In-Toeing

Introduction

In-toeing is when your child’s foot points inward instead of straight ahead when he or she runs or walks. For most toddlers, in-toeing is painless and can be normal. In-toeing can come from the toes turning in, or a rotation in the shin bone or the thigh bone.  In-toeing usually improves as children grow. Most children with in-toeing learn to walk, run, and play sports just like children whose feet point straight ahead.
 

Description

In-toeing usually happens because the bones in the leg turn inward. This is normal in most toddlers. The three parts of the leg that can be rotated inward are the thighbone (femur), the shin bone (tibia), and the foot. This may run in families.

Femoral Anteversion – This is when the thighbone (femur) has a twist and turns inward. The hip can rotate inward more than usual. Many kids with femoral anteversion can sit in a “W” position. In almost all children, thehe femur bone will gradually correct and untwist by itself. This tends to happenduring elementary school and takes place over many years. There are no braces, shoes, exercises, or chiropractic manipulations that will make this happen faster.

Tibial Torsion - This is when the shin bone (tibia) has a twist and turns inward. Many times, this is because the leg is rotated inward for the baby’s legs to fit in the mother’s womb during pregnancy. In almost all children, the tibia bone will gradually correct and untwist by itself, but this also can take years.

Metatarsus Adductus – This is when the foot is curved inward. This can look a little bit like a mild clubfoot deformity, but metatarsus adductus is very different from clubfoot. Again, this usually corrects on its own after birth, but if the foot does not improve during the first year of life, braces or casts may be recommended.

Symptoms

Most children with in-toeing have no pain or functional problems.  Frequently, families notice that the child stands, walks, or runs with the feet point inward.  Sometimes it will be noted that children who in-toe are clumsy and trip frequently.

Examination

Your doctor will take a thorough history, especially regarding birth history and developmental milestones. Any history of pain or limping should be discussed. The physical exam will include watching your child walk and run, and checking range of motion of the hips, knees, ankles, and feet. He or she will also do a neurologic examination to check muscle tightness, nerve / muscle function, and coordination. He or she will also note whether your child has femoral anteversion, tibial torsion, or metatarsus adductus.

Other Studies

The vast majority of children with in-toeing only need to be evaluated with a full history and physical exam. If there is developmental delay, limp, pain, asymmetry, or a worsening gait, other tests like x-rays may be needed.

Treatment

Normal in-toeing in a toddler requires no treatment other than observation. It can take many years for the bones to untwist as the child grows . Special shoes, braces, or chiropractic manipulation do not make the intoeing improve any faster.

If the femoral anteversion or tibial torsion remains during middle school and cause problems with tripping or walking, surgery may be considered to cut and rotate the bone. This is very rarely needed in otherwise normal children who have femoral anteversion / tibial torsion.

Outcome

In-toeing due to femoral anteversion, tibial torsion, or metatarsus adductus tends to improve as children grow.  There is a small subset of patients where the in-toeing does not resolve, however, most of these patients have no pain or functional problems.
 

More Information:

• OrthoInfo
• American Academy of Pediatrics – Pigeon toes (Intoeing)