Intoeing

Intoeing means that a child’s feet turn inward when walking or running, instead of pointing straight. It’s commonly referred to as being “pigeon-toed.” Intoeing often causes young children to trip over their own feet. In most young children, intoeing will correct itself without treatment. However, if it is still present after age 10, it is more likely to be permanent. It does not usually cause pain or lead to future problems, such as arthritis.

If the intoeing is causing pain, swelling or a limp, an evaluation by a pediatric orthopaedic specialist is recommended.

The three common causes of intoeing are:

Metatarsus Adductus (Curved Foot)

Metatarsus adductus is a condition where the front of the foot is curved inwards. It is typically noticed during infancy. The curve can be mild and flexible, severe and rigid, or anywhere in-between. Metatarsus adductus usually improves on its own between ages 4 to 6 months (particularly if it is flexible), and it typically resolves by age 2.

Stretching exercises are often recommended to help resolve the intoeing, although the effectiveness of these stretches is unclear. During these stretches, parents should hold the child’s heel firm between the thumb and index finger and use the other hand to gently push the front of the foot outward. This should be done several times a day, such as with diaper changes.

Your child may need to see a pediatric orthopaedic surgeon if the metatarsus adductus has not noticeably improved by the time your child is 6 months old, or if the curve is rigid (i.e. the curvature of the foot cannot be straightened during stretches). If your child’s metatarsus adductus is severe, your Children’s doctor may use a cast or special shoes to correct the problem. Surgery is rarely used except in the most severe cases.

Tibial Torsion (Twisted Shin Bone)

Internal tibial torsion is an inward twist of the tibia, or shin bone. It occurs before birth but is often unnoticed until the child starts to walk.

Internal tibial torsion is diagnosed during a physical exam by looking at the thigh-foot angle (TFA), which is the angle between the middle of the thigh and the foot. The TFA is determined by having the patient lie on his or her stomach with the knees bent at 90-degrees. The TFA is viewed from above the patient. In a young child, the average TFA is about five-degrees, with the foot falling outward. Children with obvious intoeing caused by internal tibial torsion often have a TFA of more than 10-degrees, with the foot falling inward.

Tibial torsion almost always improves before the child reaches school age and usually does not need treatment. Splints, braces, special shoes and exercises do not help fix this problem. Rarely, a child may need surgery if a significant twist does not go away and causes problems with walking.

Femoral Anteversion (Twisted Thigh Bone)

Femoral anteversion is an inward twist of the femur, or thigh bone, near the hip joint. It causes the knees and feet to point inward when walking.

Although this condition forms before birth, it does not often cause noticeable intoeing until ages 2 to 4. Normally, infants and young toddlers have a limited ability to rotate of the hips, which “masks” the early intoeing caused by femoral anteversion. If a child has femoral anteversion, intoeing becomes more obvious as the child gains the ability to rotate his or her hips, and the intoeing is often most prominent between ages 5 and 6. Children with femoral anteversion often prefer to sit in the “W” position as opposed to the crossed-leg position.

Femoral anteversion is diagnosed by measuring hip rotation during a physical exam. This is measured with the child lying on his or her stomach with the knees bent at a 90-degree angle. It is important to make sure the child’s pelvis is flat and level on the table during this exam. Although hip rotation varies greatly in young children, a normal 5-year-old child usually has about a 50-degree angle of inward hip rotation and a 50-degree angle outward hip rotation. Femoral anteversion is present when the inward rotation significantly exceeds the outward rotation.

Most children who have residual intoeing can function normally. The intoeing will not lead to arthritis, and will not prevent participation in any future athletic activities. Studies have shown that the use of casts, braces, splints, special shoes, and exercises do not speed up the correction, and are therefore not recommended. Although younger children with intoeing tend to stumble and fall frequently, this resolves as the child grows and gets stronger and more coordinated. However, if a child has significant walking problems that have not improved by age 8, he or she may be referred to a pediatric orthopaedic surgeon. In some cases, the surgeon may consider a derotational osteotomy, which is a surgical procedure to cut and rotate the bone until it is straight.