the lateral foot border is convex.
- The heel and hindfoot alignment are normal.
- A medial soft-tissue crease may appear in more rigid deformities.
- Parents often notice intoeing when the child begins to walk.
- The condition is painless and does not interfere with early walking or athletic activity later in life.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is clinical and based on observation and manipulation of the foot.
Physical Exam Findings:
- The foot can be tickled to observe active correction by the infant.
- The examiner manually abducts the forefoot while holding the hindfoot neutral to assess flexibility.
- Hindfoot motion remains normal, differentiating MA from clubfoot.
Classification
- By flexibility:
- Flexible MA: Forefoot can be fully corrected to midline.
- Semi-flexible MA: Partial correction possible.
- Rigid MA: No correction achievable by manual manipulation.
- By severity (Bleck heel bisector method):
- Normal: Heel bisector line passes between 2nd and 3rd toes.
- Mild: Through 3rd toe.
- Moderate: Between 3rd and 4th toes.
- Severe: Between 4th and 5th toes.
- Berg classification (by complexity):
- Simple MA: Only forefoot adduction.
- Complex MA: MA with midfoot shift.
- Skewfoot: MA with hindfoot valgus (serpentine or “Z-shaped” foot).
Imaging:
- X-rays are rarely needed in infants but may be useful in older children or rigid deformities.
- Radiographic evaluation: Metatarsus adductus angle (MAA) >15° suggests deformity.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Clubfoot (Talipes Equinovarus): Hindfoot varus and equinus deformity.
- Skewfoot (Serpentine Foot): Combination of MA with hindfoot valgus.
- Internal tibial torsion: Intoeing with a straight foot border but tibial rotation.
- Femoral anteversion: Excessive hip internal rotation causing intoeing gait.
Treatment Options
Non-Surgical (Conservative) Management
Most cases are mild and resolve spontaneously by 12–18 months of age, with 90–95% achieving normal alignment by age 4.
- Observation:
- Flexible deformities that correct actively or passively require no treatment.
- Reassure parents; follow up to ensure spontaneous resolution.
- Stretching Exercises:
- Indicated for semi-flexible deformities.
- Parents are taught to gently abduct the forefoot while stabilizing the heel, repeated several times daily.
- Footwear Modifications:
- Straight- or reverse-last shoes can help maintain corrected position.
- Avoid prolonged adducted positioning (e.g., certain sitting or sleeping postures).
- Serial Casting:
- Reserved for rigid deformities, ideally performed before 8 months of age.
- Casts are changed every 1–2 weeks to gradually correct alignment.
- Goal: achieve a straight lateral border of the foot.
Operative (Surgical) Management
Surgery is rare and reserved for persistent, severe, or rigid deformities that cause pain, difficulty wearing shoes, or gait abnormalities after failed conservative care.
Procedures include:
- Tarsometatarsal capsulotomy: For children aged 2–4 years with uncorrected deformity.
- Osteotomies (age >5 years):
- Lateral column shortening (cuboid closing wedge).
- Medial column lengthening (cuneiform opening wedge).
- Multiple metatarsal osteotomies (Hamen procedure).
These realign the forefoot with the hindfoot and restore a straight lateral border.
Recovery and What to Expect After Treatment
- Flexible cases: No intervention needed; spontaneous correction occurs with growth.
- Serial casting: Successful correction typically achieved within 6–8 weeks.
- Surgical correction: Requires immobilization for several weeks and gradual return to normal footwear.
Long-term function is excellent, with normal gait and activity.
Possible Risks or Side Effects (Complications)
- Persistent or recurrent deformity (rare).
- Overcorrection leading to mild abduction deformity.
- Complications from casting (skin irritation, circulation issues).
- Association with hip dysplasia—requires monitoring.
Long-Term Outlook (Prognosis)
The prognosis is excellent. Most deformities resolve spontaneously or with minimal treatment. Long-term studies show no association with pain or disability in adulthood. A small percentage may have mild residual forefoot adduction without functional limitation.
Out-of-Pocket Costs
Medicare
CPT Code 28270 – Soft Tissue Release (Capsulotomy/Tendon Lengthening): $111.18
CPT Code 28304 – Metatarsal Osteotomy for Structural Correction: $191.57
Medicare Part B typically covers 80% of the approved cost for these procedures after your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans coordinate with Medicare to fill the coverage gap and help reduce total patient costs.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it will act as a secondary payer. These plans often cover any remaining coinsurance or small deductibles, which typically range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your metatarsus adductus deformity or corrective surgery is related to a work injury or repetitive strain, Workers’ Compensation will cover all medical costs, including surgery, follow-up care, and rehabilitation. You will not have any out-of-pocket expenses, as the employer’s insurance carrier pays directly for all approved procedures.
No-Fault Insurance
If your condition or injury is connected to an automobile accident, No-Fault Insurance will typically cover the entire cost of treatment, including surgery and postoperative care. The only potential out-of-pocket expense may be a small deductible or co-payment based on your policy terms.
