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In-Toeing Gait In Children

Intervention is often not necessary for children with in-toeing gait. Kids grow out of it.

If you observe people’s feet as they stand or walk, you may notice that their feet generally point straight ahead or perhaps slightly outward. However, many people point their feet inward. This is called in-toeing or pigeon toes.

In-toeing is common in young children, a frequent concern of many parents and a very common referral to our Pediatric Orthopaedic Clinic. In the overwhelming majority of patients, in-toeing corrects itself with time. Treatment is only necessary in a tiny fraction of patients.

“In-toeing does not lead to arthritis or interfere with sports. Toddlers who in-toe do tend to fall more frequently, because unlike adults, toddlers cannot increase the length of their strides, but can only increase the number of steps, which results in clumsiness and tripping,” asserts Dr Brian Grottkau, Chief of Pediatric Orthopaedic Surgery at the Massachusetts General Hospital, and Assistant Professor of Orthopaedic Surgery at Harvard Medical School, Boston, MA.

Causes of In-toeing Gait
The three most common causes of in-toeing in children are twisting of the thigh bone (femoral anteversion), twisting of the shin bone (internal/medial tibial torsion) and curved feet (metatarsus adductus). Your pediatric orthopaedic surgeon will evaluate your child and determine if in-toeing is coming from the hips, legs, or feet.

schematic of different types of In-toeing gait in children
Illustration by Navina Chabria – Thank you

Femoral Anteversion
Twisting of the femur – the long bone going from the hip to the knee (called femoral anteversion) is the most frequent cause of in-toeing in children between the ages of 3 – 10 years. The leaning forward of the neck of the femur with respect to the rest of the femur, causes the knee and foot to twist inwards towards the midline of the body.

In-toeing gait in children Femoral anteversionChildren are normally born with approximately 40 degrees of internal twist, which gradually decreases to 10 – 15 degrees at adolescence and improves with further growth. Femoral anteversion is more common in females and is most noticeable between the ages of 4 – 6 years. Parents will notice that when the child is standing with the feet forward, the kneecaps (patellae) point inwards. The child’s gait is often described as being awkward or clumsy. In-toeing appears worse during running and at the end of the day when kids are tired. Children with femoral anteversion often prefer the “W” sitting position because it is more comfortable (see picture below). This should not be discouraged or avoided. Femoral anteversion decreases naturally in approximately 99% of cases. Studies have repeatedly shown that special shoes, twister cables and braces make no difference in outcome. Therefore, femoral anteversion is best treated with simple reassurance and observation.

Since most cases resolve spontaneously, surgery to correct the deformity is generally not recommended before the age of 8 – 9 years. The few indications for surgery include: a) femoral anteversion greater than 45 degrees, b) inability to rotate out the hip beyond neutral, c) functional disability, and d) severe cosmetic deformity.

Internal Tibial Torsion
In-toeing gait in children Internal Tibial TorsionIn-toeing can also be caused by an internal twisting of the shin bone or tibia. It is often noticed when a child first starts to walk and is most common between the ages of 2 – 4 years. Twisting of the tibia is a variation of normal anatomy and is caused partially by the child’s position in the womb. Parents usually bring the toddler with complaints of “bowing legs.” If the child is made to stand with the kneecaps (patella) facing straight forward, the feet appear twisted inwards.

Different braces and special shoes have been prescribed in the past for internal tibial torsion. However, none of these shoes or braces has been shown to speed up the natural resolution of tibial torsion. Therefore, simple reassurance and observation is the best treatment for in-toeing caused by internal tibial torsion.

Metatarsus Adductus
In-toeing gait in children Metatarsus AdductusAn inward facing convexity of the foot (metatarsus adductus) is the most common foot deformity in infants, occurring ~ 1 – 3 per 1000 children. Metatarsus adductus is also believed to be caused by positioning or crowding in the womb. In the majority of patients, the foot is flexible and can be passively corrected to neutral (normal) position.

In the overwhelming majority of infants and children with metatarsus adductus, the foot will naturally straighten out, requiring no treatment other than reassurance and observation. Parents can gently stretch the infant’s foot to neutral a few times each day (with diaper changes, for instance). Occasionally, if the curved foot persists, serial casting can be done, but generally not before the age of one.

Summary
Studies have shown that adult runners who have a slightly in-toed gait, derive mechanical advantage and are faster runners than their peers. “The price of being a good running athlete later on is the tripping that occurs as a toddler. No intervention is generally warranted for in-toeing,” assures Dr Brian Grottkau, Pediatric Surgeon at the Massachusetts General Hospital, Boston, MA.


17 Responses

  1. My 26 months old grandson has severe in toeing and waiting until he is 30 months old until the next follow up appointment at University of Maryland. The intoeing is not improved since its notice upon walking at age 11 months. It is felt by the doctor surgery will be necessary if by the age of 30 months the tibal torsion has not straighten. Is there an arthroscopic approach to this surgery ? Is there any special surgical method recommended ? Should there be additional time allowed before permitting surgery ? I would appreciate your opinion and guidence. Janet Limmer from Baltimore, Maryland

    • Hi Janet,

      One of our Nurse Practitioners had the following to say,

      “Surgery for intoeing is extremely rare! And it is even more rare to recommend surgery for a patient who is only 2 years of age or 26/30 months. There is no arthroscopic approach to correct the alignment in this age patient. I would definitely allow more time because the surgical treatment should remain the same even if waiting for quite some time, and generall all intoeing will correct over time.”

