What Is It?

The dictionary defines “pigeon-toed” as “having the toes turned inward.” No such colorful term can be found for feet that point outward. These foot problems can be caused by a problem that doctors call torsional deformities. This is when the long bones of the leg are turned to the inside or outside so that the toes of the feet do not point straight ahead. Either of the two main bones in the leg can be affected — the femur (between the hip and the knee) or the tibia (the larger of the two bones between the knee and the ankle). One or both legs can be affected.

Torsional deformities can lead to toes that point inward (in-toeing) or toes that point outward (out-toeing). Parents often worry that in-toeing or out-toeing will permanently interfere with their child’s ability to walk and run normally. However, in most young children, in-toeing or out-toeing is caused by a torsional deformity that appears for a short period of time, and then disappears during the normal stages of leg development. Most torsional deformities are temporary, and correct themselves by age 6 to 8. In rare cases, in-toeing or out-toeing is a sign of a permanent bone deformity or other problem that requires medical attention.

These conditions may be related to one or more of the following factors:

• The child’s position in the uterus before birth
• An inherited family tendency for in-toeing or out-toeing
• Sitting or sleeping in certain positions for prolonged periods, for example, during long hours of watching television

The most common type of torsional deformity in toddlers is when the tibia (in the lower leg) is rotated inward, leading to in-toeing. This is caused by the child’s position in the uterus before birth, and usually is seen in children younger than 2. As the body works to correct this problem during development, the tibia sometimes can turn too far in the opposite direction and become rotated outward. This can cause out-toeing, but the condition usually is temporary and will go away as the child develops.

The most common cause of in-toeing in older children is when the femur (in the upper leg) is rotated inward. This is more common in girls than boys, and usually is seen in children 3 to 6 years old. In most cases, the cause is unknown. Some experts believe that it is an inborn problem related to a child’s position in the uterus before birth. Others blame it on a child’s position while sitting or sleeping. For example, children seem to be at higher risk of developing this problem if they frequently sit with their knees pointed forward and touching and their legs folded under, splayed to either side (in the “W” position). In rare cases, this condition is caused by neuromuscular disorders, such as cerebral palsy.

Out-toeing due to an abnormal outward rotation of the femur is uncommon. The cause of this condition is unknown, but it probably is related to positioning of the legs before and after birth, and usually affects both legs. In rare cases, out-toeing is seen in only one leg and may be a sign of a serious problem with the upper part of the femur bone called slipped capital femoral epiphysis (SCFE).

Childhood torsional deformities usually are painless. The child usually does not notice the problem, and it typically does not interfere with the child’s ability to walk, run and play normally.

The doctor will review your child’s symptoms, family history and medical history. The doctor may ask the following:

• When did you first notice that your child was in-toeing or out-toeing?
• Has the problem gotten worse? If so, over how long a period?
• Does your child seem to trip or fall more often than other children?
• Does the problem seem to be worse at the end of the day or after the child has been walking or running for long periods?
• How does your child usually sit while watching television or playing games?
• Has your child ever had any orthopedic or podiatric treatment for this condition?
• Has your child ever had a serious traumatic injury involving the foot or leg, or has your child ever had surgery involving these areas?
• Did the child’s parents, grandparents or siblings ever have a similar in-toeing or out-toeing problem?

Then the doctor will examine your child, looking at:

• Your child’s legs and feet — The doctor will begin by evaluating the flexibility and range of motion of your child’s legs and feet, then feel for any tenderness or bony abnormalities and inspect the arch and general shape of the foot. Finally, the doctor will ask your child to lie on his or her belly with the knees bent. This position allows the doctor to evaluate the angles between various parts of your child’s feet and legs. By measuring these angles, the doctor will be able to determine which way the bones are rotating — inward or outward — and by how much (the degree of rotation).



• The way your child runs — Torsion problems often are more obvious during running.



• Your child’s shoes — Areas of excessive wear on shoes can provide clues about how the child is walking and abnormal bone alignment.

In most cases, the doctor can make a final diagnosis based on your child’s age and history, together with the results of a thorough physical examination. X-rays usually are not necessary.

Almost all torsional deformities are short-term conditions that go away before a child reaches adulthood. For example, inward rotation of the tibia usually disappears by the time a child is 3 or 4 years old, and inward rotation of the femur usually goes away before age 10.

Most cases of torsional deformity represent predictable stages of development and cannot be prevented. However, in some cases, sitting or sleeping in certain positions may worsen these problems. Your doctor may have suggestions regarding exercises or positions that may help to minimize any torsion.

In most cases, doctors do not treat torsional deformities because these conditions usually disappear as children grow older. In very rare cases, when in-toeing or out-toeing is caused by a bone deformity, surgery may be necessary to correct the problem.

Call your pediatrician or family doctor if you have any concerns about the way your child walks or runs, especially if your child seems to trip or fall more often than other children of the same age.

The outlook is excellent. The majority of torsional deformities go away before adolescence.

Diseases and Conditions Center

All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.