Intoeing and Out-Toeing: Causes, Treatment & When to Worry

What Is Intoeing and Out-Toeing?

Intoeing (also called pigeon-toed) is when the feet point inward when walking. Out-toeing (sometimes called duck-footed) is when the feet point outward. Both are common developmental variations in children that usually correct naturally as the bones and muscles mature during growth.

When children begin walking, many parents notice that their child's feet don't point straight ahead. Some children walk with their toes pointing inward (intoeing), while others walk with their toes pointing outward (out-toeing). These rotational variations are among the most common reasons parents bring their children to orthopedic specialists, yet in the vast majority of cases, they represent normal developmental variations rather than medical problems.

The direction our feet point when we walk is determined by the combined rotation of bones from the hip to the foot. During normal growth, these bones naturally rotate and remodel, which is why most rotational variations improve or resolve completely as children get older. Understanding the underlying causes helps parents and caregivers know what to expect and when professional evaluation is warranted.

It's important to distinguish between normal rotational variations and true orthopedic problems. While intoeing and out-toeing can look concerning, they rarely cause functional problems or long-term complications. Studies following children with these conditions into adulthood show no increased risk of arthritis or other joint problems. The vast majority of children with intoeing grow into adults with perfectly normal leg alignment.

Understanding the Anatomy

The position of the feet during walking depends on the combined rotation of three areas: the hip joint (femoral rotation), the shinbone (tibial torsion), and the foot itself (metatarsus position). Each of these areas has a normal range of rotation that changes throughout childhood. What appears as intoeing or out-toeing is often simply a child falling at one end of the normal spectrum for one or more of these rotational components.

In infants and toddlers, it's completely normal for the hips to have more internal rotation than external rotation. This gradually changes during childhood until adult proportions are reached, typically around age 8-10. Similarly, the shinbone naturally rotates outward during growth, and the foot's position can change during the first few years of life.

What Causes Children to Walk With Their Feet Turned Inward?

Intoeing in children is typically caused by one of three conditions: femoral anteversion (increased inward rotation at the hip), internal tibial torsion (inward twist of the shinbone), or metatarsus adductus (curved forefoot). All three are normal developmental variations that usually resolve with growth.

Understanding the three main causes of intoeing helps explain why children walk with their feet turned inward and provides insight into the natural history and expected timeline for improvement. Each cause has its own characteristic features, typical age of presentation, and pattern of resolution.

Femoral Anteversion (Hip Rotation)

The most common cause of intoeing in children over age 3 is femoral anteversion, which refers to the natural inward twist of the thighbone (femur). In children with increased femoral anteversion, the hip joint allows significantly more internal rotation than external rotation, which causes the entire leg to turn inward when walking.

Parents often notice that children with this condition prefer sitting in a "W" position - with knees together and feet splayed out to the sides. This position is comfortable for them because it accommodates their increased internal hip rotation. While this sitting position doesn't cause the condition, it may delay natural correction by reinforcing the inward rotation pattern.

During physical examination, a doctor will assess hip rotation by measuring how far the leg can rotate inward versus outward. Children with femoral anteversion typically have internal rotation of 70-80 degrees or more, compared to the normal 50-60 degrees, while external rotation is often reduced. Despite this imbalance, these children can typically run, jump, and play sports normally.

Femoral anteversion naturally improves between ages 4-10 as the thighbone gradually rotates outward during growth. By adolescence, most children achieve normal hip rotation. Very few adults walk with their feet turned inward due to this cause.

Internal Tibial Torsion (Shinbone Twist)

Internal tibial torsion refers to an inward twist of the shinbone (tibia) that causes the foot to point inward even though the knee faces forward. This is the most common cause of intoeing in children between ages 1-3 and is often noticeable when the child first begins walking.

Tibial torsion is thought to result partly from the cramped position in the womb during pregnancy and is often more pronounced on one side than the other. Parents may notice that the child's kneecaps point forward but the feet point inward, which is the hallmark sign of tibial torsion.

