An in-toeing or pigeon-toed walking is observed when the foot or leg rotates inward. This can be noticed on either one or both legs, and can occur from birth or can start to appear through childhood development. Parents often notice in-toeing walking when their child is active with sports or sometimes even just watching them as they are walking. Concerns often arise when first noticing this positioning, or when pain or not keeping up with other kids becomes apparent.
In-toeing is due to one of three reasons (or a combination)
- The foot is turning inward
- The shin bone is turning inward
- The thigh bone is turning inward
When the foot is turning in
Your Podiatrist will assess the foot shape of your child to see if the foot is turned more inward than it should be. Metatarsus Adductus is the name given to the condition where the in-toeing gait is due to the foot shape. It is either a flexible or fixed position. It is often diagnosed soon after birth as it is due to positioning within the womb, and is treated through massage/stretching, splinting or casting and footwear recommendations. Sometimes when mild, the foot may simply be monitored over time as some children will grow out of it.
When the shin bone is turning in
Tibial torsion is when the tibia (shin bone) itself is slightly twisted inward between the knee and ankle. It is the most common cause of in-toeing and is usually diagnosed when children start to walk. It equally affects males and females and most often affects both legs. It usually corrects without treatment and resolves by the age of 8 years old. Movement patterns can be addressed to work on correcting this positioning when caught early on. Strength and movement patterns can still be worked after the age of 7 or 8 years of age, however it may become more difficult to change as bony positions are set.
When the thigh bone is turning in
Normal femoral (thigh) positioning should reduce from infancy to the age of 8 where the bony positions are set. As shown in the image, the thigh bone develops with a bias toward an inward twist, relative to the knee and hip. Spontaneous correction can occur up to the age of 8 due to bony plasticity and adaptability. Past this age, corrections can occur with muscle strength, positional cues and stability work.
When to seek help for your child?
Generally the earlier intervention the better. The later that in-toeing is left, the more difficult it becomes to fix due to learnt movement patterns and muscle/bony adaptations.
We recommend that you have your child assessed by our Podiatrist’s if:
- You have noticed an in-toeing gait either over time or if it has recently developed
- Your child frequently trips over
- You’ve noticed slowing of pace with walking and running
- Your child is not keeping up with the other kids their age
- You are worried about the way they are walking and running
- Something doesn’t look quite right with their foot and leg positions
- They are experiencing pain in their feet, legs or hips
- There is a family history of foot and legs problems
Children’s feet and legs are often easily corrected with early intervention.
Our friendly Podiatrist’s are ready to help your child walk and run correctly!
How is intoeing diagnosed?
Diagnosis is made clinically with no need for imaging. The only indication for radiography would be for potential surgery with severe cases of intoeing metatarsus adductus. Outside of this, scans may be used to exclude pathologic conditions.
What causes intoeing?
There are different causes for intoeing depending on where the legs or feet are misaligned:
- Curved foot (metatarsus adductus), which is usually present at birth
- Twisted shin (tibia torsion), the most common cause of intoeing, which occurs around age 1 to 3
- Twisted thigh bone (femoral anteversion), which occurs around age 3 to 8
The exact causes for these foot and leg problems are not certain, but medical experts suspect that it may be related to:
- Family history of intoeing
- Cramped position in the uterus
- W position sitting
Do you need treatment for intoeing?
A majority of cases are managed primarily by observation with emphasis placed on parental reassurance.
Metatarsus adductus: is expected to resolve by 2 years of age, and any persistence is not associated with any symptoms. Rigid and severe metatarsus adductus with no flexibility may be referred for possible casts or special corrective surgery.
Internal tibial torsion: it is normal for a developing child’s feet to have increased internal angles as they grow in age. Again, parental reassurance is emphasized, as the patient is observed for spontaneous resolution by 5 years of age.
Femoral anteversion: is also spontaneous resolution over time. Femoral anteversion has the longest course, resolving around 11 years of age.
What are the symptoms of intoeing?
Most children with this condition outgrow intoeing gait between ages 8 and 10. But your Podiatrist may recommend testing if these symptoms continue or worsen:
- Feet shaped like crescent moons, mainly in infants
- Shins or thighbones that turn inward
- Limping, pain or swelling
- Problems with gait (way of walking) such as tripping or unusual clumsiness
Are there other deformities associated with intoeing?
The bulk of causes of in-toeing are most often secondary to physiologic conditions that resolve over time. Developmental dysplasia of the hip can be associated with metatarsus adductus but can present as an isolated finding as well. Clubfoot deformity is a foot deformity that is associated with multiple foot findings, including plantarflexion (cavus), adductus, varus, and equinus. Secondary causes due to underlying conditions can include cerebral palsy or other neuromuscular diseases.