What Are Pigeon Toes?

Seeing a child's toes pointing inward can be concerning for parents. This painless condition, known as pigeon toe, is common in children up to the age of 8 years and can affect one or both feet. Fortunately, the deformity often corrects itself without any treatment. In this article, we will explore the various types of pigeon toes, their diagnosis, treatment options, and management strategies.

Introduction

Definition of pigeon toes

Pigeon toes, also known as pigeon-toeing or pigeon-in-toeing, result from a rotational variation in the lower extremity, causing the foot to predominantly point inward.¹ Malformation and angular changes in the lower limbs are common issues in pediatric orthopaedics, with in-toeing frequently observed in infants and young children.

In infants 

The front of the foot and toes mostly bend in towards the middle of the foot. The outer part of the baby’s feet will mostly have a half-moon shape. This usually occurs in both feet.

Toddlers 1 to 3 years 

Pigeon toeing may look bowlegged at this age. Pigeon toeing most commonly seen in toddlers is normally due to tibial torsion, in which the shinbone rotates inwards.

Between 3 and 10 years 

Femoral anteversion commonly causes pigeon toeing in children aged 3 to 10 years. Children may frequently adopt a 'w' sitting position, where their knees appear to bend inward. The appearance of pigeon toeing may change as children begin walking and grow older, with the underlying cause often attributed to the legs rather than the feet.²

Types and causes of pigeon toes

Metatarsus adductus

Metatarsus adductus is frequently observed in infants who were in a breech position in the womb. It is also commonly seen in children whose mothers experienced low levels of amniotic fluid during pregnancy. Additionally, there may be a familial predisposition to this condition.²

Metatarsus adductus, also known as metatarsus varus, is a common congenital foot deformity characterized by inward bending of the front half of the foot, known as the forefoot. This deformity is classified into two types: 'flexible,' where the foot can be partially straightened by hand, and 'non-flexible,' where manual straightening is not possible.³ The following image illustrates the metatarsus adductus.⁵

Tibial torsion

Internal tibial torsion is primarily caused by the position of the baby in the mother's uterus. As the baby grows within the confined space of the womb, the shinbones may become twisted inward. Family history can also contribute to this condition.

In rare cases, the legs may turn outward, resulting in external tibial torsion. Both internal and external torsion are variations of normal development in children and typically do not require treatment.
Symptoms of internal tibial torsion typically become noticeable between the ages of 2 to 4 years when a child begins walking. During this time, their feet may turn inward, while their legs bow outward.
On the other hand, symptoms of external tibial torsion usually manifest between the ages of 4 to 7 years. Children with this condition may have feet that rotate outward, leading to tripping or stumbling.

The image above illustrates both internal and external tibial torsion.⁴

Femoral anteversion

Femoral anteversion, a type of pigeon toe, is observed in approximately 10% of children. It occurs when the upper leg bone, the femur, exhibits greater inward rotation at the hip joint. While the exact cause is not fully understood, it is believed to be associated with stress on the hips before birth. yet the true cause is still not known. This condition typically resolves by the age of 8 years.² Signs of femoral anteversion usually become noticeable between the ages of 2 to 4 years, with symptoms becoming most obvious when a child is 5 to 6 years old.
Common symptoms of femoral anteversion include:

• pigeon-toed walking,
• difficulty to walk with their feet close together and legs straight,
• running with legs swinging out, or
• tripping and falling frequently.

The following image illustrates femoral anteversion and retroversion.⁶

Physical examination and diagnosis

During the physical examination, the physician notes a complete birth history of the child and also asks for family history.

Metatarsus adductus

Infants with metatarsus adductus typically present with a high arch, and the big toe is visibly separated from the second toe while twisting inward. In cases of flexible metatarsus adductus, gentle pressure on the forefoot can align the heel and forefoot (referred to as a passive manipulation technique). However, in non-flexible or stiff feet, aligning the forefoot with the heel is challenging.

While diagnostic procedures are usually unnecessary for diagnosing metatarsus adductus, x-rays of the feet may be performed in cases of non-flexible metatarsus adductus.⁵

Tibial torsion

Physicians measure the rotation of the legs and feet and consider the patient's family history during diagnosis. X-rays are typically unnecessary for diagnosing this condition.⁴

Femoral anteversion

The diagnosis is made by a prenatal history, birth history, family history and physical examination by your physician.⁷ The physical examination also needs measurements to know the degree of in-toeing. These measurements are taken easily by keeping ink or chalk on the bottom of feet and letting them walk on paper to leave an impression. The physician may also use diagnostic tests like computed tomography (CT or CAT) scan, MRI and x-rays to get detailed images of your child’s thigh bone and hip joint.⁶

Treatment approaches and management 

In most cases, femoral anteversion is managed through observation, with a primary emphasis on parental reassurance. Parents are advised to manage their child's sleeping posture to mitigate the effects of the condition. Some children naturally adopt a prone position during sleep, with their hips flexed and knees fully bent, which can exacerbate the deformity. Therefore, parents can be educated to encourage better sleeping positions that promote proper alignment of the legs.¹

Metatarsus adductus 

Metatarsus adductus can be corrected regardless of the severity of the forefoot turning inward, and initiating treatment immediately after birth can improve the deformity. However, in many cases, children born with metatarsus adductus do not require treatment as the condition often corrects itself as the child grows. Physicians may guide natural correction methods, and surgery is typically reserved for severe cases.⁵ Metatarsus adductus typically resolves by 2 years of age. However, in cases of rigid and severe metatarsus adductus with limited flexibility, referral for possible serial casting may be necessary.¹

Tibial torsion 

The majority of internal tibial torsion cases can improve without medical intervention. Muscle-strengthening exercises and physical therapy can aid in improving balance and addressing difficulties with walking and standing. However, the use of orthotics is typically not effective in correcting tibial torsion.

In severe cases of tibial torsion that do not improve with growth, a physician may recommend a surgical procedure known as an osteotomy. During this procedure, the surgeon cuts the tibia bone to correct its rotation, and in some cases, the fibula bone may also require correction. The corrected bones are stabilized in place using pins or a plate and screws while the bone heals.⁴

Femoral anteversion

Femoral anteversion typically corrects gradually over time, with the longest recovery period extending until around 11 years of age. Management primarily involves observation and informing parents about the natural course of decreasing anteversion. Non-operative treatments are not typically recommended, and surgical management, if necessary, involves femoral derotational osteotomy.

However, surgery carries potential complications and is usually reserved for children older than 11 years with severe functional sequelae or cosmetic deformities.¹

FAQs

What is pigeon toe?

Pigeon toe is characterized by a rotational variation in the lower extremities or limbs, causing the foot to predominantly point inward.

What are the causes of pigeon toes?

Pigeon toe often develops either in utero or due to genetic anomalies, making prevention difficult.

Can pigeon toe get corrected? 

Yes, pigeon toe often corrects itself as a child grows. In rare and severe cases, non-surgical treatments such as moulds or casts may be used to correct foot shape, while surgical intervention may be necessary.

Summary

Pigeon toe is an orthopaedic deformity characterized by the inward pointing of the toes instead of facing straight ahead. It commonly affects young children and can manifest in three different types depending on the affected part of the lower limb. The type of pigeon toe also determines the required level of treatment to correct the issue. Despite this condition, children can typically engage in physical activities and lead fulfilling lives without impaired movement or an uneven gait.