“Pigeon-toed,” medically known as in-toeing, describes a common condition where a person’s feet turn inward instead of pointing straight ahead when walking or standing. This alignment variation is frequently observed in children as they develop their walking skills. For many children, in-toeing is a temporary developmental phase that resolves naturally as they grow and their bones mature. It is a common concern for parents, yet in most instances, it does not cause pain or lead to long-term issues.
What is In-Toeing and Why Does It Happen?
In-toeing refers specifically to the inward turning of the feet, differentiating it from out-toeing, where the feet point outward. This inward alignment stems from rotational differences in the bones of the legs, often originating from the hip, shin, or foot.
One primary anatomical cause is metatarsus adductus, which involves an inward curve of the foot itself, from the middle part to the toes. This condition is often present at birth and is the most common cause of in-toeing in infants and toddlers.
Another cause is tibial torsion, an inward twisting of the shin bone (tibia). Internal tibial torsion is often seen in toddlers, becoming noticeable as they begin to walk. The shin bone gradually untwists as the child grows, with normal alignment often occurring by around 7 to 8 years of age.
A third cause is femoral anteversion, where the thigh bone (femur) has an increased inward twist near the hip. This causes both the knees and the feet to point inward during walking. Femoral anteversion is most apparent around 4 to 6 years of age and is more common in girls. Children with this condition may sit in a “W” position. This inward twist corrects itself as the child grows, often resolving by 8 to 10 years of age.
When In-Toeing Needs Professional Attention
While in-toeing often resolves without intervention, certain signs indicate that a medical evaluation is appropriate. If the in-toeing does not show improvement with age, or if it appears to be worsening, a doctor’s visit is recommended.
A medical consultation is also advised if the in-toeing affects only one leg, rather than both. Any associated symptoms like pain in the hip or leg, limping, or difficulty with walking or running warrant professional attention. Frequent tripping or falling that seems related to the inward-pointing feet should also be evaluated.
Concerns about a child’s overall development, or if the in-toeing significantly affects their ability to participate in daily activities or keep up with peers, are valid reasons to seek medical advice. A doctor will perform a physical examination, observing the child’s gait and assessing the range of motion in their hips, knees, ankles, and feet. In rare instances, X-rays may be ordered to further evaluate the leg bones.
Approaches to Addressing In-Toeing
For the vast majority of children with in-toeing, no specific medical intervention is necessary. The condition commonly resolves naturally as the child grows and develops, with bones gradually rotating into a more typical alignment. This observational approach, often called “watchful waiting,” is the most common approach.
Historically, special shoes, braces, or specific exercises were sometimes prescribed for common developmental in-toeing. However, current medical understanding indicates that these methods are not effective in speeding up the natural resolution of the condition. Studies have found that such interventions do not help the bones untwist any faster.
Physical therapy can play a limited role, primarily if muscle imbalances or coordination deficits contribute to the gait pattern. A physical therapist can provide guidance on exercises that may help improve alignment and foot positioning over time, such as sideways walking, frog hops, or penguin walks. However, it is not a universal solution for all types of in-toeing.
Casting or bracing is rarely used, reserved for severe cases of metatarsus adductus in infants, especially if the foot is rigid or does not improve naturally. In these instances, a series of casts or special orthoses may be applied to gently stretch and reshape the foot.
Surgery for in-toeing is rare and is considered only for severe cases that cause significant functional problems, persistent pain, or disability, and have not responded to conservative management. This is not considered before a child reaches 8 to 10 years of age. A surgical procedure, such as a rotational osteotomy, involves cutting and rotating the thigh bone or shin bone to correct the alignment.