What is Intoeing?
Deformities and bending of the lower limbs are a common reason why children are referred to orthopedic specialists, a type of doctor that helps with bones and muscles. A common condition is ‘in-toeing’, which is mostly seen in babies and young kids. In-toeing, also known as ‘pigeon-toeing,’ happens when a rotation in the leg causes the foot to point inward.
It’s important to understand that children’s legs naturally grow and develop in a specific way. Newborns are born with their leg bones rotated forward by about 40 degrees. This condition is known as femoral anteversion. As the child grows, this internal hip rotation decreases and by around ten years of age, the forward rotation decreases by about half. Any unusual changes from this normal leg development and rotation should be noticed. It may simply be due to growth or it might signal other issues that stop the leg from rotating normally.
What Causes Intoeing?
In-toeing, also known as pigeon-toeing, in kids, is usually caused by three main conditions: metatarsus adductus, internal tibial torsion, and femoral anteversion. Each of these conditions has its unique symptoms and usually appears at a certain age. There are other potential causes of in-toeing too; we will discuss some of them in the paragraphs below.
Metatarsus Adductus makes the front part of a child’s foot turn inward, Internal Tibial Torsion refers to an inward twist of the shin bone, and in Femoral Anteversion, the thighbone turns inward. These conditions are quite common and usually improve as the child grows.
Risk Factors and Frequency for Intoeing
The condition most often seen in children under one year old is metatarsus adductus. This condition is present in 0.1% to 1% of all births, and is more commonly seen in girls than boys.
For children between the ages of 1 and 4 years, the most common reason they walk with their toes turned in, also known as in-toeing, is due to something called internal tibial torsion. This condition doesn’t favor any specific gender and we aren’t sure what causes it.
The third most common cause of in-toeing in children is something called increased femoral anteversion. This can show up during infancy but is usually noticed after the age of 3. The average age of diagnosis lies between 3 to 6 years of age. This condition is twice as common in girls as it is in boys.
Signs and Symptoms of Intoeing
When examining a patient for lower extremity conditions, doctors usually need to look at the whole leg, but pay special focus to the hip and thigh, the knee and lower leg, and the feet. They assess the patient’s walking and running patterns, as is suitable for their age and development stage.
Metatarsus adductus is a condition where the front part of the foot turns inward. It can be different levels of flexibility. Doctors categorize it as flexible, semi-flexible, or rigid. It has to be distinguished from Talipes Equino varus, another foot condition, as metatarsus adductus only affects the front part of the foot and not the whole foot. If the front part of the foot can be moved outward freely, the deformity is seen as flexible. If it can just get to a neutral position, it’s semi-flexible and if it doesn’t reach a neutral position it’s rigid.
Some patients will also have a condition called tibial torsion, where the shin bone is rotated inwards. It usually affects both legs and may show hand-in-hand with metatarsus adductus, femoral anteversion, or physiologic bow legging. During an examination for this condition, doctors look for signs such as a forward or outward-facing kneecap, or a rotated inner ankle bone when the patient is seated. They also check the thigh-foot angle (TFA), the measure of the difference between the direction of the leg and foot. This can be done by looking at the degree of turning of the foot when the patient is lying prone with the knees bent. Typically, the foot will angle 10 to 15 degrees away or towards the midline.
When examining patients for femoral anteversion, another condition where the thigh bone is rotated inwards, doctors look for a knee cap that faces forwards when walking or standing but turns inwards when running. Patients with this condition typically show a unique running style, referred to as a “windmill” or “egg-beater” pattern, and a preference for sitting in a “W” position. Over time, these patients show an improved comfort with outward rotation, as observed by an increased ease in sitting cross-legged.
Testing for Intoeing
If your doctor thinks you have metatarsus adductus, a condition where the front half of your foot, or forefoot, turns inward, usually, they can confirm this just by examining you. There’s typically no need to use imaging tests, like X-rays, for the diagnosis.
However, there are some circumstances in which imaging might be used. For example, if your condition is severe and your doctor is considering surgery, then they may use X-rays to obtain detailed images of your foot. Otherwise, imaging tests might be used to rule out other conditions that could be causing your symptoms.
