Intoeing means that a child’s feet turn inward when walking or running, instead of pointing straight ahead. It is commonly referred to as being “pigeon-toed.” Intoeing often causes young children to trip over their own feet. In a vast majority of young children, intoeing will correct itself with out treatment. However, if it is still present after age ten, it is more likely that it will continue to persist. Nevertheless, it typically will not cause pain or lead to future problems such as arthritis.
If the intoeing is associated with pain, swelling, or a limp, an evaluation by a pediatric orthopaedic specialist is recommended.
The three common causes of intoeing are:
The hallmark of metatarsus adductus is that the front of the foot is curved inwards. It is typically noticed during infancy. It can be mild & flexible, severe & rigid, or anywhere in between. Metatarsus adductus usually improves on its own over 4-6 months (particularly if it is flexible) with full resolution expected by age 2. Stretching exercises are often recommended to hurry the resolution, although the effectiveness of this is unclear. The parent is instructed to hold the heel firm between the thumb and index finger of one hand while the other hand applies gentle lateral pressure to the forefoot. This should be done several times a day, such as with diaper changes. Referral to a pediatric orthopaedic surgeon is indicated if the metatarsus adductus has not had a noticeable improvement by age 6 months, or if it is rigid (i.e. the curvature of the foot cannot be straightened during the aforementioned stretch maneuver). At COA, your doctor may use casting and/or special shoes to correct the more severe cases of metatarsus adductus. Surgery is rarely used except in the most severe persistent cases.
Internal tibial torsion is an inward twist of the tibia. It occurs before birth but is often unnoticed until the child starts to walk. Internal tibial torsion is best diagnosed on physical exam by looking at the thigh-foot angle (TFA), which is the angle between the axis of the thigh & foot when viewed from above with the patient lying prone and the knees flexed to 90°. In a young child, the average TFA is about 5° external. Children with obvious in-toeing due to internal tibial torsion often have a TFA of more than 10° internal.Tibial torsion will almost always improve before school age without any treatment. Splints, braces, special shoes, and exercises do not help. Rarely, surgery is done if a significant twist persists and interferes with walking.
Femoral anteversion occurs when there is an inward twist of the femur at the level near the hip joint. Although present before birth, it does not often lead to noticeable in-toeing until age 2-4. The normally limited internal rotation of the hips in infants and young toddlers “masks” the in-toeing effects of femoral anteversion early on. The in-toeing then becomes more obvious as the hips gain internal rotation, and is often most prominent at age 5-6. Femoral anteversion causes the knees and feet to point inward when walking. Children with femoral anteversion often prefer to sit in the “W” position as opposed to the crossed-leg position. Femoral anteversion is best diagnosed by measuring hip rotation with the child lying prone and the knees flexed to 90°. Care must be taken to make sure the pelvis is flat and level on the examination table. Although hip rotation varies greatly in young children, a good rule of thumb is that a normal 5-year-old child will have about 50° of internal rotation and 50° external rotation. Femoral anteversion is present when the internal rotation significantly exceeds the external rotation.
Nearly all of the other 10% of children function perfectly well despite the residual in-toeing. The residual in-toeing will not lead to arthritis, and will not inhibit any future athletic aspirations. Studies have shown that the use of casts, braces, splints, special shoes, and exercises do not hasten the correction, and are therefore not recommended. Younger children with in-toeing tend to stumble and fall frequently due to their toes hitting the opposite heel. This resolves as the child grows and gets stronger and more coordinated, even well before the in-toeing itself resolves. In the rare case of a child that has significant walking problems that has not improved by age 8, a referral to a pediatric orthopaedic surgeon is indicated for consideration of a derotational osteotomy, where the surgeon cuts and rotates the bone straight