      Hope this is helpful.
      Best Wishes,
      Arun

  2. [...] Intoeing (click link for pictures) is generally normal and does not require x-rays, special shoes, braces, casting, or surgery.  Most of the time it slowly improves by two years of age and a little more by age eight.  Doctors rarely do anything unless it is extreme, causes pain, or limp (more frequent tripping occurs in toddlerhood but should improve with time).  Even if children do not outgrow the problem, there is no evidence that arthritis or other orthopedic problems will  occur in adulthood.  In fact, intoeing can be beneficial to athletes making for faster acceleration and direction change. Think John Elway, Vera Zvonareva and Babe Ruth.  Out-toeing is less common.  It too is a variant of normal. [...]

  3. Ive Had This ‘In-toeing’ Problem Since I Was A Baby, My Feet Havent Got Any Better.. Ive Tried Special Shoes, Physiotherapy and Other Things, My Mate Had The Same Problem As Me And Had The Operation On Her Hips And Now She Is Walking Fine, This Problem Causes Me Pain Through My Legs And My Hips.. Would The Operation Be Recommended?

    • I am not sure what your clinical situation is. I recommend you see a trained Foot & Ankle surgeon to determine if any surgery will be beneficial to your situation.
      Best Wishes

  4. My 16 month old has tibial torsion and im not happy with not doing anything about it. Is there any kind of shoe for her

    • Your doctor IS the best person to advise you.
      Best Wishes
      Arun

    • I know my brother had this when he was little and the dr wanted to do nothing, well my dad the creative builder he is has the dr make like a I guess it looked like he had on a knee high boot only it was made of solid like plastic or fiberglass so when strapped in( the front had Velcro straps) he was forced to have his foot and leg straight. He wore it at bedtime only ( he was like 6 ) and I swear maybe about 8 months a year and half he was cured. I always wonder if that dr now patented my dads idea and is making tons off of his invention that really cured a patient, my brother is 28 now and is an accomplished surfer, motocross racer and also a scientist for a pharmaceutical company. I remember he didn’t like it at first but then grew attached to it .. Kind of like I had neck gear with my braces worn only at night thank god at age 11 that would have made my social life hell at school having to wear one All day. But yeah I believe u can train your body to do whatever u want with patience and determination. I know everything will be fine very rare do
      U see adults with this, but the sooner to treat the higher success rate of curing. True for Pretty much everything. Good luck.

  5. My daughter is five years old and has been diagnosed with Femoral Anteversion. The doctor that gave the diagnosis (Childrens Hospital in Boston) said that it is the most severe that he has seen in 12 years. He did not recommend surgery but also did not discourage it. It was pretty shocking to hear that she would likely never grow out of it, so much so that he said he would perform the surgery before age 8 because it was likely that not much will have changed by then. At first I did not want to consider surgery for this (I was born pigeon toed as was my mother but both of us grew out of it) now I am not so sure. What are the risks of this surgery? The Doctor that we saw said it would involve plates and pins. Do they need replacement as the child grows? This was something I neglected to ask, as I was pretty shocked to hear that she would not grow out of this naturally. Any insight would be greatly appreciated.

    • Hi Meg,
      WoW! I can imagine this must have been a big shock.
      Since this can be a serious matter, I strongly suggest you get a second opinion. Personally I think it is ALWAYS a good idea to get a second opinion.

      (Full Disclosure: I work at MGH Ortho)
      Why don’t you see one of the Pediatric Orthopaedic surgeons at Mass General? With what you know, you will be able to ask more specific, detailed questions. And if you share your own experience with femoral anteversion, perhaps they may have a different treatment plan. Also call their office; their nurse practitioners are one of the best and they see nearly 100s of such cases.

      http://www.massgeneral.org/ortho/services/treatmentprograms.aspx?id=1337

      And it will put your mind at ease too.

      Best Wishes,
      Arun

      • Dear Arun, Thank you so much for your quick reply. I will take your advice and call MGH tomorrow for an appointment. I was planning on calling MGH for a second opinion. (I am presently being seen by your amazing team at MGH for Melanoma and I credit them for saving my life.) Thank you again for your help. Best regards, Meg

        • Hi Meg,
          A quick update.
          I spoke to the Nurse Practitioner in the Pediatric Service and she was incredulous that anyone would recommend surgery. She said in the 14 years she has worked at Mass General, we have done 1 surgery for femoral anteversion, and that was “a horrible horrible case.”

          Rest assured; and make an appointment, and put your mind at ease.
          Arun

  6. If the metatarsus adductus persists after age 1, what is the general recommendation? Is casting the norm? Although I’ve read that no intervention is necessary typically when does it become something an orthopedic specialist will based on falling and pain when wearing shoes?

    • I think you may want to wait at least till age 3-4. Walking alters childrens gait and muscle development, and consequently bone adaptation.

      (Not trying to sound like an ad) If you are concerned, you should consult with a specialist pediatric orthopaedist.
      A

  7. Can you share the reasoning behind “not discouraging or avoiding” w-sitting for femoral anteversion?

  8. I’ve been pigeon toed all my life and it never corrected itself. I’m 19 years old now and I’ve never been able to play sports or run. I can barely walk without tripping over my own feet. I went to therapy as a child and I’ve tried braces and my legs never showed signs of improvement. Its painful to walk or stand for long periods of time and I experience intense pain and swelling throughout both legs. Should I try corrective surgery? Are there any other options?

    • Here is a comment from our Nurse Practitioner:

      “… cases are reviewed individually and in general intoeing is not associated with long term issues/problems. It would be very difficult to say that any swelling or pain is coming from femoral anteversion/tibial torsion, or metatarsus adductus. I would recommend that the patient see an orthopaedic specialist for further evaluation and to determine if any procedures/surgeries may be beneficial to improve function and decrease pain.”

      Thank you.

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