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A common concern of parents is when their child walks with intoeing, often referred to as “pigeon-toed”. Fortunately, the vast majority of these children are considered to have normal variants, because the intoeing typically resolves over time as a child grows and does not require aggressive treatment. The three normal variants that cause intoeing are femoral anteversion, internal tibial torsion, and metatarsus adductus. Your doctor can diagnosis these with a four-part physical exam called a rotational profile.

doctor and patient

Femoral Anteversion

Increased internal rotation of the femur (thigh bone), is called anteversion and is the most common cause of intoeing in older children. Femoral anteversion can also cause a “knock-kneed” appearance. An awkward gait is often a cause of parental concern. A child that likes to sit in a “W”, rather than cross-legged, is a sign of femoral anteversion, but sitting in a “W” position is not known to be detrimental. Your physician can evaluate your child’s femoral rotation and X-rays are not needed for diagnosis.

Treating Femoral Anteversion

Parents can be reassured that almost all cases of femoral anteversion resolve with time. Braces and orthotics have not been shown to be more effective than observation alone for treating femoral anteversion. For parents with athletically-inclined children, it is good to know that coordination and gait patterns continue to mature throughout childhood.

If femoral anteversion does not resolve or causes significant functional problems, surgical correction can be performed but typically not advised until after 10-12 years old. Surgery is more commonly used in pathologic cases of femoral anteversion (e.g. neuromuscular disease).

Internal Tibial Torsion

Increased internal rotation of the tibia (shin bone) is the most common cause of intoeing in young children and toddlers. Parents may have concern for their child “tripping over his or her own feet”. Fortunately, tibial torsion is considered a normal variant and there are no long-term consequences. Children typically show gradual improvement and resolves before 8 years of age. Derotational braces and other orthotics exist, but have not proven to alter the natural history of intoeing.

Treating Internal Tibial Torsion

Persistent cases of tibial torsion rarely require surgical intervention and is indicated only when a child has severe functional problems. Pathologic causes of internal tibial torsion, such as cerebral palsy, are more often addressed with surgery.

Fun fact: A recent study showed there actually is a high incidence of tibial torsion in high-level athletes and sprinters!

Metatarsus Adductus

Metatarsus adductus can cause intoeing and is the most common foot abnormality in newborns, occurring in 3-12% of births. The cause is unknown and can be attributed to an in utero “packaging problem”. The foot appears bean-shaped with a curved lateral border, often occurring on both feet. Metatarsus adductus is a normal variant, but can sometimes be confused with a Clubfoot. Your orthopedic doctor will be able to differentiate the two during the exam.

Treating Metatarsus Adductus

If the foot is flexible to a straight position, then no treatment is necessary. There is a near 90% rate of spontaneous resolution for metatarsus adductus, usually in the first several months of life. Observation and simple home stretching are most commonly recommended by physicians. For persistent or rigid metatarsus adductus, serial casting or foot braces can be prescribed. Metatarsus adductus rarely requires surgery and is not advised during the early years of life. The long-term outcome of a persistent adductus is most often cosmetic without causing functional issues.

little boy with two leg casts


Children that walk with their toes pointing outward may cause concern for parents. Fortunately, out-toeing is most often a benign finding.

The most common cause of out-toeing is pes planovalgus, or flat foot, which can be considered a normal variant in children. A child’s medial arch may not develop fully until after age 5. Fortunately, children who still have flatfoot later in childhood and adolescence rarely have symptoms.

Treating Flat Foot

Flatfoot that is painful is primarily managed with arch supports, custom inserts, or orthotics such as a SMO (supramalleolar orthosis). Cases of flatfoot causing severe symptoms and those with a rigid hindfoot (possible diagnosis of tarsal coalition), may need surgery if conservative measures fail.

Determining the Severity

Out-toeing can be exacerbated by external tibial torsion. Unlike most cases of internal tibial torsion, external rotation may not resolve with age. However, surgical treatment is rarely necessary, and only in symptomatic patients. Femoral retroversion, or external hip rotation, can also cause out-toeing. It is a benign finding in itself, and your physician can evaluate external femoral rotation during your exam.

Malalignment Syndrome

This uncommon diagnosis, also referred to as Miserable Malalignment Syndrome, occurs when the rotational profile reveals internal femoral rotation with external tibial torsion. The potential consequence of malalignment syndrome is abnormal forces placed across the kneecap (patellofemoral joint) and may lead to knee pain, especially in runners.

Treating Malalignment Syndrome

Conservative measures are taken first to treat Miserable Malalignment (physical therapy, bracing, and activity modification). Surgery during adolescence can be considered in those patients that do not improve.

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