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]