During normal development, the tibia naturally rotates outward as the child grows. This spontaneous improvement typically occurs by age 4-6, and virtually all children with internal tibial torsion develop normal tibial alignment by late childhood. No treatment is needed for the vast majority of cases.

Metatarsus Adductus (Curved Forefoot)

Metatarsus adductus is a condition where the front part of the foot curves inward, giving the foot a bean or kidney shape. This is the most common foot deformity in newborns, affecting approximately 1-2 per 1,000 births, and is often noticed immediately after birth.

The condition is classified based on flexibility. In most cases (approximately 85-90%), the forefoot can be easily straightened to a neutral position (flexible metatarsus adductus), and these cases typically resolve with simple stretching exercises or spontaneously during the first year of life. Rigid metatarsus adductus, where the forefoot cannot be straightened, may require serial casting.

Metatarsus adductus can also develop in older infants who sleep on their stomach with their feet tucked under, which puts pressure on the outer edge of the foot. In these cases, changing sleep position and avoiding pressure on the feet typically leads to improvement.

What Causes Children to Walk With Their Feet Turned Outward?

Out-toeing in children is usually caused by increased external rotation at the hips or external tibial torsion. Like intoeing, out-toeing is typically a normal developmental variation that improves with growth. However, out-toeing that develops in overweight children warrants medical evaluation.

Out-toeing, where the feet point outward when walking, is generally less common than intoeing but follows similar principles. The condition is most noticeable when the child is tired. Like intoeing, most cases of out-toeing resolve spontaneously as the child grows.

The most common cause of out-toeing is increased external hip rotation, which is the mirror image of the femoral anteversion that causes intoeing. In these children, the hip joint allows more outward rotation than inward rotation, causing the legs and feet to turn out during walking.

External tibial torsion, where the shinbone is twisted outward, can also cause out-toeing. This condition may persist more often than internal tibial torsion and occasionally requires evaluation if it causes functional problems or doesn't improve by late childhood.

What Are the Signs and Symptoms of Intoeing?

Children with intoeing walk with their feet pointing inward. They may trip or stumble more frequently, especially when tired, and may have bruises on their knees or shins from falls. Some children complain of leg fatigue after walking longer distances.

The primary sign of intoeing is visible - the feet point inward rather than straight ahead when the child walks. This may be more noticeable when the child is tired or has been walking for an extended period. Many parents first notice intoeing when the child begins walking independently, typically between 9-15 months of age.

Children with moderate to significant intoeing may trip over their own feet more frequently than other children their age. This happens because the inward-pointing foot can catch on the opposite leg during the swing phase of walking. As a result, these children may have bruises or scrapes on their knees and shins from frequent falls.

Some children with intoeing report leg tiredness or achiness after walking longer distances. This fatigue is typically related to the slightly altered gait pattern rather than any underlying muscle or bone problem. The discomfort usually resolves with rest and doesn't indicate a serious issue.

Despite the visible difference in gait, most children with intoeing function normally in all activities. They can run, jump, climb, and participate in sports without difficulty. In fact, some research suggests that intoeing may actually provide a slight advantage in running speed, which is why some elite sprinters have mild intoeing.

Characteristic Sitting Positions

Children with intoeing caused by femoral anteversion often prefer sitting in a W position, with knees bent, legs splayed outward, and feet behind the hips. This position is comfortable because it accommodates their increased internal hip rotation. While W-sitting doesn't cause intoeing, prolonged W-sitting may delay the natural correction that occurs with growth.

Encouraging children to sit cross-legged (criss-cross or tailor position) instead of W-sitting may help promote the natural outward rotation of the hips that occurs during growth. However, there's no need to strictly prohibit W-sitting - simply offering alternatives and gentle reminders is sufficient.

When Should You See a Doctor for Intoeing or Out-Toeing?

