In-toeing, commonly known as “pigeon-toed,” describes a gait where a child’s feet turn inward instead of pointing straight ahead when walking or running. This condition is frequently observed in infants and young children, often becoming noticeable as they begin to walk. While it can be a source of concern for parents, in-toeing is a common musculoskeletal variation that often resolves naturally. This article explores the nature of in-toeing, when medical intervention might be considered, and the various approaches available for correction.
What Is In-Toeing
In-toeing typically results from rotational differences in the bones of the leg, occurring at three main levels: the foot, the shinbone, or the thighbone. These include metatarsus adductus, internal tibial torsion, and increased femoral anteversion.
Metatarsus adductus involves an inward curve of the front part of the foot, often appearing at birth and believed to be influenced by the baby’s position in the womb. This condition is seen in about 0.1% to 1% of births and is more frequent in girls.
Internal tibial torsion refers to an inward twist of the shinbone (tibia). It is the most common cause of in-toeing in children between one and four years old, often becoming apparent when a child starts walking.
Increased femoral anteversion involves an inward twist of the thighbone (femur) at the hip. This cause of in-toeing is often most evident around ages three to six, and is twice as common in females.
These rotational variations are frequently developmental and tend to resolve naturally as a child matures and their bones grow and untwist.
When Intervention Is Considered
For most children, in-toeing is a benign condition that improves without specific intervention, often by school age. The natural resolution timeline varies depending on the underlying cause; metatarsus adductus typically resolves by age two, internal tibial torsion by age five, and femoral anteversion by around age eleven.
Medical attention may be considered if the in-toeing is severe, affects only one side, or causes functional difficulties. Functional problems can include frequent tripping, clumsiness, or difficulty participating in physical activities. If the condition persists beyond typical resolution ages, such as after eight to ten years for femoral anteversion or eight years for tibial torsion, and causes significant walking problems or cosmetic concerns, a specialist might be consulted.
Methods of Correction
For the majority of children with in-toeing, observation and reassurance are the primary approaches, as the condition often corrects naturally with growth. Special shoes, braces, or splints have generally been shown to be ineffective in changing the natural course of in-toeing caused by bone rotation. While physical therapy can help with balance and coordination, it does not directly correct the underlying bone twist.
Physical therapy may involve stretching and strengthening exercises to improve muscle imbalances and overall alignment, particularly for hip muscles. For metatarsus adductus, gentle stretching exercises or serial casting might be used in severe or rigid cases, especially in infants. Gait plates, a type of orthotic, are sometimes used to encourage outward rotation of the feet and may reduce tripping.
Surgical correction, typically an osteotomy, is considered a last resort for children. This procedure involves cutting and realigning the bone to correct the abnormal rotation. Surgery is usually reserved for older children, often after eight to ten years of age, who have severe, persistent in-toeing causing significant functional impairment, such as difficulty walking or running, or considerable cosmetic deformity.
Addressing In-Toeing in Adults
In-toeing in adults is less common and often represents a continuation of childhood in-toeing that did not naturally resolve. While mild cases may not cause issues, persistent in-toeing in adulthood can sometimes lead to discomfort, poor balance, or difficulty with certain activities. It can also be associated with pain in the knees or hips.
Non-surgical options for adults, such as physical therapy, custom orthotics, or muscle-strengthening exercises, aim to improve alignment, reduce discomfort, and enhance function. These approaches focus on improving muscle imbalances and gait patterns. Non-surgical methods are generally less effective at correcting the underlying bone rotation in adults compared to the natural resolution seen in children.
For adults experiencing significant functional problems, persistent pain, or severe cosmetic concerns due to in-toeing, surgical correction may be considered. Surgical procedures, such as derotational osteotomy, involve realigning the bones to correct the inward twist. The decision for surgery in adults is complex, weighing the potential benefits of improved alignment and reduced symptoms against the risks associated with a major operation.