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Pigeon toe

Pigeon toe, also known as intoeing, is a common condition in young children where one or both feet turn inward instead of pointing straight ahead when walking or running.^[1]^[2] This misalignment often stems from developmental variations in the bones and joints of the lower extremities and is typically painless, though it may lead to frequent tripping or a noticeable waddling gait.^[3]^[1] The primary causes of pigeon toe include metatarsus adductus, where the front of the foot bends inward and is most common in infants under 12 months; internal tibial torsion, an inward twist of the shinbone that typically appears between ages 1 and 3; and femoral anteversion, an inward rotation of the thighbone that often emerges around ages 3 to 6.^[2]^[1] These conditions arise from positioning in the uterus, genetic factors, or normal growth patterns and can affect one or both legs.^[3] In rare cases, underlying issues such as neuromuscular disorders may contribute, necessitating further evaluation.^[2] Diagnosis is usually made through a physical examination during routine pediatric visits, assessing foot position, leg rotation, and flexibility without the need for imaging in most instances.^[1]^[3] Treatment is often unnecessary, as the condition self-corrects with growth—metatarsus adductus by around 4 to 6 months, tibial torsion by school age, and femoral anteversion by ages 9 to 10 in the majority of cases.^[2] For severe or persistent cases, options include serial casting in infancy or, rarely, surgical correction after age 8 to 10 if symptoms like pain or limping develop.^[1]^[3] Braces or special shoes are generally not recommended, as they lack evidence of effectiveness.^[3]

Introduction

Definition and Characteristics

Pigeon toe, also known as intoeing, is a condition in which the feet turn inward instead of pointing straight ahead, resulting in a medial deviation of the forefoot relative to the body's midline.^[2]^[4] This inward pointing of the toes is most noticeable during walking or running and is a common variation in lower limb alignment, particularly in young children.^[1]^[3] Anatomically, pigeon toe arises from rotational deformities in the lower extremities, such as variations in the alignment of the hip, tibia, or foot bones, which cause the feet to rotate medially and alter normal gait mechanics.^[5]^[6] These deformities lead to an intoed posture where the forefoot deviates inward compared to the hindfoot, potentially affecting balance and stride efficiency, though many cases are asymptomatic and resolve spontaneously.^[7] It is commonly termed pigeon-toed gait due to the resemblance to the inward-pointing feet of pigeons.^[2]^[8] Pigeon toe should not be confused with out-toeing, its opposite condition, where the feet rotate outward during ambulation.^[6] While both represent rotational variations, intoeing specifically involves medial orientation of the feet.^[5]

Epidemiology

Pigeon toe, or intoeing, is a common rotational variation in children, affecting up to 30% of toddlers under age 6, with prevalence decreasing to approximately 7-10% in school-aged children under 8 years.^[9]^[10] This condition is one of the most frequently observed musculoskeletal concerns in pediatric primary care, often resolving spontaneously without intervention.^[11] Demographically, intoeing peaks between ages 2 and 4 years, particularly for internal tibial torsion, and shows a familial tendency in about 10% of cases, suggesting a genetic component.^[12]^[13] Femoral anteversion, a key contributor to intoeing, is twice as common in females as in males and is often bilateral.^[5] No significant ethnic variations have been consistently reported in the literature.^[14] Risk factors include genetic predisposition, as evidenced by the familial patterns, as well as prematurity and developmental delays, which may influence lower extremity alignment during growth.^[15]^[16] Intrauterine positioning also plays a role, particularly for metatarsus adductus.^[14] Historically, pigeon toe has been recognized in pediatric orthopedics since the early 20th century, but awareness and screening have increased with modern pediatric well-child visits, leading to earlier identification and reduced unnecessary interventions compared to past practices involving braces or casts.^[17]^[18]

Clinical Presentation

Signs and Symptoms

Pigeon toe, also known as intoeing, is primarily characterized by the toes pointing inward rather than straight ahead during standing, walking, or running.^[1]^[2] This inward foot position can lead to a clumsy or awkward gait, often resulting in frequent tripping or falling, particularly when the child moves quickly.^[1]^[2] The condition is typically asymptomatic and does not cause pain, fatigue, or systemic symptoms such as fever in most cases.^[1]^[2] However, parents frequently report concern over the cosmetic appearance of their child's feet or the observed clumsiness during ambulation.^[1] In rare severe instances, mild discomfort may arise from repetitive strain, though this is uncommon.^[2] Functionally, intoeing may alter weight distribution across the feet, potentially contributing to minor imbalances during weight-bearing activities, though it seldom leads to significant complications like calluses in early stages.^[1] Children with pronounced intoeing might exhibit increased stumbling, affecting coordination in play or daily movement.^[3] Evaluation by a healthcare provider is advised if intoeing persists beyond age 8 to 10 years, shows marked asymmetry between the legs, or is accompanied by persistent tripping that interferes with function.^[3]^[2] Manifestations of these signs can vary slightly by developmental age, with more noticeable effects often observed during early walking stages.^[3]