See a doctor if intoeing or out-toeing is painful, only affects one leg, is getting worse over time, is severe enough to significantly interfere with walking or activities, or hasn't improved by age 8-10. Most cases don't require medical treatment.

The vast majority of children with intoeing or out-toeing do not need medical treatment. These conditions typically resolve on their own as the child grows. However, certain situations warrant professional evaluation to rule out underlying problems or to discuss the expected natural history with a specialist.

See your primary care doctor or a pediatric orthopedic specialist if:

• The condition is painful - normal rotational variations shouldn't cause significant pain
• Only one leg is affected while the other is normal (asymmetric involvement)
• The intoeing or out-toeing is getting worse rather than improving
• The condition is severe enough to cause frequent falls or significantly interfere with walking
• The condition hasn't shown improvement by age 8-10
• You're concerned about your child's development or want reassurance about the expected course

For children with obesity who develop out-toeing, especially if accompanied by hip or knee pain, limping, or difficulty walking, prompt medical evaluation is recommended to check for slipped capital femoral epiphysis.

How Is Intoeing Diagnosed?

Intoeing is diagnosed through physical examination of hip rotation, tibial torsion, and foot shape. The doctor observes the child's walking pattern and measures joint rotation. X-rays are usually not needed unless there are unusual findings or concerns about other conditions.

The diagnosis of intoeing and identification of its cause is primarily clinical, meaning it's based on the doctor's examination rather than laboratory tests or imaging studies. An experienced clinician can usually determine the cause of intoeing within a few minutes of examination.

Physical Examination Components

The examination begins with observing the child walk. The doctor notes the foot progression angle (how much the feet point in or out), the position of the kneecaps, and the overall gait pattern. Children are often asked to walk in a straight line and may be observed running as well.

Next, the doctor examines the child lying down to assess rotation at each level. Hip rotation is measured by flexing the hip and knee to 90 degrees and rotating the leg inward (internal rotation) and outward (external rotation). Children with femoral anteversion typically have internal rotation of 70-80 degrees or more, with reduced external rotation.

Tibial torsion is assessed by measuring the thigh-foot angle with the child lying face down and knees bent to 90 degrees. This angle indicates how much the shinbone is rotated relative to the thigh.

The feet are examined for metatarsus adductus by looking at the foot's shape and assessing whether the curved forefoot can be corrected to a neutral position (flexibility).

When Imaging Is Needed

X-rays and other imaging studies are rarely needed for typical intoeing. However, the doctor may order imaging if there are concerns about hip dysplasia, bone abnormalities, or other conditions that might mimic simple rotational variations. Signs that might prompt imaging include limping, pain, leg length discrepancy, or findings on physical examination that suggest an underlying problem.

How Is Intoeing and Out-Toeing Treated?

Most intoeing and out-toeing requires no treatment because it resolves naturally with growth. Special shoes and braces are not effective for rotational problems caused by hip or tibial rotation. Metatarsus adductus may benefit from stretching exercises or, in rigid cases, serial casting.

The treatment approach for intoeing depends on its cause, severity, and the child's age. For the majority of children, the treatment is observation and reassurance, as the condition will improve spontaneously. Active treatment is reserved for specific situations.

Observation and Monitoring

For intoeing caused by femoral anteversion or internal tibial torsion, the recommended treatment is observation. Multiple high-quality studies have shown that special shoes, braces, shoe inserts, and twister cables do not speed up the natural correction that occurs with growth. These devices were widely used in the past but are now considered ineffective and are no longer recommended by pediatric orthopedic organizations.

The natural history of femoral anteversion is for gradual improvement between ages 4-10, with most children achieving normal hip rotation by adolescence. Tibial torsion typically improves by age 4-6. Very few children have persistent, functionally significant intoeing as adolescents or adults.

For children who prefer W-sitting, encouraging cross-legged sitting may help promote the natural outward rotation of the hips. However, strict prohibition of W-sitting is not necessary or recommended. Simply offering alternatives and gentle reminders is appropriate.

