In-Toeing

In-Toeing

What is in-toeing?

In-toeing, sometimes called pigeon toes, is when a feet turn inwards rather than pointing forwards when they stand, walk or run.

It is very common in babies and young children and is usually a normal variation in development.

In-toeing can come from the shape or position of different parts of the lower limb, including the:

• Foot

• Shin bone (tibia)

• Thigh bone (femur)

As children grow, their bones gradually change position and their strength, balance and coordination develop. In most children, in-toeing becomes less noticeable naturally over time.

What causes in-toeing?

There are three main causes of in-toeing in children.

Metatarsus adductus

Metatarsus adductus is when the front part of the foot curves inwards.

It is usually noticed during infancy and can affect one or both feet.

In mild cases, the foot is flexible and can be gently moved towards a straighter position.

A foot that is very curved, stiff or difficult to move may need assessment by an appropriate healthcare professional.

Internal tibial torsion

Internal tibial torsion means that the shin bone (tibia) is rotated inwards.

The knees may point forwards while the feet turn inwards when the child walks.

This is particularly common in toddlers and usually improves naturally as the child grows.

Exercises, special shoes or splints do not generally make the shin bone rotate outwards more quickly when the torsion is part of normal development.

Femoral anteversion

Femoral anteversion occurs when the thigh bone (femur) is rotated further forwards and inwards.

This can cause both the knees and feet to appear to point inwards.

It is often more noticeable in school-aged children and commonly improves as the child grows.

Some children may also sit in positions such as a “W” sitting position, although this is not itself a cause of femoral anteversion.

Why does in-toeing happen?

Developmental differences in the position of the foot, shin or thigh can be influenced by normal growth and, in some cases, the child's position before birth.

In most children, there is nothing that parents have done to cause in-toeing.

The important question is whether the in-toeing is affecting the child's comfort, movement or participation, rather than simply how their feet look.

Who does in-toeing affect?

In-toeing is common in babies and children, and the different causes tend to become noticeable at different stages of development.

• Metatarsus adductus – usually noticed in babies

• Internal tibial torsion – commonly noticed in toddlers

• Femoral anteversion – often more noticeable in preschool or school-aged children

For most children, the alignment improves naturally as they grow.

Many children with in-toeing do not need treatment, braces, special shoes or surgery.

Some children continue to have some degree of in-toeing as they get older without it causing any significant problems.

What does in-toeing look like?

Parents may notice that:

• One or both feet point inwards when walking

• The feet turn inwards more noticeably when running

• The knees may also point inwards

• The front of the foot may have a curved appearance

• The child may appear to trip more frequently

• The child may look less steady during running or changing direction

The amount of in-toeing can also vary depending on the child's activity, footwear and fatigue.

Does in-toeing cause pain?

Most children with developmental in-toeing do not have pain.

They are usually able to walk, run, play and take part in normal activities without difficulty.

However, some children may experience functional difficulties alongside their in-toeing, such as:

• Frequent tripping

• Reduced balance

• Poor coordination

• Difficulty running or changing direction

• Muscle weakness

• Reduced confidence during physical activity

• Difficulty keeping up with friends

• Reduced participation in PE or sport

Pain, swelling or a significant change in walking should not automatically be attributed to in-toeing and may need further assessment.

When should my child be assessed?

Most in-toeing does not require treatment.

Parents or carers should consider seeking professional advice from a GP, physiotherapist or other appropriate healthcare professional if:

• The child has persistent pain

• There is swelling

• The child has a noticeable limp

• Only one side is significantly affected

• There is a clear difference between the two legs

• The in-toeing is becoming noticeably worse

• The child is experiencing frequent trips or falls

• Falls are interfering with school, play or sport

• There is significant weakness or poor coordination

• The child's walking or running ability is being affected

• The child's development or movement pattern is otherwise concerning

An assessment can help determine whether the in-toeing is simply part of normal development or whether another factor needs to be considered.

Can physiotherapy help with in-toeing?

Physiotherapy does not usually change the underlying rotation of the bones causing developmental in-toeing.

However, physiotherapy can be helpful when in-toeing is associated with weakness, reduced balance, poor coordination, frequent falls or difficulty participating in activities.

At Positive Steps, we look at the child as a whole rather than focusing only on the direction of their feet.

What might a physiotherapy assessment include?

