The Intoeing Dilemma – What’s Normal? What Needs to be Referred?

Published on in Orthopaedics Update

Parents are often concerned with the appearance of lower extremities in children. Often, recurrent falls, underperforming in sports and clumsiness are thought to be a result of abnormal lower limb alignment and development. Intoeing — also referred to as being “pigeon-toed” — is one of the most common complaints from caregivers, coaches and teachers.

Causes of intoeing

There are three primary causes of intoeing:

  • Femoral anteversion is characterized by increased anterior torsional angle in the proximal aspect of the femur. It often runs in families, with an incidence of 10 percent. Children with femoral anteversion prefer to sit in the W-position, have difficulty sitting in the cross-legged position, and tend to kick their feet out to the sides when running, while the patella is facing inwards (rotates medially). (There is no need to discourage W-sitting, as there is no scientific evidence to show that this position causes harm to the core muscles, hips, knees, or any other parts of the body.)
  • Tibial torsion is caused by internal/medial rotation of the tibia. The cause is unknown but often runs in families. Besides the cosmetic concerns, internal tibial torsion can predispose kids to tripping and falling, mostly at the end of the day and when they are tired. Children tend to compensate for their tibial torsion by turning their feet outwards (making the feet parallel) during gait. This can give the false impression of geno varum, or bowlegs, because the patella is facing outwards during the gait and creates a “false deformity” during gait.
  • Metatarsus adductus is an inward curvature in the midfoot that can give the false impression of turning-in of the entire limb. The cause is unknown, but it may be related to the intra-uterine position. It is usually a flexible and asymptomatic deformity that often improves spontaneously in the first year of life. While there is a rigid form of this condition that may need treatment, most persistent, flexible deformities don’t need any intervention.

Natural history and treatment

Most causes of intoeing tend to improve over time. By 8 to 10 years of age the adult rotational alignment is achieved. However, that does not mean that the child won’t continue to have some intoeing. The child generally grows up to have legs that resemble those of the parent from whom they inherited the trait.

While occasional tripping may occur, most children learn to compensate for any rotation and have no symptoms. There is no need to restrict activities. Many studies have suggested that intoeing may even improve sports function, as intoers tend to be more effective runners and jumpers.

Bars, shoes, orthotics, and twister cables were used in the past to treat intoeing, but there is no scientific evidence that these devices have any effect on the natural tendency toward partial or complete correction by the 8 to 10 years of age.

When should you refer to a pediatric orthopedic specialist?

  • Asymmetric deformity
  • Worsening of deformity over time
  • Pain that limits activities