Definition

Intoeing, commonly referred to as pigeon-toed, is a condition where the feet turn inward, preventing them from pointing straight ahead while walking or running. It is a frequent occurrence in young children, particularly during the first few years of life. Parents usually notice this condition when their child is an infant or just beginning to walk. Children with intoeing often trip or assume awkward positions while moving.

While intoeing can seem concerning, it does not stop children from learning how to walk or run. In most cases, the condition improves on its own without the need for braces, casts, or medical procedures. As the child grows and improves their walking and running skills, their feet will naturally align. Although uncommon, intoeing can persist into adulthood in rare cases.

Typically, the feet simply turn inward, and the condition is not associated with pain or inflammation. However, if a child experiences pain, limps while walking, or shows signs of swelling in the feet, they should be seen by a doctor for a proper evaluation.

Causes

The exact cause of intoeing, where a child’s feet turn inward instead of straight ahead, is not fully understood. This condition can affect children of various ages, and several factors may contribute to the inward-turning of the feet. Some of the possible causes include:

• A family history of inward-turning feet during childhood.

• A restricted space in the uterus, which can cause compression of the fetus and affect the position of its feet.

There are three primary causes of intoeing, which can either occur independently or be related to other muscle and bone issues:

• Metatarsus Adductus

This condition involves the foot turning inward, while the outer part of the foot remains straight. Metatarsus adductus is believed to be linked to the fetus’s position during pregnancy.

• Internal Tibial Torsion

The tibia is the lower leg bone, and internal tibial torsion refers to the inward twisting of this bone (located between the ankle and knee). This condition can occur before birth when the fetus’s lower leg rotates to fit within the confined space of the womb. After birth, the baby’s leg should naturally rotate back to its normal position.

However, if the tibia remains turned inward, it results in internal tibial torsion, a condition commonly seen in infants and children.

• Internal Femoral Torsion (Femoral Anteversion)

In this condition, the femur (thigh bone) undergoes excessive forward rotation near the pelvis, causing the upper part of the thigh to bend inward. As a result, the hips curve inward instead of outward.

Risk Factor

Certain factors increase the chances of a child developing intoeing, including:

• Pregnancy with multiple fetuses (e.g., twins).

• Low levels of amniotic fluid (oligohydramnios), where the fetus’s space is limited, leading to compression.

• A large fetus.

• A breech position, where the baby’s buttocks are low in the uterus.

Although rare, some other conditions may be associated with intoeing, such as:

• Cerebral palsy, a group of neurological disorders that affect movement, muscle tone, and posture.

• Clubfoot, a congenital condition where the feet are twisted out of their normal position.

• Developmental hip joint disorders.

• Other uncommon body deformities.

Symptoms

Intoeing is characterized by the inward turning of a child’s feet while walking or running, instead of the feet pointing straight ahead. This condition usually does not cause pain or joint inflammation. The appearance of intoeing may vary, depending on which part of the foot or leg is turned inward.

• Metatarsus Adductus

In metatarsus adductus, a child's foot turns inward from the middle of the foot to the toes. Some cases are mild, but in others, the foot may turn more severely inward and feel stiff. In more severe cases, the condition may resemble clubfoot, a more serious foot deformity that requires immediate medical intervention after birth.

• Internal Tibial Torsion

Internal tibial torsion occurs when a child begins walking, and the foot bends inward due to the tibia bone (in the lower leg) twisting, causing the foot to point inward.

• Internal Femoral Torsion

In this condition, both the knees and feet of a child turn inward while walking. This is a common condition in young children, typically seen between the ages of 5 and 6. When sitting on the floor, children with internal femoral torsion may sit with their feet turned outward and their knees bent in a “W” shape, with their buttocks positioned between their heels.

Other signs of inward turning that may be noticed include:

• A crescent-shaped foot, particularly in infants.

• A noticeable limp when walking.

• Difficulties walking, such as frequent stumbling or falling.

Diagnosis

The appearance of a child’s feet and lower limbs is usually quite clear, and any concerns about their walking or leg position can be discussed with a doctor. The doctor may ask about the child’s medical history, including pregnancy and birth details, and will conduct a physical exam of the legs and feet.

If needed, the doctor may recommend additional tests, such as imaging studies. X-rays or CT scans may be used to examine and assess the bones in the legs and feet.

Management

Metatarsus Adductus

In most cases, infant feet are flexible and tend to improve naturally without treatment within the first 4-6 months, or even up to 2 or 3 years of age.

For more severe foot deformities or very stiff feet in infants aged 6-9 months, therapy may be necessary. Treatment typically involves the use of casts or special shoes, and this approach has a high success rate.

Casts are applied regularly to stretch and lengthen the child’s muscles. It’s important to keep the cast clean and dry to avoid discomfort or odor.

Surgical intervention to straighten the leg is rarely required.

Internal Tibial Torsion

This condition usually resolves on its own without the need for treatment, typically before the child reaches school age or by the age of 8. Special shoes, splints, or exercises are generally not beneficial for this condition.

If the curvature is severe and causes significant problems with walking, surgery may be considered for children who are at least 8-10 years old.

Internal Femoral Torsion

Internal femoral torsion generally resolves by the time the child reaches age 10, without the need for therapy. Exercises, braces, or special shoes are not effective for treating this condition.

Surgery is rarely required unless the child is older than 9 or 10 years and has a severe deformity that causes tripping or difficulty with walking. 

Complications

Intoeing typically does not cause pain or prevent a child from walking or running. The condition tends to improve over time, and the feet usually start pointing straight as the child grows older, enhancing their walking and running skills.

However, if left untreated, some complications may arise, including:

• An unbalanced gait, which increases the risk of injury.

• Reduced athletic performance due to difficulty with running and jumping.

• Foot deformities.

• Joint inflammation.

Prevention

Prevention involves identifying and managing risk factors that can increase the likelihood of developing a condition. The causes of intoeing cannot be altered, so there is no direct way to prevent it. However, regular checkups during pregnancy can help identify potential risk factors, such as low amniotic fluid, a large fetus, or a breech position, that might contribute to the condition.

When to See a Doctor?

Intoeing is a common condition in children. It is understandable for parents to feel concerned about their child’s condition, especially when the child is too young to express discomfort or pain.

You should consult a doctor if:

• Intoeing is observed in only one leg.

• The condition is severe, the leg becomes stiff, and there is no improvement over time.

• Intoeing causes frequent stumbling in school-aged children, interfering with their ability to participate in activities.

Additionally, if the child experiences pain, swelling, or limping along with the inward turning of the feet, a visit to the doctor is advised.

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