Children who walk with their feet turned in

In brief

Many children walk with their toes pointing inwards (in-toeing). In most cases it is due to normal variations in the development of the femur, tibia or foot, which improve on their own with growth and need no treatment. Insoles, special shoes and braces do not usually change bone rotation. It is worth seeing a specialist if the child limps, has pain, is getting worse or there is a marked difference between the two sides.

Typical age

From the first years to about age 8, depending on the cause

Also known as

Intoeing · Pigeon-toed walking · Internal rotation gait · Femoral anteversion · Internal tibial torsion

What is it?

In-toeing is when, during walking or running, the toes point towards the midline of the body instead of straight ahead. It is a common reason for consultation in childhood and, in most children, is a normal variant of musculoskeletal development. It usually causes no pain and does not prevent normal activities.

The direction the foot points depends on the shape and rotation of several bones. So in-toeing does not have a single cause: it can come from the femur, the tibia or the foot itself. Identifying where the rotation comes from makes it possible to explain to families how it is likely to evolve and whether any treatment is needed.

The three main causes are:

• Femoral anteversion: the femur has a rotational alignment that makes the knees and feet tend to point inwards. It usually becomes most noticeable between 3 and 6 years of age, especially when running or walking fast.
• Internal tibial torsion: the tibia is rotated inwards. It is common in young children and may be seen from the time they start walking.
• Metatarsus adductus: the front of the foot curves inwards relative to the back. It is usually spotted in infancy and may be related to the baby’s position in the womb.

These variants usually improve as the child grows. Femoral anteversion usually decreases during childhood, while internal tibial torsion tends to correct in the first years of life. Flexible metatarsus adductus also usually improves on its own.

Signs parents may notice

Families may notice one or more of the following:

• The toes point inwards when walking or running.
• The child seems to walk “pigeon-toed”.
• The knees also point inwards, especially when running.
• The child often sits in a “W” position, with knees bent and feet out to the sides.
• The child trips over their own feet or seems less coordinated when running, especially in the early years.
• One foot seems more curved inwards than the other.
• The walking pattern changes with age and is more obvious in certain activities.

Occasional tripping is common during development and does not necessarily mean there is a problem. However, if falls are very frequent, interfere with play or come with pain or difficulty walking, an assessment is advisable.

When to see a specialist

It is advisable to see the paediatrician or a paediatric orthopaedic specialist when in-toeing raises concerns, limits the child’s activities or does not follow the expected course.

An assessment is advisable if:

• The problem clearly affects only one leg or there is marked asymmetry.
• The rotation gets progressively worse instead of better.
• The child has pain in the hip, thigh, knee or foot.
• There is a persistent limp or difficulty walking and running.
• Falls are frequent and limit the child’s activities.
• The foot deformity is rigid or cannot be gently corrected.
• The walking pattern appears suddenly or comes with weakness or other neurological changes.

When is it urgent?

An urgent assessment is needed if the child suddenly cannot bear weight on the leg, or has severe pain, fever with joint pain or a sudden loss of strength. These symptoms are not typical of a common rotational variant and other causes need to be ruled out.

How is it diagnosed?

Diagnosis is based on the medical history and physical examination. Most children do not need X-rays or other imaging tests.

During the assessment, the specialist watches how the child walks and runs, the direction of the knees and feet and whether both legs are symmetrical. They also examine movement of the hips, knees and ankles, and the shape of the foot.

Specific tests are used to identify where the rotation comes from:

• Femoral anteversion: internal and external hip rotation and leg alignment are assessed.
• Internal tibial torsion: the orientation of the tibia and the axis of the foot relative to the knee are evaluated.
• Metatarsus adductus: the curve of the forefoot is examined to see whether it can be gently corrected or is rigid.

X-rays and other tests are reserved for selected situations, such as persistent pain, marked asymmetry, an atypical deformity or suspicion of another condition. In exceptional cases, when a bone deformity needs to be measured to plan surgery, specific imaging studies may be used.

Treatment

Conservative treatment

Most children with in-toeing need no treatment. The usual approach is to explain the cause to the family and monitor progress during growth.

1. Observation and follow-up

When the examination confirms a normal developmental variant, clinical follow-up where indicated is enough. The outlook is usually good and the rotation tends to decrease with age.

2. Normal physical activity

The child can walk, run, play and do sport according to their abilities. There is no need to restrict physical activity if there is no pain or other associated problem.

3. Insoles, special shoes and braces

Insoles, corrective shoes and braces have not been shown to correct femoral anteversion or internal tibial torsion. They should not be routinely prescribed to change the direction of the feet in a typical developmental walking pattern.

In metatarsus adductus, treatment depends on the flexibility and severity of the deformity. Flexible forms usually improve on their own. If the deformity is rigid or marked, the specialist may consider specific treatment, which in some cases may include corrective casts.

4. Physiotherapy

Exercises and physiotherapy can be helpful if there is a specific functional need, such as a balance problem or an associated motor difficulty. However, they do not in themselves correct bone torsion of the femur or tibia.

Surgical treatment

Surgery is exceptional and is only considered in older children or adolescents with a significant, persistent and symptomatic rotational deformity that markedly limits walking or daily activities.

The decision is not based only on the feet pointing inwards, but on the severity of symptoms, the clinical examination, the size of the deformity and its functional impact.

In selected cases a derotation osteotomy may be performed, an operation in which the bone is cut and its rotation corrected. Depending on where the problem comes from, it may be done on the femur or the tibia. The bone is stabilised with an appropriate fixation system.

This surgery requires general anaesthesia and usually a short hospital stay, whose length depends on the technique, the child’s age and progress. Recovery includes clinical and X-ray check-ups and a gradual return to activity.

Operating on a normal developmental variant that causes no significant limitation is not recommended. The decision must be individual and made by a team experienced in paediatric orthopaedics.

Outlook and recovery

The outlook depends on the cause of the in-toeing. In most children the alignment improves on its own and leaves no lasting effects.

• Internal tibial torsion: usually improves during the first years of life, often before age 4–5.
• Femoral anteversion: usually becomes less noticeable during childhood, especially between ages 6 and 8, although some internal rotation may persist later.
• Flexible metatarsus adductus: usually improves during the first months or years of life. Rigid forms need individual assessment.

When only observation is needed, the child can go to school and play sport normally, as long as there is no pain or functional limitation.

If derotation surgery is exceptionally performed, recovery takes longer and depends on the bone operated on, the fixation and bone healing. Weight-bearing, return to school and return to sport are decided individually according to clinical and X-ray progress; there is no single timetable that applies to every child.

This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.