In-toeing (Pigeon-Toed): Rotation of the Leg Bones in Children

The short version

In-toeing is one of the most common reasons a parent brings a healthy child to see me. The child walks or runs with the feet pointed inward, sometimes trips, and a grandparent or a coach has noticed. Almost always, what I find is a normal child whose leg bones are rotated a little more than an adult's, which is exactly how children's legs are built. Here is what I tell families.

• Young children's leg bones are rotated inward more than adults' are. That is normal, and the range of normal is wide.
• The bones untwist on their own as the child grows. For the thighbone, this takes until about age 8 to 10.
• Braces, special shoes, inserts, twister cables, and exercises do not speed this up. The bones correct from the inside, with growth.
• Sitting in a "W" is not harmful and is not the cause.
• Surgery is very rarely needed, and only for an older child with a severe twist that still causes real problems.
• A few signs mean it is not simple in-toeing: one-sided, painful, a limp, or a child who is losing skills. Those are at the end of this guide.

Where in-toeing comes from

The feet point in because somewhere between the hip and the toes, a bone is turned inward. There are three places that can happen, and the child's age usually tells me which one it is.

The foot (metatarsus adductus), in babies. The front half of the foot curves inward, so the sole is shaped like a kidney bean. This comes from the way the baby was folded in the womb. In most babies the foot is flexible: I can gently straighten it with my fingers, and it straightens on its own, usually within the first year or two and in nearly all children by school age. A foot that is stiff and cannot be straightened by hand is uncommon and is treated with gentle stretching and sometimes a short series of casts in infancy.

The shin (internal tibial torsion), in toddlers. The shinbone is twisted inward between the knee and the ankle, so when the child stands with the kneecaps facing forward, the feet point in. This is the usual cause of in-toeing in a child who has just started walking, from about age 1 to 3. The shinbone untwists with growth, usually by about age 4 to 6. Toddlers with tibial torsion trip more than other toddlers, and that improves as it corrects.

The thighbone (femoral anteversion), in children 3 and up. The upper end of the thighbone, where it fits into the hip socket, is twisted forward more than it will be in adulthood. To keep the hip seated, the whole leg turns inward, so the kneecaps point toward each other as well as the feet. This is the usual cause of in-toeing from about age 3 onward, often most noticeable between ages 4 and 6. Children with increased anteversion sit comfortably in a W, run with their legs swinging out to the sides like an eggbeater, and can turn their hips far inward but not very far outward.

Many children have more than one of these at once, and all three are normal variations of growth, not deformities or diseases.

How I examine a child for in-toeing

I watch your child walk and run down the hall, and I look at where the kneecaps point compared with the feet. Then I do what is called a rotational profile, with your child lying face down on the exam table with the knees bent. In that position I can turn each hip inward and outward and see how far it goes, look down the shin to see how the foot lines up with the thigh, and look at the shape of the sole. It takes a few minutes and does not hurt. I write down the numbers, and if we meet again a year later, I measure them again, so you can see the change for yourself.

No X-rays are needed for ordinary in-toeing. I order them only when something on the exam is not typical.

The wide range of normal

The key fact about femoral anteversion is how much of it a healthy child has. At birth, the upper thighbone is twisted forward by about 30 to 40 degrees. In an adult, the figure is about 10 to 15 degrees. The difference is made up by growth: the bone untwists by roughly one and a half to two degrees a year on average, fastest in the first few years and more slowly later, until it reaches the adult range at about age 8 to 10.

Because every child is somewhere along that path, a young child who turns the hips far inward on my exam table is usually not abnormal at all. The hips of a healthy 4-year-old can often rotate inward much farther than an adult's can, and the range I accept as normal at each age is wide. "Increased" anteversion in a preschooler is, in most cases, just anteversion that has not finished correcting yet. That is why the usual plan is to watch, and why I am confident telling you so.

The W-sitting question

Children with femoral anteversion often sit on the floor with their knees forward and their feet out to either side, in the shape of a W. Parents are frequently told to stop this. The truth is simpler: children sit this way because their hips rotate inward easily, so the position is comfortable for them. The W-sitting is a result of the anteversion, not the cause of it, and there is no good evidence that it harms the hips or slows the correction. I do not ask families to police how a child sits. If you prefer to encourage other positions, that is fine, but it is not treatment.

Why braces, special shoes, and twister cables do not help

For many years, children with in-toeing were put in night bars that held the feet turned out, in shoes with wedges, in twister cables that ran from a waist belt to the shoes, and in corrective shoes. When these treatments were studied properly and compared with children who were simply watched, the bones untwisted at the same rate with or without them. A bone rotates with growth from inside; a device on the outside of the leg does not reach it. Those devices did cause discomfort, sleep trouble, skin problems, teasing, and expense, so they have been abandoned. The same goes for inserts, exercises, and physical therapy for ordinary in-toeing: there is nothing wrong with the muscles, and no exercise changes the twist of a bone.

What does help is time, and letting your child walk, run, climb, and play as much as possible. That is the treatment.

When surgery is considered

A very small number of children keep a severe twist in the thighbone past the age when it should have corrected, usually older than 8 to 10, and it causes a real problem: constant tripping, pain in the knees or hips, or trouble keeping up in sports because the feet and knees point so far in. For those few children, the thighbone can be cut and rotated into a better position and held with a plate or a rod while it heals (a derotation osteotomy). I reserve this for a persistent, severe, symptomatic twist in an older child, after a careful exam and measurements on a scan, and never for appearance alone. The same operation on the shinbone is occasionally done for a severe tibial torsion that has not corrected by about age 8. In many years of practice, these are rare operations.

Signs that it is not simple in-toeing

In-toeing from the three normal causes above is on both sides, painless, and slowly improving. Please make an appointment if you see any of the following, because they point to something else:

• One-sided in-toeing, or a clear difference between the two legs.
• Pain in the hip, thigh, knee, or foot.
• A limp, or a child who tires quickly or refuses to walk.
• Losing skills: a child who walked well and is now stumbling more, or a toddler who is late to walk, since this can point to a problem with the nerves or muscles rather than the bones.
• A foot that cannot be straightened by hand, or a foot that also points downward and cannot be brought up, in a baby.
• In-toeing that is getting worse rather than better, or that is still marked after about age 10.
• A stiff hip, or a child with other developmental concerns. An in-turned foot in a baby is also one of the things that prompts me to check the hips carefully for developmental dysplasia of the hip.

Common questions

• Will my child grow out of this? Almost always, yes. Metatarsus adductus usually straightens in the first year or two and nearly always by school age, tibial torsion by about age 4 to 6, and femoral anteversion by about age 8 to 10.
• Will it affect sports? No. In-toeing does not slow children down or raise their injury risk. Some sprinters in-toe.
• Will it cause arthritis later? There is no evidence that ordinary in-toeing leads to arthritis of the hips, knees, or feet.
• My child trips a lot. Is that from the in-toeing? Often, yes, especially in toddlers with tibial torsion, who catch one foot behind the other when they run. It improves as the shin untwists. Tripping that is getting worse, or is new in a child who used to run well, is a reason to come in.
• Should I stop the W-sitting? You do not need to. It is a sign of the anteversion, not a cause.
• Should we come back? If you would like the reassurance, I am glad to measure the rotation again in a year so you can see the change. If your child is doing well, you do not have to.

Learn more

OrthoInfo (AAOS), Intoeing: orthoinfo.aaos.org (opens in a new tab)

My guides to out-toeing, flexible flatfoot, and developmental dysplasia of the hip.

This information is for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. For specific concerns about your child, consult a board-certified, fellowship-trained pediatric orthopaedic surgeon.

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