Intoeing (pigeon toes) is a presentation that is often worrisome to parents. A healthcare provider with complete and accurate information about normal development and variations of normal development can reassure parents and family members that intoeing is a common problem that usually resolves on its own.
Inward rotation of the foot, tibia and femur occurs in utero. This internal rotation lessens throughout fetal development.1 Newborns have external muscle contractures of the hip, secondary to intrauterine position. As a child grows into infancy and begins to crawl and stand, these contractures resolve and internal rotation becomes more pronounced.1
Pes planus (flat foot) may also be noted at birth. This common finding reflects that the fat pad in the arch of the foot is obscuring the foot arch. Fat pads on the feet are common in infancy.
Even after fat pads are gone, at approximately 2 to 3 years of age, a child still may appear flat-footed when standing. This is called a flexible flat foot, and it is most likely caused by ligamentous laxity when the foot bears weight.2,3 This may remain for life, and special shoes or shoe modification will not change the foot.
Lower Limb Variations
Three types of lower limb variations occur in newborns: pes planus, angular variations and torsional variations. Angular variations can be divided into two subcategories: genu varum and genu valgum.
Genu varum (bowlegs) typically occurs between birth and 18 to 24 months of age.3,4 It is most obvious when the child begins to walk. In many children, genu varum reverses and genu valgum (knock knee) is present until around age 3 or 4, when maximum valgus takes place.4
Typically, the angle between the tibia and the femur is 15 degrees varus at younger than 1 year and 0 degrees at 2 years. At around age 3 to 4 years, 12 degrees valgus angulation may occur. It may regress back to approximately 5 to 7 degrees valgus by age 7 or 8, where it remains permanently.1-4
A concern that requires orthopedic referral is suspected Blount disease, a growth disorder affecting the tibia. This disease causes 1% of genu varum cases.3,4 Signs of Blount disease are:3,5 greater than 15 degrees varus in an infant without a decrease in angulation by age 2; asymmetric appearance of lower extremities; short stature; knee angle two standard deviations outside the mean; obesity; Hispanic or black race; early ability to walk; and/or family history of the disease. The child with Blount disease typically has a positive lateral thrust of the knee while ambulating.5
Torsional variations can be divided into three subcategories: metatarsus adductus, internal tibial torsion and increased femoral anteversion. Each category has specific characteristics and assessment requirements.
In metatarsus adductus, the metatarsal bones in the forefoot are rotated medially. Metatarsus adductus occurs in approximately 1 per 1,000 live births and is the most common congenital deformity.1-3 Metatarsus adductus is present at birth and usually results from in utero positioning.6 Metatarsus adductus is often considered a "packing abnormality," especially in twins or multiple births due to decreased room available in utero.5
Metatarsus adductus can occur bilaterally or unilaterally; the left side is affected more often than the right side. This condition is more prevalent in girls. It differs from clubfoot because the heel in metatarsus adductus is never in a varus position.2,5
Internal tibial torsion is a medial rotation, or twisting, of the tibia.2,6 It is the most common cause of intoeing.1 Internal tibial torsion is usually present at birth, but it often does not become prominent until the child begins to walk. The condition occurs about equally in girls and boys.2
Internal tibial torsion is usually asymmetric, with the left side more affected than the right.2 As in metatarsus adductus, internal tibial torsion is usually caused by positioning in utero. It has been argued, however, that internal tibial torsion can be caused or worsened by particular positioning while sleeping or sitting.1,7 Tucking the legs, pressure from the mattress during prone sleep or habitual sitting on feet can twist the tibia. This twisting in a habitual manner can cause a delay in spontaneous resolution of the problem.1,2
Increased femoral anteversion is an inward twisting, or excessive medial rotation, of the femur.2,6,7 At birth, the femur bone is anteverted from 25 to 40 degrees, and the femoral head is rotated anteriorly in relation to the femoral condyles. As the child grows, a gradual decrease in femoral anteversion occurs.
Increased femoral anteversion is often bilateral, and it occurs more often in girls.1 Children with increased femoral anteversion often sit in a "W" position and may be uncomfortable sitting cross-legged. A family history of increased femoral anteversion is often reported.1 Spontaneous resolution is typical, but it is the last of the three variations to resolve.1,2
Assessment of a child with intoeing should begin with questioning about the parents' observations of the child's altered gait, when they first noticed it, and what they know about the problem. A complete birth history of the child, including developmental milestones and significant personal and family medical history, should be obtained. Particular attention should be paid to any report of a history of developmental dysplasia of the hips (DDH) in the child or a family member. A complete medical history helps direct the clinician's line of thinking and include or exclude certain other diagnoses, such as cerebral palsy, muscular dystrophy, metabolic bone disease, neurologic disorders or DDH. If any of these diagnoses are suspected, an immediate referral to an appropriate specialist is warranted.
To begin the physical examination, have the child walk and run down a hallway to allow observation of gait. Make sure the patient is wearing a short gown or shorts that do not obstruct the legs. During the observation of ambulation, look for foot progression angle (FPA) and the shape of the foot arch while standing.
FPA (Figure 1) is the angle between the axis of the foot and the patient's line of progression while walking.1,2 After this observation, the clinician estimates the average degree of intoeing or outtoeing. This progression angle can be classified as a negative foot progression angle indicative of intoeing or as a positive foot progression angle (outtoeing).
Figure 1: Internal tibial torsion is measured by placing one finger each over the anterior medial and lateral malleoli and measuring the angle between the two. Photo courtesy the author.
Figure 2: Internal rotation of the hips. Photo courtesy the author.
