Parents, grandparents, and even complete strangers may comment on intoeing (“pigeon toeing”) in kids. This is one of the most common concerns at the pediatrician’s office and often leads to a pediatric orthopedic referral. Most cases of intoeing are normal variations of growth development and only require parental education with reassurance.
Intoeing is typically caused by one of three different anatomic variations or most commonly created by a combination of these features including metatarsus adductus, internal tibia torsion, and/or increased femoral anteversion. The appearance of intoeing may also be worsened during the development of walking and coordination between the ages of 1-5 years old. These musculoskeletal variations typically present without pain or significant impact on activities of daily living. Patients with intoeing may stumble or trip more often than patients without intoeing.
Metatarsus adductus creates a bean-shape to the foot with a c-shaped curve to the lateral border causing the toes to point inward. This is more common in infants and toddlers and may be attributed to intrauterine positioning. This curve is often flexible and corrects with slight tickling of the foot. Internal tibial torsion and femoral anteversion create an inward rotation of the limb and subsequently create an inward appearance of the feet. Internal tibial torsion is more common seen in toddlers or young children. During this same time frame, increased femoral anterversion may also become more apparent or may present slightly later. Medial femoral torsion causes the patella to point inward and decreases external rotation at the hip. This alignment may lead to an “egg-beater” pattern with running and an increase in “W” sitting position (opposite position of sitting cross-legged). These limb rotations are common and are typically age-appropriate with improvement as the patient ages. Patients require full rotational profiles to evaluate the underlying causes of intoeing and any potential asymmetry. Although the vast majority of intoeing presentations improve significantly without intervention, not all cases of intoeing completely resolve. Intoeing is very unlikely to cause long-term complications on interfering with activity.
Most causes of intoeing require simple reassurance and parental education. This management can typically be provided in primary care offices. Abnormal presentations that require additional work-up would include asymmetry or unilateral appearance on exam, pain complaints, spasticity, developmental delay or a history of a condition that may increase the risk of atypical causes including developmental dysplasia of the hip, cerebral palsy, clubfeet, etc. Gait patterns should not interfere with routine activities and indications for referrals should be considered for pain, foot rigidity, limb asymmetry, or delayed milestones. Consultations may also be beneficial for significant parental concern allowing for additional reassurance in most cases.