Pigeon toes (intoeing)

Most people's feet point straight ahead or outward. In some people, however, their feet point inward. This is called intoeing or "pigeon toes”.

Children under the age of two years usually have some degree of intoeing as part of their normal development, which will usually go away without any treatment as they grow up. However, in a few children, it does not get better on its own and may need to be treated.

Intoeing may cause the child to stumble and trip but it does not cause pain and does not lead to other conditions such as arthritis. There may be difficulty with getting shoes to fit correctly, and some children may be concerned about looking different.

Intoeing differs from club foot, which is when the top of the foot is twisted downward and inward.

Causes

Intoeing tends to run in families. Prevention is not usually possible because the condition occurs as the result of developmental or genetic abnormalities that cannot be controlled. Three main conditions cause intoeing.

Metatarsus adductus (curved foot)

This is thought to result from the curled-up position of the baby before birth. The child’s feet may curve in from the middle of one or both feet. Mild to moderate forms of this condition tend to correct themselves in the first four to six months of life.

Femoral torsion (twisted thighbone)

The femur (thigh bone) is the bone that runs from the hip to the knee. In femoral torsion, the femur is rotated inwards, causing the knees and feet to point inwards. This is common in babies and the condition usually resolves by the age of 10 years. It is often first noticed between the ages of two and four years. Children with femoral torsion may have difficulty sitting in a cross-legged position and tend to sit on their knees with their feet flared out behind them.

Tibial torsion (twisted shin)

The tibia (shin bone) is the bone at the front of the leg that runs from the knee to the ankle. In tibial torsion, the tibia is rotated inwards, causing the feet to point inwards. Again, this is common in babies, and the tibia normally straightens by the age of 18 to 24 months. If tibial torsion does not resolve, it is usually first noticed when the child starts walking.

Treatment

Most causes of intoeing correct themselves in early childhood and do not require treatment. Treatment may be required, however, if the degree of intoeing is severe and/or it does not resolve over time.

In cases of severe metatarsal adductus, casting or splinting of the feet may be recommended. The cast/splint stretches the feet into a straight position. It is recommended that this treatment is completed before the child is of walking age.

Another treatment is for the child to wear special shoes during the day. These shoes, called reverse-last shoes, hold the foot in the correct position. Surgery to straighten the foot is seldom required. There may be some residual curve in the feet after treatment but this will not affect activity and does not cause any discomfort.

Tibial and femoral torsion nearly always resolve without treatment. However, in cases of severe tibial or femoral torsion that cause difficulties with walking, surgery may be recommended. Surgery involves cutting the femur or tibia and repositioning it outward, so the toes point straight ahead.

Surgery is not usually considered until after the age of eight years as the leg bones continue to grow straighter until around that age. Splints, special shoes and exercise programmes have been shown not to help in the treatment of tibial and femoral torsion.

References

OrthoInfo (2020). Intoeing (Web Page). Rosemont, IL: American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases--conditions/intoeing [Accessed: 28/10/20]
O’Toole, M.T. (Ed.) (2027). Metatarsus varus. Mosby’s Dictionary of Medicine, Nursing & Health Professions (10th ed.). St Louis, MI: Elsevier.
MedlinePlus (2020). Metatarsus adductus (Web Page). Bethesda, MD: US National Library of Medicine (NIH). https://medlineplus.gov/ency/article/001601.htm [Accessed: 28/10/20]

Last Reviewed: October 2020

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