II. Definitions
- In-Toeing (Pigeon-Toed)
- Foot Internal rotation (long axis) relative to the line of progression (movement when walking)
III. Epidemiology
- Common finding in age <6 years (up to 25 to 30% of children)
- Most cases are benign in this age group (80 to 95%)
IV. Differential Diagnosis
- Intoeing encases several underlying leg abnormalities
- Intoeing may occur at any level down leg kinetic chain
- Intoeing causes by age (most common causes)
- Infant (age <1 year): Metatarsus Adductus
- Toddler (age 1 to 3 years): Internal Tibial Torsion
- Child (age 3 to 6 years): Femoral Anteversion (usually bilateral)
V. Approach
- Step 1: Evaluate gait and rotational profile (Torsional Profile)
- See Foot Progression Angle (Gait Rotational Angle)
- Confirm In-Toeing with Out-toeing
- Level of abnormality may be apparent by gait
- Step 2: Evaluate hip rotation
- See Hip Rotation Evaluation in Children
- Limited lateral hip rotation (less than -10 to 20)
- Step 3: Evaluate Thigh to Foot Angle
- Negative angle suggests Medial Tibial Torsion
- Step 4: Evaluate for foot deformity
- Curved foot suggests Metatarsus Adductus
- Step 5: Evaluate for toe deformity
- Great toe abducted suggests searching toe
VI. Management
- Foot rotation changes overtime as bone grows (up to age 10 to 15 years)
- Age <6 years
- Intoeing is present in up to 30% of children age <6 years and benign in up to 95% of cases
- No referral needed if symmetric and painless (reassure parents)
- Referral Indications
- Asymmetric or painful findings
- Age >6 years with angulation >2 SD from normal
VII. References
- Schmale (2003) AAFP Board Review, Seattle
- Baird (2025) Am Fam Physician 111(2): 125-39 [PubMed]
- Rerucha (2017) Am Fam Physician 96(4): 226-33 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| Concepts | Finding (T033) |
| SnomedCT | 206822004, 269038003, 156858002, 268131002, 77599005, 274148003 |
| English | Toeing-in, [D]In-toeing (context-dependent category), [D]In-toeing, in-toeing, pigeon toed, pigeon toes, in toe, intoe, intoeing, to pigeon, Pigeon toed, toe in, Intoing, Intoeing, Toe, overlapping - acquired, Overlapping toe - acquired, [D]In-toeing (situation), In-toeing, Intoe, Pigeon toe, Pigeon toe (finding), Toeing-in (finding), pigeon toe |
| Dutch | O-teen, lopen met naar binnen gedraaide voeten |
| French | Pied cagneux, Démarche en rotation interne |
| German | Einwaertsdrehen der Fuesse beim Gehen, Einwaertsdrehen der Fuesse |
| Italian | Dito del piede a piccione, Andatura da piede varo |
| Portuguese | Pontas dos dedos dos pés para dentro, Rotação interna do pé |
| Spanish | Pie varo, [D]metatarso varo (categoría dependiente del contexto), Rotación interna del pie, Pigeon toe (finding), Pigeon toe, [D]metatarso varo, [D]metatarso varo (situación), metatarso varo (hallazgo), metatarso varo, desviación interna de los dedos de los pies (hallazgo), desviación interna de los dedos de los pies |
| Japanese | 内股, ｳﾁﾏﾀ, ｳﾁﾜ, うちわ |
| Czech | Chůze špičkami vytočenými dovnitř, Addukční noha |
| Hungarian | Galambujj-szerű elváltozás (varus lábujj), Varus ujj |