Treatment Options for Intoeing
In most cases, watching and waiting is the best approach to manage these issues that can affect how children’s legs and feet develop. This method often involves reassuring parents that these conditions usually improve on their own. Parents can help their child’s condition by not allowing them to sleep in positions that make the condition worse. For example, some children sleep on their stomachs with their hips and knees bent and their foot turning inward under their hips. This can cause more twisting in the feet, known as metatarsus adductus. Encouraging children to sleep in different positions can help reduce such deformities. Metatarsus adductus usually improves by the time a child is two years old, and it’s rare that it causes any problems for the child if it continues past this age. But, if the child’s foot remains inflexible and twisted, they may be referred for treatment, which might include casting, a process where a plaster or fiberglass cast is applied to help straighten the foot.
For children showing signs of tibial torsion, where the bone in the lower leg (tibia) twists inward, it’s important for parents to know that it’s normal for the legs of growing children to turn in towards each other more as they get older. This is usually temporary and corrects by itself by the time the child is around five years old. Any persisting cases of tibial torsion are unlikely to cause long-term problems. However, in rare cases where twisting of the tibia causes problems with appearance or function, surgical correction could be considered.
Similarly, a condition called femoral anteversion, where the upper leg bone (femur) twists inwards, will usually correct itself over time. This generally happens by around the age of 11 years. Persisting cases are rare, and it is even rarer that they cause any problems. Just like with the other conditions, reassurance and observation are key, and parents should be comforted that the condition will usually decrease naturally. There are no recommended non-surgical treatments for this condition. Surgery is used very sparingly for severe cases because it could result in complications and is only considered for children older than 11 years suffering from severe physical impacts or distress over appearance.
What else can Intoeing be?
Most cases of in-toeing, which is when the feet turn inward instead of pointing straight ahead, naturally get better over time. However, it’s important for doctors to check for other less common conditions that cause similar symptoms. These might include hip dysplasia (a condition where the hip joint doesn’t form properly), deformities of the lower leg, or clubfoot (a specific type of foot deformity).
- Hip dysplasia can be linked to another foot condition called metatarsus adductus, but it can also occur on its own. Regular check-ups and appropriate medical imaging can help doctors tell if it’s simply the hip being a little loose, which is normal as the hip develops, or if it’s hip dysplasia.
- Any deformities in the lower leg can be spotted by a detailed physical exam. A condition separated from normal causes of in-toeing.
- Clubfoot is a complex foot deformity and includes multiple foot issues, such as the foot pointing down (plantarflexion or ‘cavus’), the foot bending inwards (adductus), the foot tilted inwards (varus), and the foot pointing downwards (equinus). These are remembered using the acronym CAVE.
- Conditions like cerebral palsy or other neuromuscular diseases can also cause in-toeing. If a doctor’s exam shows other signs beyond the lower legs, they should consider these possible conditions.
What to expect with Intoeing
The overall outcome for these three conditions is generally positive, each with their own specific recovery timelines.
Possible Complications When Diagnosed with Intoeing
Direct complications are rare, but it’s crucial to recognize that certain conditions can be connected. Metatarsus adductus, a foot deformity seen at birth, is linked to the positioning in the womb. Health professionals should be aware that other conditions related to the baby’s positioning inside the womb may occur alongside it. These include torticollis (a twisted neck) and developmental dysplasia of the hip, a condition where the hip joint hasn’t formed correctly, which often happens in both hips.
Possible Health Conditions:
- Metatarsus adductus
- Torticollis
- Developmental dysplasia of the hip (often seen in both hips)
Preventing Intoeing
The most important part of managing this condition is regular check-ups with your family doctor. This helps to keep an eye on the situation and give confidence to the patient’s family. Some family members might already know about previous methods used for correcting in-toed feet, such as braces, inserts for shoes, changing the way shoes are worn, and using splints during sleep. However, it’s important for families to understand that these methods are not recommended for these conditions. The development of the lower limbs often follows a natural path, and family members should take comfort in this.