Age-Specific Variations

In infants aged 0 to 1 year, pigeon toe most commonly manifests as metatarsus adductus, a flexible inward curving of the forefoot that affects approximately 0.1% to 1% of newborns and occurs with equal frequency in boys and girls due to intrauterine positioning.^[5]^[19] This presentation often appears as a "C"-shaped foot at birth, with the forefoot turned inward while the hindfoot remains straight, and it typically improves by 4 to 6 months and resolves by age 1 to 2 years through natural growth and remodeling.^[3]^[2] During ages 1 to 4 years, internal tibial torsion predominates, where the shinbone rotates inward, leading to a noticeable pigeon-toed gait during early walking and increased frequency of falls or tripping. This variation stems from the normal internal rotation of the tibia present at birth and is often familial, with the feet pointing toward the midline as the child begins to ambulate more actively. It generally corrects itself by age 4 to 5 years without intervention.^[5]^[3]^[2] In children aged 3 to 6 years, femoral anteversion becomes the primary contributor, characterized by an inward twist of the thighbone that causes both knees and feet to turn in, potentially impacting balance during activities like running or sports participation. This condition, which is twice as common in females, typically peaks in severity around ages 3 to 6 and arises from increased intrauterine pressure, resulting in a compensatory internal rotation of the hips.^[5] Overall, the majority of pigeon toe cases across these age groups exhibit spontaneous resolution by adolescence, with metatarsus adductus correcting by age 1 year, tibial torsion by age 4 to 5 years, and femoral anteversion by ages 9 to 10 years, though ongoing monitoring is essential to identify any persistent or progressive forms that may require further evaluation.^[5]^[3]^[2]

Etiology

Metatarsus Adductus

Metatarsus adductus is characterized by a medial curvature of the forefoot, involving adduction of the metatarsal bones relative to the hindfoot, which imparts a C-shaped appearance to the foot.^[5] It represents the most common congenital foot deformity and the primary cause of intoeing, or pigeon toe, observed in newborns, with an incidence of approximately 1 to 2 per 1,000 live births.^[20] The condition affects both genders equally and is bilateral in about 50% of cases.^[19] The pathophysiology stems from intrauterine positioning, where constraints on the fetus lead to medial deviation of the forefoot at the tarsometatarsal joint.^[19] This results in soft tissue contractures rather than bony abnormalities in most instances. Metatarsus adductus is classified based on flexibility: flexible forms allow correction to neutral or beyond with manual pressure, indicating correctable deformity; semi-flexible forms reach neutral; and rigid forms resist correction due to underlying structural changes.^[5] In its contribution to pigeon toe, metatarsus adductus produces isolated forefoot intoeing, sparing the tibia and femur, and typically manifests at birth without progression beyond infancy unless rigid.^[1] It may coexist with clubfoot (talipes equinovarus), where metatarsus adductus represents a milder component of the forefoot deformity, though it lacks the hindfoot equinus and varus seen in full clubfoot.^[21] Diagnosis occurs at birth through clinical evaluation, including the foot molding test, where gentle pressure is applied to the forefoot while stabilizing the hindfoot to assess correctability and classify severity.^[22]

