In-toeing

Many parents are concerned that their children walk with their toes pointed inward. This is known as pigeon toes. Many of today’s parents were treated with special shoes or some other device for in-toeing when they were children. Therefore, they are concerned that their children also require some treatment and want to start that treatment before it is too late.

In-toeing usually arises from one or a combination of three areas; the foot, leg, or hip.

In-toeing - Foot

A child’s foot should have a straight outside border. If the outside border of the foot curves in, it is termed metatarsus adductus (MTA), and can lead to in-toeing. This is generally diagnosed in infants. A line drawn thru the heel should intersect with the second toe of the foot. The image shows a foot with MTA where the line intersects with the fourth toe.

Treatment involves stretching the front of the foot to straighten it out. Stretching is done with exercises, braces, special shoes, or casts. These are pictures of a bebax orthosis, which is used for infants, and a cast which is used for older children. Most often, stretching is all that is needed to correct the problem.

In-toeing - Leg

Many children are born with a twist in their leg bone (tibia). This twist comes from the child’s legs being bundled up prior to birth. This condition is termed tibial torsion. It can be internal or external with internal being much more common and a cause of in-toeing. You may notice that while a child’s knee is facing forward, his foot may be pointing inward.

We diagnose internal tibial torsion by measuring the thigh-foot angle. With the child laying on his stomach and his knee bent, we measure an angle made by drawing a line thru the child’s foot and thigh. If there is internal tibial torsion, the foot will be pointed in relative to the thigh. We have to be careful to account for some rotation in the ankle. The picture to the right demonstrates an internal thigh-foot angle.

Internal tibia torsion was once commonly treated with a device called a Denis-Browne bar. The bar was connected to shoes which were pointed outward. The child would sleep with the device. The idea was to untwist the tibia by rotating the feet outward.

Studies have now shown that internal tibial torsion will get better on its own up to about six years of age. In studies, children who use the bar and shoes did no better than children who did not. For this reason, the bar and shoes are only rarely used today. Instead, the focus is on educating the parents about the natural history of internal tibial torsion and looking at it as a part of a child’s development and not as an abnormality.

In-toeing - Hip

The third potential cause of in-toeing comes from a twist in the hips. This is referred to as femoral anteversion. The hip is a ball and socket joint. The ball does not fit into the socket straight from the side; instead, it is pointed forward approximately fifteen degrees in adults. This forward twist of the ball of the hip joint is termed anteversion.

Infants are born with increased anteversion, around forty degrees, which decreases during the first ten years of life to approach ten degrees. If this anteversion is slightly increased, then a child would be able to turn her hips in more than she could turn them out. This is demonstrated in the picture below. The midpoint of the hip range of motion is with the hips rotated in. This also rotates the child’s knees and feet inward, causing in-toeing.

These children find it easy and comfortable to sit W-style on the floor because this position requires hip internal rotation. Just like tibial torsion, this condition gets better with time so usually no treatment is needed. Some activities that strengthen hip external rotation, such as, ballet, skating, and gymnastics, help children better control their hip rotation, allowing their feet to be pointed straighter. Often, children will in-toe more as the day goes on because they get tired and internally rotating their hips is a comfortable position, which does not require a lot of muscle energy to maintain.

To summarize, a combination of things is often responsible for in-toeing. It is not uncommon for a child to be seen at two years of age and diagnosed with internal tibial torsion. The parents are told the in-toeing will correct by five years of age. When the child is six years old many still in-toe and the parents will ask why. Now, the femoral anteversion, which was there all the time, is noticed. Still, the in-toeing should decrease for the next few years and no treatment is indicated.

These conditions are usually symmetric, meaning both legs are effected about the same. If the in-toeing is asymmetric, then this could be a sign of a more serious problem. Occasionally, hip dysplasia can present as with asymmetric in-toeing, so careful attention is paid to the examination of the hips and an x-ray of the hip may be obtained. Normally, I do not get x-rays when the in-toeing seems to be developmental.