In-Toeing

In-Toeing (Pigeon-Toed)
1. Foot Internal rotation (long axis) relative to the line of progression (movement when walking)

Common finding in age <6 years (up to 25 to 30% of children)
1. Most cases are benign in this age group (80 to 95%)

Intoeing encases several underlying leg abnormalities
Intoeing may occur at any level down leg kinetic chain
1. Hip: Medial Femoral Torsion (Femoral Anteversion)
2. Leg: Medial Tibial Torsion (Internal Tibial Torsion)
3. Foot: Metatarsus Adductus
Intoeing causes by age (most common causes)
1. Infant (age <1 year): Metatarsus Adductus
2. Toddler (age 1 to 3 years): Internal Tibial Torsion
3. Child (age 3 to 6 years): Femoral Anteversion (usually bilateral)

Step 1: Evaluate gait and rotational profile (Torsional Profile)
1. See Foot Progression Angle (Gait Rotational Angle)
2. Confirm In-Toeing with Out-toeing
3. Level of abnormality may be apparent by gait
Step 2: Evaluate hip rotation
1. See Hip Rotation Evaluation in Children
2. Limited lateral hip rotation (less than -10 to 20)
  1. Medial Femoral Torsion
Step 3: Evaluate Thigh to Foot Angle
1. Negative angle suggests Medial Tibial Torsion
Step 4: Evaluate for foot deformity
1. Curved foot suggests Metatarsus Adductus
Step 5: Evaluate for toe deformity
1. Great toe abducted suggests searching toe

Foot rotation changes overtime as bone grows (up to age 10 to 15 years)
Age <6 years
1. Intoeing is present in up to 30% of children age <6 years and benign in up to 95% of cases
2. No referral needed if symmetric and painless (reassure parents)
Referral Indications
1. Asymmetric or painful findings
2. Age >6 years with angulation >2 SD from normal