Depending on the child's age and symptoms, we may assess:

• Foot position and flexibility

• Hip, knee and ankle movement

• Lower-limb alignment

• Rotation of the thigh and shin

• Lower-limb strength

• Balance and coordination

• Walking pattern

• Running pattern

• Jumping and landing

• Changing direction

• Frequency and circumstances of trips and falls

• Participation in school, play and sport

We will also consider the child's overall development and whether further medical, orthopaedic or specialist assessment may be appropriate.

How can physiotherapy help?

Where functional difficulties are present, physiotherapy may include:

Balance and coordination

Play-based activities can help children develop balance, coordination and control during standing, walking, running and more challenging movements.

Strength

Strengthening exercises may focus on the hips, thighs, legs and ankles where weakness is contributing to difficulties with movement.

Running, jumping and changing direction

For children who are struggling with sport or physical activities, physiotherapy can include practice of functional skills such as:

• Running

• Jumping

• Hopping

• Landing

• Changing direction

• Balancing on one leg

These can be progressed according to the child's age and goals.

Managing trips and falls

We can look at when and why trips are happening and identify strategies to improve the child's balance, strength, coordination and confidence.

The aim is not necessarily to eliminate every trip, but to help the child move more safely and confidently.

Supporting confidence and participation

If in-toeing or frequent falls have made a child less confident, physiotherapy can provide opportunities to practise movement in a supportive environment and gradually build confidence.

What does physiotherapy look like at Positive Steps?

There is no single physiotherapy programme for in-toeing.

A child with mild in-toeing who is walking, running and playing normally may not need physiotherapy at all.

For a child experiencing functional difficulties, our sessions are tailored around their individual needs and goals.

This may include:

• Play-based movement activities

• Strength exercises

• Balance and coordination activities

• Walking and running practice

• Jumping and landing

• Sport-specific activities

• Strategies to reduce the impact of trips and falls

• Education for parents and carers

• Advice for schools and nurseries

• Monitoring development and movement over time

For older children and teenagers, rehabilitation can be adapted around their hobbies, sport and physical goals.

Working with parents, schools and other professionals

Children's movement does not just happen during physiotherapy sessions.

At Positive Steps, we can work with parents, carers, schools, nurseries and sports clubs where appropriate to help strategies carry over into everyday life.

Some children may also benefit from input from other professionals, such as:

• GPs

• Paediatricians

• Orthopaedic specialists

• Podiatrists

• Orthotists

• Occupational therapists

• Other healthcare professionals

Where further assessment is required, we can help identify when referral to another professional may be appropriate.

Does in-toeing need surgery?

Surgery for developmental in-toeing is uncommon.

Most children improve naturally as they grow and do not need surgical treatment.

In rare cases, surgery may be considered for an older child with significant persistent rotational differences that are causing substantial functional problems.

This would normally be considered by an appropriate orthopaedic specialist after careful assessment.

What are the goals of physiotherapy for in-toeing?

The goals will depend on the individual child and may include:

• Developing strength

• Improving balance and coordination

• Supporting confident walking and running

• Reducing the impact of trips and falls

• Improving movement control

• Supporting participation in school, play and sport

• Building confidence with physical activity

• Helping families understand their child's development

• Monitoring movement as the child grows

• Identifying when further assessment may be needed

How can Positive Steps help?

In-toeing is very common in children and, in most cases, is simply part of normal development.

Our focus is not on trying to “straighten” a child's feet when their alignment is a normal developmental variation. Instead, we look at how the child is moving and what they are able to do.

Where in-toeing is associated with falls, weakness, balance difficulties, poor coordination or reduced participation, physiotherapy can help build the physical skills and confidence needed for everyday activities, play and sport.

At Positive Steps, we create individualised programmes around each child's needs, interests and goals.

Always finding what can be done.

If you have concerns about your child's walking, running, balance or frequent trips and would like to find out whether physiotherapy could help, get in touch with the Positive Steps team to arrange an assessment.

Contact us

Find out more

If you are concerned about your child's walking or the way their feet turn inwards, speak to your GP, physiotherapist, paediatrician or another appropriate healthcare professional.

Useful sources include:

• NHS – children's musculoskeletal and orthopaedic information

• Association of Paediatric Chartered Physiotherapists (APCP)

• British Orthopaedic Association – children's orthopaedic information