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Approach to the child with in-toeing

Scott B Rosenfeld, MD
Section Editor
William Phillips, MD
Deputy Editor
Mary M Torchia, MD


In-toeing ("pigeon-toeing") is a rotational variation of the lower extremity where the feet or toes point toward the midline during gait (figure 1). Out-toeing is a rotational variation of the lower extremity where the feet or toes point away from the midline during gait (figure 1).

In-toeing and out-toeing are among the most common anatomic musculoskeletal variations encountered by pediatric primary care providers and a frequent reason for referral to a pediatric orthopedic surgeon. However, most children with in-toeing or out-toeing have variations of normal lower-extremity development that will improve spontaneously and can be monitored by the primary care provider.

An understanding of the normal growth and development of the lower extremity is essential in evaluating a child's rotational alignment and helps to elucidate the mechanism of in-toeing. The most common causes of in-toeing in children are metatarsus adductus, internal tibial torsion, and increased femoral anteversion. These rotational variations are seen in normal, healthy children, and rarely persist into adolescence. Even when persistent, in-toeing rarely causes dysfunction [1]. History and examination generally are sufficient to distinguish common rotational variations from less common pathologic causes of in-toeing and out-toeing (eg, hemiplegic cerebral palsy). (See 'Evaluation' below.)

This topic will provide an overview of lower-extremity rotational development, common causes of in-toeing, pathologic causes of in-toeing that must be excluded, and an approach to the evaluation and management of the child with in-toeing. Out-toeing is discussed separately. (See "Approach to the child with out-toeing".)


Rotational alignment of the lower extremity is determined by the alignment of the foot, the rotation of the tibia in relation to the transcondylar axis of the femur (tibial torsion), and the rotation of the neck of the femur in relation to the transcondylar axis of the femur (femoral anteversion) (figure 2). In-toeing and out-toeing may be accentuated between six months and five years, when children are developing their walking and coordination skills [2]. Normal growth and improved coordination typically lead to spontaneous resolution of rotational variations (table 1).

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Literature review current through: Nov 2017. | This topic last updated: Feb 15, 2017.
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