Figure 3: External rotation of the hip.. Photo courtesy the author.
It is important to remember that some patients "mask" their problem during this observation. This is sometimes called "doctor walking." The best way to prevent this is to have the patient run several times up and down the hallway. Have the patient heel walk, toe walk and hop on a single leg to exert him- or herself. This exertion will cause fatigue and reduce the effectiveness of the compensatory mechanisms.1,7 Foot progression angle may be normal if a child has a combined torsional deformity.2
Next, proceed to the examination room and have the patient sit on the edge of the examination table or a parent's lap with legs hanging over the edge. Observe the sole of the foot. Normally, the lateral border of the foot is straight. If metatarsus adductus is present, a bean shape or "C" shape of the foot will be evident. The medial border of the foot is concave and the lateral border is convex. The hindfoot will be in neutral alignment. The heel cord will be supple. Stabilize the hindfoot while abducting the metatarsals (forefoot). If the forefoot can be abducted to neutral, it is considered a flexible deformity.
Internal tibial torsion can be measured in several ways. The first involves assessing the lower extremities while the patient's legs continue to hang freely from the table. Position the knee so that the tibial tubercle faces forward. Then place the thumb and index finger over the anterior medial and lateral malleoli (Figure 2). Measure the approximate angle between the two malleoli. The normal range between the two malleoli at maturity is 5 degrees medial to 15 degrees lateral rotation.5
Another way to determine if tibial torsion is present is to have the child lie prone with knees flexed to 90 degrees. Find the axis of the thigh with one arm of a goniometer. Push down slightly on the foot, as if the patient were weight bearing. Position the other arm of the goniometer along the axis of the foot, through the second toe. The angle that is formed is the degree of tibial torsion. If a goniometer is not available, another similar technique can be performed. Have the patient lay prone, knees at a 90-degree angle. Draw an imaginary line down the center of the posterior thigh and another line down the center of the foot. The angle of these two intersecting lines represents the degree of internal tibial torsion.
Finally, to determine if femoral anteversion is present, have the child lie prone on the examination table with knees flexed at 90 degrees and at pelvis level. Internally and externally rotate the lower legs, with knees still flat on table (Figures 3 and 4). If internal and external rotation is equal in degrees, no femoral anteversion is present. Increased femoral anteversion would be present if internal rotation were increased while external rotation were decreased. Typically, internal rotation is increased up to 90 degrees and external rotation can be decreased to 0 to 10 degrees. However, there is no absolute norm, and measurements may change with skeletal maturity.1
Metatarsus adductus, internal tibial torsion and increased femoral anteversion usually resolve spontaneously. As the child grows and matures, the deformity corrects itself.
A child with metatarsus adductus can be followed by a primary care provider every 2 to 4 months to monitor for resolution of the deformity. Gentle stretching of the foot performed daily can encourage correction.
Internal tibial torsion also usually resolves spontaneously in children. However, serial evaluations and observations by the primary care provider every 4 months are needed to document improvement. Resolution of the deformity usually occurs by age 8.
Increased femoral anteversion, like the other two deformities, usually resolves on its own. Resolution of this deformity may take longer due to rate of skeletal maturity, and therefore should be followed by a primary care provider until resolved.2
Parents of children with metatarsus adductus, internal tibial torsion or increased femoral anteversion require reassurance that these problems will likely resolve with age. Clinicians should explain that complete resolution may not occur in all cases, but significant improvement is probable.
Reassure families that none of these three conditions will affect athletic ability or development. They do not cause bunions, knee problems or degenerative hip problems.7
A parent of a child with metatarsus adductus can be taught gentle stretching exercises of the foot. The parent should hold the heel in midline and press on the lateral convex prominence of the fifth metatarsal, using his or her thumb. Using the other hand, the parent should then pull the toes into abduction.
Parents of a child with internal tibial torsion and increased femoral anteversion should discourage him or her from sitting in a "W" position and from sleeping prone on legs. These interventions do not resolve the issue, but they do help prevent further severity.
Reassurance is Key
Intoeing is a common complaint seen in the primary care setting and in orthopedic offices. All three torsional variations, metatarsus adductus, tibial torsion and femoral anteversion, can present as intoeing. A thorough medical history and a thorough clinical examination usually reveal a self-resolving issue. Reassurance to parents is often all that is needed to calm the family's fears and to reassure them that their child is normal and will lead a full, active life.
1. Ryan DJ. Intoeing: a developmental norm. Orthop Nurs. 2001;20(2):13-18.
2. Sass P, Hassan G. Lower extremity abnormalities in children. Am Fam Physician. 2003;68(3):461-468.
3. Burns C, et al. Musculoskeletal Disorders. In: Pediatric Primary Care: A Handbook for Nurse Practitioners. 3rd ed. St. Louis, Mo.: Saunders; 2004: 1047-1082.
4. Colyar M. Assessment of the musculoskeletal system. In: Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003: 142-143.
5. Wallach D, Davidson R. Pediatric Lower Limb Disorders. In: Pediatric Orthopaedics Core Knowledge in Orthopaedics. 1st ed. Philadelphia, PA; Mosby; 2005: 197-223.
6. Common disorders: In-toeing. http://www.childrensorthopaedics.com/intoeing.html
7. The Orthopaedic Examination: Clinical Application. In: Herring J, eds. Tachdjian's Pediatric Orthopedics. 4th ed. Philadelphia, PA: Saunders; 2008:69-70.
Elizabeth Badowski is a pediatric nurse practitioner in the Department of Orthopedics at Nationwide Children's Hospital in Columbus, Ohio. She has completed a disclosure statement and reports no relationships related to this article.