Pigeon toe, medically known as in-toeing, is a gait pattern where the feet turn inward instead of pointing straight ahead during walking or running. This common condition in young children often concerns parents. The inward turning is usually a result of normal variations in bone development and growth. The condition is rarely painful and typically does not interfere with a child’s ability to run or play sports as they get older.
Identifying the Anatomical Source of In-Toeing
Managing in-toeing depends on identifying the specific bone or joint where the inward turning originates. A medical professional uses a physical examination, known as a rotational profile, to pinpoint the source of the twist, which can occur at three different levels of the leg. Determining the location is important because each source has a different typical age of onset and a different natural course of resolution.
The first potential source is Metatarsus Adductus, where the front part of the foot curves inward. This is the most common cause of in-toeing in infants and is often present at birth due to the baby’s position in the womb. The foot appears C-shaped, but the ankle and leg are normally aligned.
The second source is Internal Tibial Torsion, an inward twist of the tibia, or shin bone. This twist is usually noticed when a child begins walking, typically between the ages of one and three years. The child’s kneecaps point straight ahead, but the feet turn inward due to the rotated lower leg.
The third source is Femoral Anteversion, an inward twist of the femur, or thigh bone, at the hip joint. This cause is most common in preschool and school-aged children, often becoming noticeable between the ages of four and six. A child with this condition often sits in a “W” position, and both the knees and the feet point inward.
When Observation Is the Primary Treatment
For the majority of children with in-toeing, the recommended course of action is observation. This approach is based on the predictable natural history of tibial torsion and femoral anteversion, which spontaneously resolve in most cases as the child grows. The body naturally corrects the rotational alignment of the bones over time as the child develops strength and motor coordination.
Internal tibial torsion generally corrects itself relatively early, with normal alignment typically achieved by four to six years of age. Femoral anteversion takes longer to resolve, as the hip joint gradually derotates over childhood. The inward twist of the femur improves in more than 80% of affected children, usually resolving by eight to ten years of age.
Interventions like special shoes, braces, or foot inserts are generally not effective for correcting the rotational misalignment caused by tibial or femoral issues. Pediatric specialists advise parents to avoid positions that can exacerbate the problem, such as “W-sitting,” where the child sits with their knees together. Encouraging diverse physical activities and walking styles allows the child’s body to naturally remodel the bone structure.
Active Medical Strategies for Correction
While most cases resolve without intervention, active medical strategies are reserved for the minority of children whose in-toeing is severe, causes significant functional problems, or fails to correct naturally by the expected age. For metatarsus adductus, a non-surgical approach is often used in infancy if the foot is not flexible enough to be manually straightened. This involves serial casting, where a series of plaster casts are applied to gently stretch and realign the forefoot over several weeks.
For issues originating higher up in the leg, like tibial torsion and femoral anteversion, non-surgical devices such as braces, specialized shoes, or orthotics have shown minimal proven efficacy in correcting the underlying bone rotation. Older methods using heavy metal braces are almost never used today due to their ineffectiveness and potential to restrict normal development.
Surgical intervention, known as a derotational osteotomy, is considered a last resort. It is reserved for severe, persistent cases that continue past the age of eight to ten and result in significant functional impairment. The procedure involves cutting the twisted bone—either the tibia or the femur—and rotating it back into correct alignment before fixing it in place. This surgery is only performed when the deformity is causing pain, frequent falls, or significant difficulty with walking and running.