Example
David Nguyen was diagnosed with metatarsus adductus and required both a soft tissue release (CPT 28270) and a metatarsal osteotomy (CPT 28304) for structural correction. His estimated Medicare out-of-pocket cost for the osteotomy was $191.57. Since David had supplemental coverage through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedures.
Frequently Asked Questions (FAQ)
Q. What is metatarsus adductus?
A. Metatarsus adductus is a congenital foot deformity in which the front half of the foot, or forefoot, is turned inward.
Q. Is metatarsus adductus the same as clubfoot?
A. No, metatarsus adductus is different from clubfoot as it only affects the forefoot, whereas clubfoot involves the entire foot being turned inward and downward.
Q. What causes metatarsus adductus?
A. The exact cause is unknown, but it is thought to be related to the baby’s position in the womb, especially when space is limited.
Q. How common is metatarsus adductus?
A. It is one of the most common foot deformities in infants and can occur in one or both feet.
Q. How is metatarsus adductus diagnosed?
A. It is typically diagnosed through physical examination, but X-rays may be used in older children to assess bone alignment.
Q. Can metatarsus adductus correct itself without treatment?
A. Yes, in many cases the deformity improves on its own during the first year of life.
Q. What are the treatment options for metatarsus adductus?
A. Treatment options may include observation, stretching exercises, casting, special shoes, or surgery in severe cases.
Q. When is treatment necessary for metatarsus adductus?
A. Treatment is necessary if the deformity is rigid or does not improve with growth and stretching.
Q. What is the role of stretching exercises in treating metatarsus adductus?
A. Stretching exercises are used to gently correct the inward curvature of the foot in flexible cases.
Q. How is casting used in treating metatarsus adductus?
A. Serial casting is used to gradually correct the deformity in more rigid cases over a period of weeks.
Q. When is surgery considered for metatarsus adductus?
A. Surgery is considered in older children if the deformity is severe and has not responded to non-surgical treatment.
Q. What does surgical treatment for metatarsus adductus involve?
A. Surgical treatment may involve releasing tight soft tissues or cutting and realigning bones to correct the foot position.
Q. Can metatarsus adductus affect walking?
A. In most cases, children with metatarsus adductus walk normally, especially if the deformity is mild or corrected early.
Q. What is the long-term outlook for children with metatarsus adductus?
A. The long-term outlook is generally excellent, especially when treated appropriately, with most children having normal foot function.
Summary and Takeaway
Metatarsus adductus is a common, usually self-limiting congenital foot deformity involving inward deviation of the forefoot with normal hindfoot alignment. Most cases resolve spontaneously or with simple stretching and observation. Serial casting is effective for rigid deformities, and surgery is reserved for persistent or severe cases. The long-term prognosis is excellent, and the condition does not affect athletic ability or cause disability later in life.
Clinical Insight & Recent Findings
A 2025 study published in the Journal of Foot and Ankle Research investigated how the severity of hallux valgus (HV)—a common forefoot deformity—relates to the presence of metatarsus adductus (MA).
Reviewing 294 feet, researchers found that MA was significantly more common among patients with HV, with prevalence rates rising in parallel with HV severity—from just 4.9% in normal feet to 31.7% in severe HV cases when using the modified Engel’s angle. The study confirmed that MA and HV are closely linked deformities that can influence each other’s progression and surgical outcomes.
The modified Engel’s angle was identified as the most reliable and sensitive method for diagnosing MA associated with HV, making early detection crucial for optimal surgical planning and to reduce recurrence risk after bunion correction. (“Study on hallux valgus and metatarsus adductus correlation – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Care is typically managed by pediatric orthopedic surgeons or podiatrists, with guidance from physical therapists for stretching and monitoring.
When to See a Specialist?
Parents should seek evaluation if the child’s foot curvature persists beyond 6–12 months or appears rigid and uncorrectable by gentle manipulation.
When to Go to the Emergency Room?
Emergency care is rarely required unless there are signs of circulation problems (blue or cold toes) from tight casts or other unrelated acute issues.
What Recovery Really Looks Like?
Most children resume normal growth and activity without limitations. Follow-up exams ensure correction and rule out associated hip abnormalities.
What Happens If You Ignore It?
Untreated, severe or rigid MA may cause gait disturbances or cosmetic concerns. In rare cases, residual deformity can predispose to hallux valgus or metatarsalgia in adulthood.
How to Prevent It?
Prevention is not possible, but early detection and gentle stretching can optimize outcomes. Parents should avoid constrictive footwear in infancy.
Nutrition and Bone or Joint Health
A balanced diet with sufficient vitamin D and calcium supports normal bone growth and alignment.
Activity and Lifestyle Modifications
Allow infants to move their feet freely and avoid restrictive swaddling. Encourage barefoot kicking and crawling to promote natural muscle development and flexibility.
Dr. Mo Athar
