Intoeing, also referred to as being “pigeon-toed” is a common foot alignment in children and in some cases can remain into adolesense and adulthood. Parents and coaches are often concerned, particularly when one foot is signficantly different from the other.
The biggest questions to answer are:
Is the intoeing normal?
What’s likely to happen over time?
Does it need to be be assessed and managed?
How do you correct it?
So lets try to unpack each of these!
Is intoeing normal?
Yes it is. Studies over 30 years agree that around 25–30% of children <6 years old may exhibit intoeing gait as a part of normal development, and intoeing in iteslf is not an abnormality (1).
Intoeing is actually the result of one or more of the following characteristics:
Metatarsus adductus - the foot is turned inwards
Internal tibial torsion - the lower leg
Internal femoral torsion - the thigh bone
Images souced from RCH - Intoeing in Children Fact Sheet (2)
2. What’s likely to happen over time?
As the body matures, most cases of intoeing tend to improve over time. However, in some cases intoeing does persist into adolesense and adulthood. Most children learn to compensate for any rotation and have no symptoms. There is no need to restrict activities. It should be noted that gait patterns in children and adults do have a degree of variability and asymetry. The normal foot progression angle (the angle of the foot relative to direction of movement for children through to adults is reported as being within −3° and +20° (a minus sign denoting an intoed gait pattern). Whilst a measurement outside these values should suggest an abnormal gait pattern, there is no indication as to what degree of intoeing would constitute a pathological outcome (3).
Image souced from Auptimo
3. Does it need to be assessed and managed? The case for further intervention is much stronger in those in which the intoeing: Is asymetrical and/or only affects one leg.
Is thought to be affecting participation in activites
Is thought to be contrinuting to pain
A 10 year old with intoeing to the left foot during walking.
4. How do you correct it?
As previously acknowledged, intoeing is the resultant gait pattern caused by the presence of a number of different underlying characteristics, be they structural or postural Anytime intoeing is being treated, we need to think both proximally (knee, hip) and distally (foot). In other words, what can I do for the patient proximally with their musculoskeletal system and what can I do distally with their musculoskeletal system and foot orthoses/shoes?
For intoeing, proximally, strengthening the external hip rotators and stretching the ligaments/tendons that limit external hip range of motion will usually be somewhat helpful. Distally, foot mobilisation, streching and using orthoses may help.
It should be noted that intoeing should not be treated so as to cause new symptoms from the treatment. A wise and balanced approach to treatment is necessary to prevent harm to the intoeing child and these cases should never be treated with the goal of simply giving the child a normal angle of gait, at the expense of increased pain or decreased activity levels. If you have any feedback on this article or questions about intoeing feel free to contact me.
References:
Evans AM (2017) Mitigating clinician and community concerns about children’s flatfeet, intoeing gait, knock knees or bow legs Journal of Paeditarics and Child Health 53:1050-1053
Royal Childrens Hospital (2011) Intoeing in children - Orthopaedic Fact Sheet https://www.rch.org.au/uploadedFiles/Main/Content/rheumatology/intoeing.pdf
Uden H, Kumar S (2012) Non-surgical management of a pediatric “intoed” gait pattern – a systematic review of the current best evidence Journal of Multidisciplinary Healthcare 5:27-35
The information contained in this article is intended to assist, not replace, discussion with your doctor or health care professional.
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