Tibial Torsion

Tibial torsion refers to the internal rotation of the tibia relative to the femur, a common rotational deformity in the lower extremity that positions the feet medially.^[5] At birth, the tibia typically exhibits approximately 0 to 5 degrees of internal torsion, which normally progresses to 15 to 20 degrees of external torsion by age 8 through gradual remodeling during growth.^[23]^[24] This condition is most prevalent in young children, particularly between ages 1 and 4, and is often bilateral.^[25] The pathophysiology of tibial torsion primarily involves delayed postnatal remodeling of the tibia, which is initially shaped by the confined intrauterine position where the legs are often rotated inward.^[1] In most cases, this is a physiologic variation that resolves spontaneously as the child grows, with external rotation occurring progressively through early childhood.^[5] Genetic factors may contribute to persistence in some families, though the majority of instances are idiopathic and self-limiting.^[13] Tibial torsion contributes to pigeon toe by causing the feet to point inward during stance and gait, as the medially rotated tibia alters the foot's alignment relative to the thigh.^[25] This medial deviation is most noticeable during the toddler years, peaking between ages 2 and 5, when walking patterns emphasize the rotational misalignment.^[1] Associated findings include a thigh-foot angle exceeding 20 degrees of internal rotation, measured with the child prone and knees flexed at 90 degrees, where the angle between the thigh axis and foot bisection indicates the degree of tibial malrotation.^[25] Normal thigh-foot angles are age-dependent, ranging from -27° to +20° at age 1 year (mean 0°), -15° to +25° at age 3 (mean 7°), and approaching 0° to +30° by age 7 (mean 15°).^[26] Values more negative than the age-appropriate lower limit (e.g., less than -20° at age 1 may still be within normal variation, but less than -15° at age 3 warrants evaluation) suggest significant internal torsion. The condition is typically symmetric and does not usually impair function, though it may lead to compensatory gait adjustments.^[5]

Femoral Anteversion

Femoral anteversion is characterized by an excessive forward rotation of the femoral neck relative to the posterior aspect of the femoral condyles, leading to inward pointing of the knees and feet. In typical development, the angle of femoral anteversion measures approximately 30-40 degrees at birth and gradually decreases to 8-15 degrees in adulthood as the femur remodels through growth and weight-bearing activities.^[27]^[28] This normal progression reflects the adaptation of the lower limb for bipedal locomotion, with the anteversion angle reducing by about 2 degrees per year during early childhood.^[29] The pathophysiology of excessive femoral anteversion involves a delay in this remodeling process, often influenced by genetic factors or the intrauterine positioning of the fetus, which can predispose the femur to persistent medial rotation. It tends to run in families and is more prevalent in females than males.^[28]^[30] This condition arises from incomplete retroversion of the femoral neck during skeletal maturation, where the high anteversion present at birth fails to regress adequately, resulting in altered alignment of the entire lower extremity.^[31] In relation to pigeon toe, or intoeing, excessive femoral anteversion contributes by causing compensatory internal rotation of the hip, which transmits down the kinetic chain to rotate the tibia and foot inward, often becoming clinically apparent after age 5 when the child is more active.^[6] This proximal deformity at the hip level affects the whole lower limb, distinguishing it from more distal causes like tibial torsion. Associated findings include markedly increased hip internal rotation, often exceeding 70 degrees, and squinting patellae, where the kneecaps appear to face inward due to the rotational misalignment.^[6]^[32] In older children, this may manifest briefly as gait patterns with prominent internal foot progression angles.^[33]

Diagnosis

History and Physical Examination

The diagnosis of pigeon toe, or intoeing, begins with a thorough history taking to identify potential contributing factors and rule out underlying conditions. Clinicians inquire about family history of rotational deformities, as excessive femoral anteversion often has a familial pattern.^[34] Birth history is assessed for complications such as intrauterine malpositioning, which can lead to metatarsus adductus.^[5] Developmental milestones are evaluated for delays, alongside the progression of the intoeing since infancy, noting whether it has improved, persisted, or worsened over time.^[5] The physical examination focuses on non-invasive assessment of the lower extremities to quantify the degree of intoeing and identify its level. Gait is observed during walking and running, with particular attention to the foot progression angle; a value less than 0 degrees indicates intoeing, as the feet turn inward relative to the line of progression.^[34] Rotational profiles are measured, including the thigh-foot angle in the prone position (normal range 10–15 degrees external rotation) and hip internal/external rotation (total arc approximately 90 degrees, with excessive internal rotation greater than 70 degrees suggesting femoral anteversion).^[5]^[34] Flexibility is tested at the foot and knee, such as attempting to correct metatarsus adductus to neutral or beyond; flexible deformities overcorrect, while rigid ones do not.^[5] Neurological evaluation is incorporated through coordination checks and assessment of muscle tone to exclude conditions like cerebral palsy.^[5] Red flags warranting further investigation include unilateral intoeing, associated pain, or limping, which may signal pathologies such as hip dysplasia or neuromuscular disorders rather than idiopathic intoeing.^[5] These findings vary by age, with metatarsus adductus common in infants and femoral anteversion predominant after age 3.^[34]

