Pediatric In-Toeing

In-toeing is a common gait or walking abnormality in which children walk with an inward or internally rotated attitude of the foot or leg. It is often referred to as walking “pigeon-toed.” Aside from appearing irregular, this type of gait pattern can lead to hip, knee, or back pain, and can cause tripping and falling.

An inward posture that causes in-toeing in children can result from a deformity of the foot, leg, or hip. A careful history and physical exam will often reveal the level of the deformity. Sometimes imaging studies such as x-rays may be obtained to aid in the proper diagnosis. Internal rotation at the level of the hip, also known as femoral anteversion or internal femoral torsion, is common in children ages 2-7. Aside from displaying an in-toe gait pattern, these children will often sit in a “W” position because their internally rotated hips cause this position to feel more natural. Femoral anteversion typically resolves on its own by age 10. In severe or more persistent cases, devices such as braces and orthotics may be considered to help control some of the inward rotation of the hip.

Internal rotation at the leg or knee level is referred to as internal tibial torsion and is most common in toddlers. It is considered normal for the leg to have some level of internal rotation in children. As we age, the lower leg de-rotates and the deformity begins to resolve. As a result, the vast majority of children with internal tibial torsion outgrow the deformity by age 10-12. If a child does not outgrow the deformity, they may be fitted for an orthotic with a specialized device referred to as a gait plate, which encourages the child to land with their feet in a straight position when they walk.

In-toe walking caused by a foot deformity is referred to as metatarsus adductus because the metatarsal bones of the foot are deviated in an inward direction. This deformity is apparent at birth, before the child starts walking. Parents may describe their child’s foot as being “C shaped” and may even suspect that the child has club foot. If detected early, metatarsus adductus can be treated by applying weekly casts to improve the position of the feet. This technique is called serial casting. If diagnosed later in life, special shoes or orthotics may be used. In severe cases or in older children who have not responded to conservative techniques, surgery may be considered to reposition the foot into a straight position.

There are numerous reasons that a child may walk with an in-toe gait. No parent should assume that their child will simply outgrow this walking pattern. If you notice any abnormalities with how your child walks, do not hesitate to make an appointment with the doctors of Advanced Podiatry.

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