Intoeing, or pigeon toes, refers to a condition in which the feet point inwards, instead of pointing straight ahead. This problem is quite common among young children. It may be present at birth, and by the age of four about 30% of children show intoeing. However, most of the time, it is mild and corrects itself before puberty and only 4% of adults retain this problem.
Intoeing can occur due to bone deformities or movement disorders and, in some cases, can be a combination of both.
Fortunately, most of the cases of intoeing fall into the normal category and do not hold any threats for normal development of the child. However, while diagnosing the condition, the neurological status of the child should always be assessed carefully. Certain problems during pregnancy or during childbirth such as bleeding during the early phase of pregnancy, premature birth, intracranial hemorrhage, etc, may cause neurological disturbances, which may contribute to intoeing by creating an imbalance in muscle strength.
There are also certain diseases associated with intoeing such as:
Rickets: Predominantly caused by vitamin D deficiency in children; the bones become soft and more liable to fracture and deformation, such as bowed legs
Blount’s disease is a bone growth disorder, characterised by outward bowing of the legs below the knees.
In normal children, intoeing is mostly due to skeletal problems and frequently more than one deformity is involved. The age of the child plays an important role in pinpointing the cause of the problem.
Intoeing due to deformity of the feet:
When present at birth, intoeing is mostly the result of a problem within the skeleton of the foot. Several conditions can appear as intoeing in newborns such as:
- Metatarsus adductus: the foot bends inwards from the middle (metatarsus: bones of the midfoot, adductus: from adduction, movement towards midline)
- Hallux varus: the big toe points inwards, away from the second toe (Hallux=big toe, Varus= inward angulation)
- Club foot: feet are turned inwards at the ankles, also present at birth
- High arched feet (pes cavus)
Metatarsus adductus is by far the most common cause of intoeing in newborns. In this condition the feet are curved, i.e., they are bent inward from the middle. The defect becomes obvious when you observe the soles of the feet that appear curved inwards. The defect is obvious at birth and the suspected cause is the position of the baby in the uterus, which may have pressed the feet in this way.
In 90% of cases, metatarsus adductus corrects by itself as the child grows.
Stretching the foot may help to straighten its shape. If there is a pronounced curve or it is rigid and does not show any improvement, treatment may be required, which includes putting braces or casts on the feet, which stretch the feet to straighten them.
However, there are different opinions regarding how and when to treat the condition and whether treatment is required at all.
Many doctors are of the opinion that if there is no improvement in four to six months after birth, braces should be applied. The treatment with casts or braces is usually recommended until the child starts walking.
Intoeing caused by metatarsus adductus does not cause any pain or future bone problems. However, if it troubles the child during walking or with fitting shoes, then treatment should be sought.
Intoeing due to a rotated lower leg bone (Internal Tibial Torsion):
This is the most common cause of intoeing in children. This deformity involves the tibia, which is the stronger of the two bones located in the knee and ankle. This bone normally has a little inward twist in newborn babies but it straightens before the child starts to walk, usually within the first year of life.
However, in some cases, it does not straighten sufficiently and the intoeing becomes apparent as the child starts to walk. Although the feet point inwards, the knees point straight ahead, which shows the defect lies below the knee level.
The deformity corrects itself by the time the child is three to four years old.
There is one treatment option that involves using shoes with an attached bar that rotate the feet outwards so that they point straight ahead. However, it has not been always effective, moreover, there is the problem of patient compliance, as children usually do not cooperate with this form of treatment.
There is no evidence of this abnormality leading to any problems in the future, such as bone diseases or problems with normal walking or running patterns. If the problem is severe and affects the appearance, then surgery may be advised, but not before 9-10 years of age. The surgery involves cutting the bones and rotating them to the normal position.
Intoeing as a result of a twisted thigh bone (Femoral Torsion):
This usually appears in children after two years of age. The cause is an inward twist of the thigh bone (femur) at its upper end. As a result, the hip turns inwards and the result is intoeing; in this case the knees also twist inward. Such children, often adopt a “W” position when they sit down, in which they have their legs bent backwards at the knees with feet spread outwards behind.
Some inward twist is present at birth. However, as the child starts to walk, the muscles and ligaments (fibrous attachments between bones) become loose and the thighbone twists further inwards, worsening the condition, which becomes apparent between 2-4 years of age.
Most of the time, the condition corrects all by itself like other causes of intoeing and by the age of 6 or 7 years, the feet usually turn straight.
Treatment with braces or using special shoes has not been proved very effective. Mild cases require no treatment, while in severe cases when the child has a problem walking then surgery is advised.
Femur rotation is also known as knock-knees. Surgery for the correction of intoeing should only be decided after careful consideration and is not performed before 9 to 10 years of age, to allow time for natural correction.