In-Toeing In Children – What You Need To Know

Child development can be overwhelming as it is natural as a parent to want to make sure you are doing all things with-in your power to give your child the best chance for developmental success.

We often see parents in our practice who are concerned about their childs in-toeing gait pattern, sometimes referred to as “pidgeon toed”.

This article should hopefully give you an insight in to where that in-toeing may be stemming from and when it requires ringing an alarm bell.

What is In-Toeing?

Simply put, in-toeing is when a child’s feet turn inwards across the midline when walking. It can be noted when the child is walking but is generally more evident when the child is running.

In-toeing does not typically cause children pain or discomfort and tends to spontaneously correct itself over time. Changes in the degrees of in-toeing can continue to be noted in children as old as ten years of age.  

What are the causes?

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

1. Femoral Anteversion

Femoral anteversion/torsion is the most common cause of in-toeing in children between the ages of 3-10 years. The femur is the long bone that goes from the hip to the knee. Femoral anteversion is a condition in which the neck of the femur leans forward. This causes the lower extremity on the affected side to rotate internally. The average child is born with approximately 40 degrees of femoral anteversion. This will gradually decrease to 10-15 degrees at adolescence and continues to improve with further growth. Femoral anteversion is more common in females, and is usually most noticeable between the ages of 4-6 years. Parents will notice that when the child is standing with the feet forward, the patellae (kneecaps) will point inwards.

Sometimes parents will also describe the child’s gait as awkward or clumsy. The in-toeing will often appear worse with running and at the end of the day when fatigued. Femoral anteversion will decrease spontaneously in 99% of cases. Studies have repeatedly shown that special shoes and braces make no difference in outcome. Therefore, femoral anteversion is usually treated with reassurance and observation.

Surgical correction (derotational femoral osteotomy) is rarely indicated for femoral anteversion.

2. Tibial Torsion

Internal tibial torsion causes an in-toeing gait from a twisting of the tibia. It is most often first noticed when a child is just beginning to walk. The inward twist is a variation of normal anatomy and is caused partially by the child’s position in the uterus. Sometimes the child will be presented with complaints of “bowing legs.” Examining a child with internal tibial torsion with the patellae straight, you will notice the feet will appear to be in the in-toed position. Many different braces and special shoes have been prescribed in the past for internal tibial torsion. However, none of these shoes or braces have been shown to speed up the natural resolution of tibial torsion. Therefore, simple reassurance and observation is the best treatment for in-toeing caused by internal tibial torsion.

3. Metatarsus Adductus

Metatarsus adductus is a curving inward of the foot. It is the most common foot deformity in infants, occurring in 1-3/1000 children. Metatarsus adductus is believed to be caused by intrauterine positioning or crowding. The majority of children will have a flexible metatarsus adductus, meaning that the foot can be corrected by manual manipulation. The majority of infants and children with metatarsus adductus require no treatment other than reassurance and observation. The foot will spontaneously straighten out in about 90-95% of patients. Parents can gently stretch the infant’s foot to neutral a few times each day (with diaper changes, etc). Straight-last shoes are also occasionally used in the treatment of metatarsus adductus.


If you want book an assessment at one of our clinics we would be happy to assess your child. We often find that compiling some short videos ahead of time can be helpful as our tiny patients can sometimes have their own agenda. We are even happy to offer guidance virtually to ease the stress of coming to an appointment.

Call us for more information (416) 887-4109