Imaging Studies

Imaging studies are not routinely indicated for the diagnosis of pigeon toe, or intoeing, as the condition is primarily assessed through clinical examination in most pediatric cases. They are reserved for rigid deformities that do not improve with observation, significant asymmetry between limbs, or failure to show natural progression toward resolution, as well as to exclude underlying pathologic conditions such as skeletal dysplasia or neuromuscular disorders.^[5]^[1] Common imaging modalities include plain radiographs, such as anteroposterior (AP) and lateral views of the foot, which evaluate bone alignment in cases of suspected metatarsus adductus. For associated hip dysplasia, ultrasound is preferred in infants under 6 months of age; plain radiographs are used in older children to assess contribution to intoeing.^[35] In more complex scenarios involving rotational deformities, computed tomography (CT) scans are utilized to quantify tibial or femoral torsion, while magnetic resonance imaging (MRI) may be employed for detailed soft tissue evaluation or when minimizing radiation exposure is prioritized, though it is less common due to higher cost and need for sedation in young children.^[5]^[34]^[36] Key measurements derived from imaging include the transmalleolar axis for tibial torsion, which is the angle formed between a line connecting the medial and lateral malleoli and a reference line along the posterior aspect of the femoral condyles; normal values in children range from 0° to 20° of external torsion, with greater internal torsion contributing to intoeing. For femoral anteversion, CT or MRI measures the angle between the femoral neck axis and the posterior condylar axis of the knee, with values exceeding 25° considered abnormal in older children and indicative of persistent deformity.^[37]^[38]^[34] Limitations of imaging in pediatric intoeing include the risk of ionizing radiation exposure from X-rays and especially CT scans, which is a significant concern in children due to their greater sensitivity and longer lifespan for potential carcinogenic effects. Additionally, imaging is not cost-effective for the majority of cases, with clinical examination sufficient in approximately 90% of referrals, as supported by studies showing that over 85% of children evaluated for intoeing require no further radiological investigation.^[5]^[39]^[40]

Management

Conservative Approaches

Conservative management of pigeon toe, or intoeing, primarily involves observation and reassurance for parents, as the condition resolves spontaneously in the vast majority of cases without intervention.^[2] In children younger than 8 years, intoeing typically corrects itself due to natural growth and remodeling of the lower extremities, with most cases caused by tibial torsion or femoral anteversion resolving by ages 8 to 10.^[6] Regular follow-up with a primary care physician is recommended to monitor progress and ensure no underlying pathology, with referral to orthopedics if the deformity worsens or causes functional limitations.^[5] For metatarsus adductus, the most common cause in infants, flexible or mild cases are managed with watchful waiting, as most resolve by age 1 year without treatment.^[3] In rigid or severe cases, serial casting over 6 to 9 weeks can correct the deformity, achieving high success rates in early intervention.^[2] Parental education emphasizes avoiding unprescribed corrective devices, as they lack evidence of benefit and may hinder natural development.^[3] Physical therapy is generally not recommended for tibial torsion or femoral anteversion, as stretching exercises and orthotics have shown no efficacy in altering rotational alignment.^[5] However, for symptomatic metatarsus adductus, gentle home stretching exercises may be advised to promote foot eversion, though evidence for broader use remains limited.^[1] Overall, conservative approaches yield success in 80% to 90% of cases through spontaneous resolution, reducing the need for invasive procedures.

Interventional Treatments

Surgical interventions are rare and indicated only for severe, persistent deformities that significantly affect walking or cause pain after conservative measures fail by age 8-10 years, or in cases of severe pain, functional impairment such as frequent tripping, or significant gait abnormalities.^[2] These interventions target persistent deformities from metatarsus adductus, tibial torsion, or femoral anteversion that do not resolve naturally and impact quality of life.^[7] For severe, rigid metatarsus adductus, serial casting serves as an initial interventional approach, particularly when initiated before 8-9 months of age. The procedure involves gentle manipulation to abduct the forefoot followed by application of long-leg or short-leg plaster casts, changed weekly to progressively correct the adduction deformity. Treatment duration typically spans 8-12 weeks, with success rates higher in flexible cases, though it may require follow-up to prevent recurrence.^[7]^[1] In older children with persistent tibial torsion causing marked intoeing, a supramalleolar tibial derotational osteotomy is performed to realign the tibia by cutting and externally rotating the bone, often secured with plates or screws. This is generally considered for patients over 8 years with torsion exceeding three standard deviations from normal and ongoing functional issues. For femoral anteversion contributing to severe deformity, a proximal femoral derotational osteotomy may be indicated around age 9-10 years or older, involving a similar bone cut and rotation to normalize hip alignment. Tendon transfers, such as those addressing muscle imbalances, are rarely employed due to limited efficacy in primary intoeing correction.^[2]^[25] Risks associated with these procedures include infection (rates typically less than 1% in pediatric orthopedic surgery), nerve injury, compartment syndrome, and delayed union, though overall complication rates remain low at around 3% for derotational osteotomies. Recovery involves non-weight-bearing for 4-6 weeks post-surgery, followed by casting or bracing, with full functional recovery generally achieved in 3-6 months through physical therapy to restore strength and gait.^[41]^[42]^[43]

