In-toeing

Definition: condition in which a child walks/stands with the toes pointing inward; often more noticeable in toddlers and usually improves with age

Medical terminology: intoeing, metatarsus adductus, metatarsus varus, false club foot

In-toeing is the most common reason for referral to a foot clinic or pediatric orthopedic clinic. It can be very worrisome for a parent to see their child having trouble walking, tripping over own feet or complaining of foot, knee or back pain.

If you notice your child walking awkwardly or having difficulty walking, it is important you seek medical attention to prevent the progression of symptoms through adulthood.

What does in-toeing look like?

  • Toes are pointed inward
  • Awkward walk (unstable)
  • Child may trip over own feet while walking
  • Tend to sit in the ‘W’ position (encourages in-toeing)
  • Complaints of tired, sore feet
  • May avoid walking
  • Knee or back pain
  • Flat feet

What causes in-toeing?

There are many different causes for in-toeing but are related to developmental unwinding from the hip to the foot. The cause of in-toeing may originate from the hip, thigh bone (femur), knee, shin bone (tibia), the foot or a combination of the above.

Hip – Internal femoral position

  • The hip is in an internally rotated position allowing the leg to be in an in-toed position
  • The thigh bone is internally positioned and the surrounding soft tissue (hip ligaments) help hold the internal position

Knee – Internal tibial position

  • Shin bone (tibia) has developed and functions in an internally rotated position
  • Sometimes growth disorder of the knee and tibia cause the tibia to be angled inward

Foot – Metatarsus adductus

  • Child’s toe bones (metatarsals) have developed in an inward position
  • The inward toe bones cause the foot to look intoed

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Thigh bone (femur)- Femoral antetorsion

  • The thigh bone has excessively internally rotated causing the rest of the leg to be internally rotated (in-toed)
  • The shaft of the thigh bone is internally twisted

Shin bone (tibia) – Internal tibial torsion

  • The shin bone has not fully rotated outward leaving the tibia bone in an internally rotated position
  • internally rotated shin bone turns foot inwards

How do you treat in-toeing?

There are different factors that determine the treatment plan for in-toeing.

  • Age of the child
    • Hip may continue to unwind (externally rotate) till the age of 14
    • Shin bone (tibia) unwinds till the age of 6-7 years old
    • Foot bones can be reshaped with manual manipulations or casts when very young
  • What is the cause of the in-toeing?
    • Due to the hip, knee, or foot
    • Or a combination of body parts
  • How severe is the disorder?
    • Slight rotational or positional issues may resolve themselves

Different methods that may be used for treating in-toeing include:

  • Serial casting – used in children under 8 months to realign bones
  • Manipulations – used in newborns to encourage proper alignment
  • Bracing – used to correct rotational and positional deformaties
  • Orthotics – gait plates can be used to force proper walking
  • Footwear – help support ankle and can be flared outwards to force straight toes
  • Exercise – strength different muscles to encourage proper alignment
  • Bone Surgery – for severe cases

If you are concerned about your child’s feet, it is important you see a foot specialist to perform a full examination. The earlier treatment is started, the better chance to correct an irregularities that the child may have.