Intoeing Gait
Many parents are concerned if their child toes-in when walking. Generally, this represents a normal variant. However, your doctor will be assessing a number of factors when a child is brought in for an evaluation of this question. Various neurological conditions and congenital hip conditions can be associated with an abnormal gait (walking pattern). Once your child has been evaluated and it is determined that there are no other problems, an intoeing gait may be related to excessive inward twist of the femur (thigh), tibia (leg) , or foot segments of the lower limb. As with many physical characteristics, inheritance plays a role.

Thigh Segment
The most common cause of an intoeing gait, in an otherwise normal child, is excessive inward twist (torsion) of the femur, called femoral anteversion. Children with this form of intoeing will intoe more when they are tired. There is potential for the degree of torsion to diminish with time; the proximal femur will remodel up to age 6-7 years old and sometimes even into teenage years. There are no long term problems with excessive femoral anteversion. In young children, they may trip over their feet when walking or running. Special shoes have no effect on the femoral bone. There are no exercises for bone and no orthoses (braces) that can untwist the bone. Surgery can theoretically change the rotational alignment of the femur, though the risks often outweigh the benefits and this surgery is rarely recommended. Children who toe-in often sit on their feet with their legs in the shape of a “W”. While sitting on your feet does not cause abnormal inward twist of the bone, it may impair the normal process of derotation which occurs with age. Therefore, your child should be discouraged from sitting on their feet. A table and chair set may be helpful. The use of a chair while watching TV is also recommended. A booster chair for the dinner table is another suggestion which may be helpful.

Leg Segment
Intoeing may also be associated with abnormal inward twist (torsion) of the tibia. This is generally seen in very young children and represents a variant of normal. Children with internal tibial torsion will appear to be bow-legged when they walk. As with the femoral segment of the limb, the natural history of internal tibial torsion is resolution with time. Babies may sleep on their abdomen (stomach) with their feet tucked under them. This sleeping pattern generally does not persist as they become older. Most toddlers will remodel their tibias up to the age of 2-3 years. The same recommendations are made for the management of this segment of the limb as for the thigh and avoid an abnormal sitting posture.

Out-toeing may be seen when the tibia is externally rotated more than average. This pattern is also a variant of normal. As with the thigh segment of the limb, there is no “treatment” which can internally rotate the tibia except surgery. Again abnormal sitting can aggravate this problem.

Foot
Children may rarely intoe from a condition in the foot. Although more common 20 years ago, metatarsus adductus still occurs. The foot is shaped like the letter “C”. Generally, this is the result of position while in the uterus. If the foot is flexible, no treatment is necessary as the foot will straighten itself with normal muscle function. Occasionally, the foot will have a rigid deformity present. This type of problem may require the use of several casts to correct the abnormal curvature. There is a condition called “skewfoot” which has abnormal configuration of the bones in the foot. This may present with what appears to be a rigid metatarsus adductus deformity. Unfortunately, the diagnosis of this must await maturation of the foot as x-rays do not demonstrate this abnormality until the child is 3-4 years of age. We begin to suspect this condition if the foot does not respond to cast treatment.