Treatment of Metatarsus Adductus

Metatarsus adductus is the one cause of intoeing where active treatment may be beneficial, particularly for rigid cases in young infants.

Flexible metatarsus adductus (where the forefoot can be straightened manually) usually resolves spontaneously. Some doctors recommend gentle stretching exercises, which can be performed during diaper changes. To perform the stretch, stabilize the heel with one hand and gently stretch the forefoot outward with the other hand. This stretch can be repeated 10-20 times, several times a day.

Rigid metatarsus adductus (where the forefoot cannot be straightened) may benefit from serial casting, where the foot is placed in progressively corrective casts over several weeks. This treatment is most effective when started early, ideally in the first 6 months of life. After casting, a splint or special shoes may be recommended to maintain the correction.

For metatarsus adductus that develops in older infants due to sleeping position, changing the sleep position and avoiding pressure on the outer foot typically leads to improvement without other treatment.

When Surgery Might Be Considered

Surgical treatment for intoeing is rarely needed and is reserved for severe cases that don't resolve naturally and cause significant functional problems. Surgery is almost never performed before age 8-10 because most cases will improve spontaneously before then.

When surgery is indicated, the procedure is typically a derotational osteotomy, where the bone (usually the femur) is cut and rotated to a better position, then fixed with metal hardware while it heals. This is a significant surgery with a substantial recovery period and is only recommended when the benefits clearly outweigh the risks.

For persistent metatarsus adductus that hasn't responded to conservative treatment, soft tissue releases or corrective osteotomies of the foot bones may be considered in rare cases.

Does Intoeing Cause Long-Term Problems?

No. Research shows that childhood intoeing does not lead to arthritis or other joint problems in adulthood. Children with intoeing can run, play sports, and participate in all activities. Very few adults walk with their feet turned inward.

One of the most common concerns parents have about intoeing is whether it will cause problems later in life. Fortunately, long-term studies have consistently shown that childhood rotational variations do not lead to arthritis in the hips, knees, or ankles.

A study following children with intoeing into adulthood found no increased risk of degenerative joint disease. The natural remodeling of bones that occurs during growth typically corrects the rotational variations, and adults who had intoeing as children have normal joint alignment and function.

Children with intoeing can participate in all normal childhood activities without restriction. They can run, jump, climb, play sports, and be physically active. In fact, some research suggests that mild intoeing may provide a slight biomechanical advantage in sprinting, which is why some elite athletes have mild intoeing.

The main short-term issue for children with moderate to significant intoeing is increased tripping and falling. This is usually a minor inconvenience rather than a serious problem and tends to improve as the intoeing resolves and the child develops better coordination.

Can Intoeing or Out-Toeing Be Prevented?

Intoeing and out-toeing caused by normal developmental variations cannot be prevented. However, avoiding certain positions may help promote natural correction: encourage cross-legged sitting instead of W-sitting, and avoid prone sleeping with feet tucked under for infants.

Because most intoeing and out-toeing represents normal developmental variation, it cannot be prevented. The rotational position of the bones is largely determined by genetics and intrauterine (in the womb) positioning before birth. Parents should not feel that they did something wrong or could have prevented their child's intoeing.

However, certain habits may influence the natural correction of rotational variations:

• Sitting position: Children with increased internal hip rotation often prefer W-sitting. While this position doesn't cause the condition, encouraging cross-legged sitting may promote the natural outward rotation of the hips that occurs during growth.
• Sleep position: Infants who sleep prone (on their stomach) with their feet tucked under may develop metatarsus adductus from pressure on the outer foot. Placing infants on their back to sleep (which is also recommended to reduce the risk of sudden infant death syndrome) avoids this issue.

It's important to maintain perspective about these recommendations. Occasional W-sitting is not harmful, and there's no need to strictly prohibit it. Simply offering alternatives and gentle reminders is appropriate. The goal is to encourage variety in sitting positions rather than to create anxiety about one particular position.