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.
Illustration by Navina Chabria – Thank you
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.
Children 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 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.
An 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.
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.
Filed under: Foot & Ankle, Hip, Knee, Medical Education, Orthopaedic, Patient Education, Pediatric Tagged: | children, Femoral anteversion, foot, gait, In-toeing, Metartus adductus, Patient Education, pediatric, pigeon toes, Tibial torsion