In-Toeing in Children

Noticing that your child or grandchild's feet turn in can cause alarm, prompting a visit to the pediatrician or orthopaedist. Such a condition may become apparent shortly after the child is born or when the child begins to stand or walk. Often, the walking child seems to be clumsy or to trip over his or her feet. One or a combination of three processes most commonly cause in-toeing: metatarsus adductus, internal tibial torsion, and femoral anteversion. Fortunately, they rarely require treatment and usually get better with time.

Metatarsus adductus, often called pigeon toes, is the most common foot condition seen by orthopaedists who treat children. It occurs when the front of the foot is turned inward, facing the other foot (Fig. 1). Boys and girls are equally affected. Although the cause is not known, some doctors think it results from the child being tightly packed in the mother's womb. Most children's feet straighten naturally without treatment. Occasionally, they need casts, orthoses, or special shoes to correct the condition. In rare cases, correction does not occur naturally or with nonoperative treatment, so the child may need surgery.

Internal tibial torsion and femoral anteversion are similar conditions, which are often called knock knees. The former refers to twisting of the tibia (shin bone); the latter, to twisting of the femur (thigh bone) (Fig. 2). Each condition causes the foot to turn inward. Twisting of these bones is normal in a young child and typically resolves as he or she grows. With internal tibial torsion, the leg gradually straightens by age three; with femoral anteversion, by age eight. Pediatricians and orthopaedists once used special shoes, night splints, and cables to "untwist" these bones. However, treatment does not change the natural course of the conditions and, therefore, is not recommended. Straightening of the legs with surgery is rarely needed and is not performed until natural correction has stopped.

Although in-toeing usually results from one of these conditions, it also may be due to a less common condition that requires special treatment. For example, it may occur if one or both parents had rotational deformity (twisting of the bones). In-toeing may occur in children with a condition such as cerebral palsy. Therefore, the doctor will take a careful medical history as part of the child's evaluation. Through the evaluation, an orthopaedist can determine what, if any, treatment is necessary for in-toeing in a child.

James Alfandre, M.D.
Columbus, Georgia

Further reading
1. Morrissy RT, Weinstein SL, eds. Lovell and Winter's Pediatric Orthopaedics. 4th ed. Philadelphia, PA: Lippincott-Raven; 1996.
2. Wenger DR, Rang M, eds. The Art and Practice of Children's Orthopaedics. New York, NY: Raven Press; 1993.