The 'pigeon toed' problem

April 30, 2013 Kathleen Moen, MD

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 raise concerns with your child’s physician about how your child is walking or running, or perhaps a concern was raised by the child’s grandparents who may have known a child years ago who was treated with a brace or special shoes for a similar issue. Intoeing gait is a common reason for referral of your child 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 and determines up until 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 from within the uterus. You can tell metatarsus adductus is present when seeing a curve to the outer border of the foot when looking at it from the bottom.

The foot most commonly is flexible and 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. The cause of this is thought to be secondary to intra-uterine positioning and a molding of the limb. Frequently it involves both legs and is symmetric. It does not seem to be painful and typically improves over time, resolving on its own often 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 instead of sitting cross-legged. While there has been a long-standing concern that “W sitting” is bad, a cause of intoeing and a reason that it persists, there is no scientific data that would support this. Femoral anteversion most commonly improves without the need for specific treatment, typically by age 8.

Treatment of these conditions in the past was to utilize a nighttime brace called a Dennis Brown bar. This brace is comprised 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 will 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 most likely improves as the child’s motor control matures and typically gets better even quicker than the intoeing improves.

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 might be signs of something serious.

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