The "pigeon toe" problem

April 30, 2013 Kathleen Moen, MD

close up of a toddler's feet in blue sneakers with toes pointed in toward each other


In this article:

  • Pigeon toe, or intoeing, is a condition in which a child walks with their feet rotated inward.

  • A Swedish pediatrician explains that intoeing can be caused by various factors but usually resolves on its own without treatment.

  • Pigeon toe usually does not cause pain, asymmetry or progressive changes, which may be a sign of a different, more serious problem.

Have you noticed that your child walks with his or her feet rotated inward instead of pointing straight ahead? This could be described as intoeing and is sometimes referred to as being “pigeon toed.”

As a parent, you may have noticed it when your child is walking or running, or perhaps a child’s grandparents, who may have known a child years ago who was treated with a brace or special shoes for a similar issue, noticed the problem. Intoeing gait in children is a common reason for referral to a pediatric orthopedic surgeon.

Intoeing stems from one of, or a combination of, three areas: the foot, the lower leg and the hip. Which area is contributing determines the likelihood that it will resolve over time without treatment and can indicate at what age one may expect improvement.

The most frequent case of intoeing in infants and young toddlers arises from the foot and is called metatarsus adductus. This is a curving that starts at the midportion of the foot and extends out to the toes. Metatarsus adductus is present at birth and is thought to be caused by molding of the feet within the uterus. You can tell metatarsus adductus is present when seeing a curve of the outer border of the foot when looking at it from the bottom.

Since feet are flexible, metatarsus adductus is likely to resolve on its own over time, often by 6 to 9 months of age. It typically does not interfere with shoe wear, nor does it prevent or interfere with mobility. Occasionally, metatarsus adductus is particularly severe or stiff. In those instances, casting may be used to improve foot position.

For toddlers, the most common cause of intoeing is tibial torsion, or a twist through the shin portion of the log. Similar to metatarsus adductus, the cause is thought to be due to the position of the fetus in the uterus. Frequently it involves both legs and is symmetric. It does not seem to be painful and typically improves over time, usually resolving on its own by age 4.

For school-age children, the most common cause of intoeing gain is excessive femoral anteversion, a turning inward of the whole leg from a twisting in at the hip. The patella or knee caps in these children are rotated inward. This process is more common in young women than young men. These children have more internal rotation at their hip than external rotation, making it much easier for them to sit in a “W sit” position (in which their knees are bent in front and the legs and ankles are to either side of their hips) instead of sitting cross-legged. While there has been a long-standing concern that “W sitting” causes and reinforces intoeing, there is no scientific data that supports this. Femoral anteversion most commonly improves without the need for specific treatment, typically by age 8.

In the past, these conditions were treated with a nighttime brace called a Dennis Brown bar, which consisted of orthopedic shoes attached to a bar with the shoes rotated outward. Bracing is no longer routinely used to treat intoeing. In fact no special shoes, inserts or braces have been shown to hurry the resolution any faster or any more reliably than just time and “Mother Nature” alone.

Many parents of young children who have intoeing from either tibial torsion or femoral anteversion report that their children seem to trip or stumble more than other children. This tripping may well be due to the toes “catching each other” during running. The tripping or unsteadiness usually improves as the child’s motor control matures and typically gets better even quicker than the intoeing resolves.

As a parent, you may be understandably concerned about whether intoeing will cause long-term functional problems as your child grows into adulthood. Intoeing has not been shown to cause wear-and-tear changes or arthritis to hips, knees or spine, even in those adults for whom mild intoeing persists.

Intoeing will improve over time. Rarely are there findings like pain, asymmetry or progressive changes, which can be signs of a more serious condition. 

Find a doctor

If you have questions about a child’s intoeing, contact the Pediatrics Department at Swedish. We can accommodate both in-person and virtual visits.

Whether you require an in-person visit or want to consult a doctor virtually, you have options. Swedish Virtual Care connects you face-to-face with a nurse practitioner who can review your symptoms, provide instruction and follow up as needed. If you need to find a doctor, you can use our provider directory.

Join our Patient and Family Advisory Council.

This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.

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