When a child first begins to walk, parents often notice a pattern where the feet turn inward instead of pointing straight ahead. This presentation, commonly referred to as being “pigeon-toed,” is a frequent observation in early childhood development. This inward-turning gait, medically termed in-toeing, represents a rotational variation in the bones of the lower leg. Understanding the specific origins of this rotation can provide reassurance about this generally temporary phase in a child’s physical growth.
Defining In-Toeing and Its Prevalence
In-toeing is the visual presentation of a gait where the toes point toward the midline of the body during walking or running. This is typically a rotational variation that occurs anywhere from the hip down to the foot. The appearance is nearly always a normal, painless part of a child’s musculoskeletal development. It is one of the most common reasons for a parent to seek advice from a pediatrician or orthopedic specialist.
The condition is widespread in toddlers and young children, often becoming most apparent when they begin to walk, usually between the ages of one and three. For the vast majority of children, this inward alignment will spontaneously correct itself as the child grows and the lower body matures. Observation is the only intervention required.
Causes Originating in the Shinbone and Foot
Two primary causes of in-toeing originate in the bones below the knee joint.
Metatarsus Adductus
The earliest cause seen in infants is a foot deformity known as metatarsus adductus. This condition involves the front half of the foot, the metatarsals, turning inward from the midfoot, giving the foot a slight C-shape. It is often attributed to the compressed positioning of the baby within the uterus before birth.
Metatarsus adductus is the most common cause of in-toeing in children younger than one year of age. Nearly 85% of these cases resolve without any intervention within the first 18 months of life. If the foot is rigid and cannot be manually straightened, a healthcare provider may recommend casting or special shoes to help guide the alignment.
Internal Tibial Torsion
The second common cause in this region is internal tibial torsion, which involves an inward twist of the tibia, or shinbone. This inward rotation is thought to develop because of the way the legs are positioned in the womb. Internal tibial torsion is typically the predominant condition causing in-toeing in children between the ages of one and four years.
The twist in the shinbone causes the foot to point inward even though the knee may be pointing straight ahead. As the child grows, the tibia naturally rotates outward, and this condition generally resolves gradually. Normal alignment is usually achieved by the time the child reaches school age, typically between four and six years.
Cause Originating in the Hip
A third common cause of in-toeing originates at the hip joint. This condition is called femoral anteversion, and it involves an inward twist of the femur, or thigh bone. All babies are born with approximately 40 degrees of inward rotation in the thigh bone, which naturally decreases to about 15 degrees in adulthood. Femoral anteversion represents a persistence of this inward twist.
This hip-based rotation allows the hip to turn inward much more easily than it can turn outward. As a result, the child’s knees and feet both turn inward when walking, which is often most visibly pronounced around the ages of four to six years. Children with this rotational profile often find it comfortable to sit in a “W” position, where their knees are together and their feet are flared out to the sides.
The prognosis for femoral anteversion is excellent, as the condition nearly always corrects itself as the child matures. The inward twist of the femur progressively decreases until the alignment resembles that of an adult, typically resolving by the age of eight or ten. Treatment is rarely needed, as the condition does not typically lead to problems with arthritis or function later in life.
When Medical Intervention Is Necessary
While in-toeing is almost always a temporary, self-correcting developmental variation, parents should consult a healthcare professional if they observe specific signs:
- The in-toeing is significantly more noticeable on only one leg (asymmetrical deformity).
- The child is experiencing pain in the legs or feet, or has a noticeable limp.
- In-toeing suddenly develops after the age of five.
- The rotational angle is severe enough to cause frequent tripping and falling.
- The condition does not show signs of improvement past the age of eight.
In the rare event that treatment is needed, it often involves physical therapy or serial casting. Surgery is only considered for severe, persistent cases after age nine.