Pediatric In-Toeing

In-toeing is a common complaint among parents who's children are at or near walking age.  It will frequently bring parents in with their young children, who may say that the child “walks funny” or is “pigeon-toed”.  It is most often noticed by the parents as the child begins to watch, typically around 12 months of age, but may present at anytime during childhood for various reasons. 

In-toeing, particularly in children less than 8 or 9 years old, is usually harmless.  It may represent a normal variation of anatomy and development, and will usually resolve with time.

However, what often brings parents in to the specialist’s office is that their child walks with limp, trips over their feet, is in pain, or has difficulty keeping up with their peers.  In these cases, a through evaluation of in-toeing is warranted by the specialist.

Of the many things that may cause a child to walk with their toes pointed inwards, there are three things that are seen most often.  These are internal rotational positions of the hip, leg, and foot. 

In the hip, femoral anteversion may cause the child to have an in-toed gait.  This is a condition whereby the femur is rotated inwards.  At the femoral head, where the bone inserts into the pelvis to create the hip joint, an increase in internal rotation can cause this to happen.  It is typically most noticeable around the time a child begins Kindergarten, at about 5 or 6 years old.  The child may “W” sit, where they sit with their legs behind them, putting pressure on the legs.  This can reinforce the malaligned position of the femur, and is typically discouraged in children with mild femoral anteversion. 

Most cases of femoral anteversion will resolve over time, reaching a normal position by the time the child is 10.  For severe cases, surgery may be necessary to cut the femur bone and rotate it into a more normal position. 

Working down from the hip, the next level that may cause pediatric in-toeing is in the leg at the tibia-fibula segmnt.  Internal tibial torsion is normal until the age of 2, where as the child walks the tibia begins to untwist.  The leg usually normalizes by the time the child is 10.  For severe cases of internal tibial torsion, resulting in significant disability or pain, surgery may be required to cut the tibia and fibula and realign them in a more normal position.

In the foot, a positional deformity called metatarsus adducutus may contribute to in-toeing.  This is commonly seen at birth, and may represent a normal variation.  In severe cases, treatment may be required to straighten out the foot.  Typically conservative measures are used first, such as straight-lasted shoes or specialized bars and braces that help to straighten out the foot.

If conservative therapy fails, surgery may be required to straighten out the foot.  However, this is reserved for severe, unrelenting and rigid cases.

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com