Intoeing Gait in Children – Information for Referrers

A very common reason for children to be referred to the orthopaedic clinic is for intoeing. This is sometimes referred to as being pigeon toed or hen toed, and simply means that the child walks with their feet pointing inwards. It is usually what we would describe as a normal variant and very rarely requires treatment. It is common and usually affects both sides. Intoeing is thought to affect 1 in 6 of all children, and is therefore more common than being left handed!

The position of the foot in space is affected by three things:

1. The shape or position of the femur
2. The shape or position of the tibia
3. The shape of the foot.

In most cases the intoeing is often due to persistent femoral anteversion and turns the whole limb in while the child walks. It is usually not a problem with the feet and therefore special shoes or insoles make little difference. In most children the intoeing improves gradually as they grow and is much less obvious by the time they reach the age of about 8.

Parents often comment that their child trips and falls more often at however this tends to resolve as the child grows stronger, develops more co-ordination and control of their muscles. Intoeing does not affect a child’s ability to walk and should not delay their development. It is often more evident when a child is tired and if they are more flexible.

Most will correct over time, but some children will be able to turn their hip in more than out even as an adult. Some parents will also be able to in-turn more. In lots of ways children often end up like their parents. There is nothing to stop the child walking with their feet pointing forwards if they want to. It just happens to be easier to walk the way they do. Many children improve with time. However, they often tend to intoe when tired, not concentrating or running fast.

When you walk, the position of your foot comes from 3 different places. All of these are reasons why your child may intoe. The most common reason actually comes from your child’s thigh!

The Shape of the Thigh Bone

At birth the femur points forwards by approximately 40 degrees with relation to the hip. This is termed the femoral anteversion. As a child grows, this untwists to an adult level of around 10-15 degrees by the age of about 8. This happens gradually over time. It is quite common for this twist to resolve more slowly and this causes the whole leg to turn in and is the most common cause of an intoeing gait. You can imagine on yourself that if the hip is turned in then the whole leg and foot will turn in. It is termed persistent femoral anteversion and is most evident in children around the age of 2-4 years old and commonly resolves spontaneously as the child grows older and taller. Persistent femoral anteversion is more common in girls than boys and commonly runs in families. This requires no treatment as it is simply the way that person’s body is built and is one end of a normal range.

The Shape of the Lower Leg/Shin BoneThe tibia usually has slight external rotation resulting in a slightly outward position of the foot. However, as with anything in life, there is a variation in what would be considered normal. There may be slight internal rotation of the tibia which will result in intoeing, the technical term is tibial torsion. This is typically seen in toddlers and will normally correct of its own accord by age 4-5 years old as the bones grow, walking pattern matures and the bones straighten up. No specialist input is normally necessary.

The Shape of the Foot Occasionally a child’s foot itself may be curved. The best way to tell this is to by looking at the lateral border of their foot whilst sitting. This is usually straight but occasionally there may be a curve here and if so termed metatarsus adductus. This is an inward turning of the foot. The foot is usually fully flexible and correctable and has often been caused by the baby being cramped in the womb. Most will resolve spontaneously, if the foot appears stiffer then stretches may be suggested by a physiotherapist in the first instance. This is usually picked up when a child is fairly small, usually before they walk.

As mentioned most cases of intoeing gait will resolve spontaneously as achild gets older. Clumsiness and falling improve naturally as the child gains more co-ordination, balance and control of their muscles. No treatment is usually required.

Sitting in a W position can encourage an intoeing gait pattern and therefore encouraging the child to sit in other positions is advised such as with their legs crossed.

As the child gets older practicing an out-toeing walking pattern (Penguin walking) may help to strengthen the muscles and keep the feet straight.

Occasionally an intoeing gait may be an indicator of an underlying problem. The reasons for referral include:

• Unilateral intoeing. This may suggest a pattern of increased tone or developing hemiplegia.
• Asymmetry. If there is significant asymmetry then referral should be considered.
• Frequent falling in a school age child.