In­toe­ing hap­pens when the feet turn in­wards when walk­ing. It is al­so known as pi­geon toes for ob­vi­ous rea­sons. It is very com­mon and oc­curs in about one in every four chil­dren un­der the age of six years, when it spon­ta­neous­ly dis­ap­pears. On the whole, no treat­ment is ever need­ed. How­ev­er, it’s an­oth­er of those pesky leg ap­pear­ances that make par­ents con­cerned.

As men­tioned last week, in­toe­ing makes chil­dren prone to trip­ping, or look awk­ward when walk­ing or run­ning, but it’s all show and has no sub­stance.

There are three com­mon caus­es of in­toe­ing. In­toe­ing that oc­curs at birth and lasts un­til two years. In­toe­ing that oc­curs be­tween one and four years. And in­toe­ing that oc­curs be­tween three to six years.

At birth, in­toe­ing is very com­mon. It’s when the front part of the foot turns in­ward, rather like a bean, due to the po­si­tion it had, squashed up in the womb. (Pic­ture 1) The in­toe­ing oc­curs on both feet but is usu­al­ly worse on one side. It is move­able, i.e. you can straight­en it with just a lit­tle ef­fort, and this dif­fer­en­ti­ates it from a club­foot, which is a fixed de­for­mi­ty and needs surgery. This type of po­si­tion­al in­toe­ing straight­ens out on its own, but par­ents and cer­tain para­med­ical prac­ti­tion­ers like to boast that they cured the “club­foot” by mas­sage.

In tod­dlers, the cause is dif­fer­ent. Some­times when the ba­by starts walk­ing, the shin­bone twists it­self in­ward, caus­ing the feet to point in­ward but the kneecaps to point straight ahead. (Di­a­gram 1) The ex­act cause is un­known, but again it is be­lieved to be caused by in­trauter­ine mould­ing and is more com­mon in some fam­i­lies. Chil­dren with this con­di­tion like to sit in the ‘w-sit­ting’ po­si­tion (Pic­ture 2), so this po­si­tion should be dis­cour­aged.

Again, this harm­less but fright­en­ing growth de­vel­op­ment self-cor­rects by age 4 or 5. As is com­mon with most chil­dren’s leg and feet prob­lems, or­thotics, shoe mod­i­fi­ca­tions and brac­ing are not ef­fec­tive in cor­rect­ing tib­ial tor­sion. Oc­ca­sion­al­ly, mus­cle-strength­en­ing ex­er­cis­es or phys­i­cal ther­a­py may help with bal­ance and dif­fi­cul­ties with gait.

In old­er chil­dren, aged 3 to 6 years, the most com­mon cause by far is some­thing called “In­ter­nal femoral tor­sion”. (Di­a­gram 2) It af­fects about one in every ten chil­dren and is slight­ly more com­mon in girls, per­haps be­cause par­ents are more ob­ser­vant about their girl-child’s legs. At birth, the prob­lem was the foot. As the child aged, the prob­lem be­came the leg and shin­bone. Now, at an old­er age, the prob­lem is even high­er up, the thigh­bone. Femoral an­tev­er­sion is where the thigh­bone, or fe­mur, turns in­ward at the hip joint. You can try di­ag­nos­ing it by hav­ing the child lie down on its back, hold­ing the legs by the an­kle and twist­ing the en­tire low­er ex­trem­i­ty in and out. You will no­tice that the leg twists in a lot more than it can twist out. Again, the po­si­tion of the foe­tus in the womb or ge­net­ic fac­tors play a role. It’s sur­pris­ing how of­ten a moth­er will say, yes, me and my sis­ter have that too. It is not linked to any spe­cif­ic or long-term dis­abil­i­ty. How­ev­er, as ex­pect­ed by now, this usu­al­ly im­proves on its own by age 10 to 12.

If it doesn’t, this in­toe­ing due to a struc­tur­al hip ro­ta­tion has ad­van­tages for elite adult ath­letes. The great base­ball play­ers at short­stop or third base, where ex­treme phys­i­cal low­er limb pow­er and mo­bil­i­ty are need­ed, have all been in­toed. A pi­geon-toed stance in base­ball re­stricts and chan­nels low­er-half en­er­gy and acts like a tight spring, caus­ing them to pop off the ground un­usu­al­ly fast. The same goes for many sprint­ers, es­pe­cial­ly those with the faster starts.

What to do for in­toe­ing? Usu­al­ly noth­ing. It’s con­sid­ered nor­mal if the child feels no pain, runs and plays nor­mal­ly, the in­toe­ing looks the same on both sides, and it im­proves as they grow. Less than 1 per cent of chil­dren ever need med­ical or sur­gi­cal treat­ment.

It’s of con­cern if the in­toe­ing caus­es pain, if there is a dif­fer­ence be­tween the lengths of the limbs, if it caus­es se­vere limp or hap­pens on on­ly one side, or gets worse over time or per­sists past ado­les­cence.

It may al­so be a prob­lem in those rare fam­i­lies who have a fam­i­ly his­to­ry of rick­ets due to a kid­ney prob­lem or one of those strange dis­eases as­so­ci­at­ed with oth­er very ob­vi­ous bone and fa­cial ab­nor­mal­i­ties.