Prognosis and Complications

Natural History

Pigeon toe, or intoeing, is a common pediatric gait variation characterized by the feet turning inward during walking, primarily due to metatarsus adductus, internal tibial torsion, or femoral anteversion. In idiopathic cases, the condition follows a benign natural history, with the vast majority resolving spontaneously as the child grows without requiring intervention. Longitudinal observations indicate that rotational alignment in the lower extremities evolves predictably during development, driven by growth-related remodeling of bone and soft tissues.^[6] The progression varies by underlying cause. Metatarsus adductus, the most frequent form in infants, typically corrects spontaneously within 6 to 12 months as the forefoot aligns with the hindfoot through natural growth and weight-bearing activities. Internal tibial torsion, often prominent between ages 1 and 3 years, generally resolves by age 4 to 6 years as the tibia externally rotates in response to ambulatory demands. Femoral anteversion, which peaks around 4 to 6 years and contributes to intoeing in older toddlers, diminishes progressively, achieving normal alignment in most children by 10 to 12 years through femoral neck retroversion during skeletal maturation.^[19]^[44]^[25]^[45]^[6] Resolution rates are high across etiologies, with approximately 99% of idiopathic cases self-resolving without intervention, though outcomes are influenced by initial severity—flexible, mild deformities correct more readily than rigid or severe ones. For metatarsus adductus, 85% to 90% of flexible cases resolve by 12 months; for tibial torsion, over 90% correct by age 8; and for femoral anteversion, nearly all achieve resolution by adolescence. Monitoring milestones include reassessment at the onset of walking (around 12 months), school entry (ages 5 to 6 years), and adolescence (ages 12 to 14 years) to track progress and rule out persistence.^[28]^[8]^[46]^[6]^[44]^[25] Historical data from longitudinal studies spanning the 1950s to 2000s affirm the benign course of idiopathic intoeing. For instance, a 1974 cohort study of normal children documented the progressive decrease in tibial torsion and femoral anteversion, correlating with improved gait alignment by school age, supporting observation over treatment in uncomplicated cases. Subsequent research through the late 20th century reinforced these findings, showing minimal persistence into adulthood (less than 4%) and no long-term functional deficits in resolved cases.^[47]^[48]

Potential Long-Term Issues

Although most cases of pigeon toe (intoeing) resolve spontaneously without long-term consequences, persistent forms into adolescence or adulthood can lead to rare complications. In cases of excessive femoral anteversion that do not correct, patients may experience anterior knee pain due to patellofemoral maltracking and instability, often exacerbated by activities involving knee flexion.^[49] Similarly, untreated persistence increases the risk of stress fractures and secondary arthritis in the lower extremities, though direct causation of arthritis is not universally established.^[1] Femoral-related intoeing has been associated with an elevated risk of developmental hip dysplasia, particularly when linked to intrauterine positioning abnormalities like metatarsus adductus, necessitating screening in asymmetric or severe presentations.^[5] Uncorrected asymmetry in persistent cases may rarely contribute to early osteoarthritis in the hip or knee joints due to altered biomechanics.^[1] In non-idiopathic instances, pigeon toe can signal underlying neuromuscular disorders, such as cerebral palsy, which accounts for a small fraction of cases overall given the rarity of these conditions.^[1] Early intervention, including observation, physical therapy, or surgery in severe persistent cases, significantly reduces the likelihood of these complications by promoting natural correction and addressing biomechanical imbalances.^[5] Persistent intoeing may also raise cosmetic concerns in adulthood, potentially leading to self-consciousness during social or physical activities.^[1] Studies note associated psychological impacts, including emotional strain from peer perceptions in school-aged children with noticeable gait deviations.^[3]

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In-toeing gait in children is a common cause for parental concern. 30% of children in-toe at the age of 4 years but the condition persists in only 4% of adults.
[48]
Proximal femoral derotation osteotomy for idiopathic excessive ...
Jul 4, 2017 · Mean femoral anteversion angle was 40.8° (28°–53°). External rotation of extended hips improved significantly, from 30° to 51.8° (p < 0.0001).