Introduction

In-toeing, also known as pigeon-toeing, is a physical deformity which causes the foot to be directed inwards. It typically occurs in infants and children and is a result of a developmental abnormality in the lower limb, which leads to an inward-facing foot causing either the foot, leg, or thigh to be internally rotated. Those with in-toeing can be impacted in varying ways, particularly as the cause of the condition can vary from patient to patient. Physical examination is the main method of diagnosing the disease. The degree to which the foot is directed inwards typically decreases with time, and usually the condition ultimately resolves spontaneously, without the need for treatment, though some patients may benefit from physiotherapy, orthotic devices, specialised shoes, and surgery.^1,2,3

Causes of in-toeing

There are three major causes of in-toeing, these being metatarsus adductus, internal tibial torsion, and femoral anteversion, with these conditions causing internal rotation of the foot, leg, and thigh, respectively.¹

Metatarsus adductus

Metatarsus adductus is where the bones of the foot point inwards, causing the foot to resemble the shape of the letter C. This is the most common cause of in-toeing in children under one year of age, with it occurring in 0.1 - 1% of births and being more frequent in those assigned female at birth compared to those assigned male at birth.¹

Internal tibial torsion

Internal tibial torsion is where the shin bone, which is also known as the tibia, is rotated internally. This is the most common cause of in-toeing in children aged one to four years.¹

Femoral anteversion

Femoral anteversion is where the thigh bone is inwardly twisted. This condition most commonly presents itself between the ages of three and six years. Similar to the metatarsus adductus, those assigned females at birth are more likely to be diagnosed with this disease.¹

Signs and symptoms of in-toeing

In-toeing presents as internal rotation of the foot which may be accompanied by the leg or thigh being internally rotated too. This physical deformity may be accompanied by difficulty walking or running.¹

Diagnosis of in-toeing

A physical examination is typically the sole technique that is required to confirm a diagnosis of in-toeing. A physical examination involves a physician inspecting and feeling the body to check for any potential abnormalities. In the case of potential in-toeing, a physical examination would focus on the region of the body stretching from the top of the thighs to the tips of the toes.^1,4

Several conditions can present similarly to in-toeing and, therefore, need to be ruled out when confirming a diagnosis of in-toeing:¹

• Developmental dysplasia of the hip: Developmental dysplasia of the hip is a condition where the hip joint does not properly form which causes looseness of the hip joint. In more severe cases, developmental dysplasia of the hip can cause hip dislocation. Furthermore, this disease can lead to difficulty moving, pain, and osteoarthritis
• Clubfoot: Clubfoot, also known as talipes equinovarus, is a condition that presents at birth due to an abnormality in the development of tendons which causes the foot to be rotated inwards and the bottom of the foot to often face horizontally or upwards. The foot may have a shape that resembles a kidney, a deep crease on the inside, and a high arch
• Cerebral palsy: Cerebral palsy is a condition caused by damage to areas of the brain that are responsible for muscle movement. How the condition impacts patients can impact people vastly from person to person, with signs and symptoms potentially including delays in sitting up and walking, stiffness or floppiness of the body, weakness of the arms and legs, uncontrolled movements, walking on tiptoes, speech and vision problems, and learning disabilities

Treatment of in-toeing

In-toeing typically resolves on its own over time. However, sometimes, certain techniques can improve recovery or be of use when the condition does not spontaneously resolve.^1,2,3

Physiotherapy

Sometimes, in-toeing can create difficulty for patients when it comes to walking and running. In these cases, physiotherapy can serve as a helpful treatment. A physiotherapist can assess whether a patient is walking or running normally and can implement an exercise plan to help a patient’s movement return to normality.⁵

Orthotic devices

Some patients with in-toeing, particularly those facing difficulties with movement, may benefit from orthotic devices. Orthotic devices are used to help correct physical deformities or to help patients move with a physical deformity. There are various orthotic devices which may be used depending on the specific needs of a patient.^6,7

Specialised shoes

Wearing specialised shoes may allow patients with in-toeing to walk and run with more ease. Typically, shoes fitted with insoles or that have a wedge are used to improve movement.⁸

Surgery

Surgery is typically resorted to when other, more conservative, treatments are not successful in alleviating the condition, or the disease does not resolve spontaneously. As the causes of in-toeing can vary, the appropriate surgery can differ from patient to patient. A surgeon can evaluate the condition to determine what procedure, if any, is most suitable. Surgery tends to be reserved for patients older than 11 years of age due to possible post-surgical complications.¹ 

FAQ's

Is in-toeing painful?

In-toeing is typically not painful and also tends to not be accompanied by other signs and symptoms.¹

Should I see a physician for in-toeing?

If you suspect that in-toeing may be present, seeing a physician can allow for the condition to be diagnosed and for other conditions that present similarly to in-toeing to be ruled out from the diagnosis. Furthermore, when in-toeing persists later into childhood or causes additional signs and symptoms, seeing a physician can allow for a suitable treatment option to be adopted.¹

What lifestyle modifications can help improve in-toeing?

As in-toeing may sometimes cause problems with movement, certain lifestyle modifications may be helpful for patients dealing with difficulty walking and running. Among these lifestyle modifications are exercises recommended by a physiotherapist and the use of specialised shoes.^1,2,3,5,8

Can in-toeing be prevented?

In-toeing is a condition that presents at birth and cannot be prevented.¹

What are the indications that in-toeing is improving?

An improvement in in-toeing is indicated by the internally rotated toe, which is the characteristic feature of in-toeing, gradually rotating outwards.⁹

Summary

In-toeing, also known as pigeon-toeing, is a condition characterised by the foot facing inwards, as opposed to being straight. Infants and children are primarily impacted by this disease. In-toeing is the result of an abnormality in the development of offspring that results in either the bones of the foot, leg, or thigh being internally rotated. As a result of the different causes of in-toeing, how the condition presents may vary from patient to patient. Diagnosis of the disease can typically be done through a physical examination. Treatment is often not necessary as the condition commonly resolves by itself over time. However, some patients may benefit from physiotherapy, orthotic devices, specialised shoes, and surgery.