Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What Is In-Toeing?

In-toeing — commonly called “pigeon toed” — refers to a gait pattern where a child’s feet point inward rather than straight ahead during walking. It’s one of the most common reasons parents bring children to podiatrists and orthopedists, and it causes significant parental anxiety. The good news: the vast majority of in-toeing in children is normal, resolves without treatment, and requires only observation.

At Balance Foot & Ankle in Howell and Bloomfield Township, we evaluate children with in-toeing frequently. Understanding the three distinct anatomical causes helps clarify which children need intervention and which simply need time to develop.

Three Anatomical Causes of In-Toeing

In-toeing can originate from three different levels of the lower extremity, each with a different natural history and treatment approach.

Metatarsus adductus is a forefoot deformity present at birth where the front of the foot curves inward. The hindfoot and ankle are normal. In most cases it resolves spontaneously during the first 2 years of life. If the foot is flexible (can be passively corrected to neutral), observation is appropriate. Rigid metatarsus adductus may require serial casting in infancy.

Internal tibial torsion involves inward twisting of the tibia (shin bone). It’s the most common cause of in-toeing between ages 1–3 years. As children begin walking, internal tibial torsion causes their feet to point inward. The vast majority resolves spontaneously by age 6–8. Braces and special shoes have not been shown to accelerate resolution and are no longer routinely recommended.

Femoral anteversion (medial femoral torsion) is the most common cause of in-toeing in children ages 3–8. The femur is angled excessively forward, turning the knees and feet inward. Affected children often prefer to sit in a “W” position on the floor. Resolution occurs spontaneously through normal bone remodeling in the vast majority — by age 8–10 most children have completely normal gait. Femoral anteversion requiring surgical derotational osteotomy is very rare.

When to Seek Evaluation

Evaluation is appropriate when: in-toeing is severe or worsening rather than improving with age; there is a family history of persistent deformity requiring treatment; the child is tripping and falling significantly more than peers; symptoms are painful or causing functional limitation; or the deformity is present on only one side (asymmetric presentation warrants closer evaluation to rule out neurological cause).

What We Assess in the Office

Our evaluation includes measurement of the foot progression angle during walking, thigh-foot angle (assessing tibial torsion), hip internal and external rotation range of motion (assessing femoral version), and examination of the foot itself for metatarsus adductus or tarsal coalition. Gait analysis is performed by observing the child walking from the front, back, and side.

The Role of Orthotics and Footwear

For most types of in-toeing, orthotics and special shoes do not change the natural history of the deformity — they simply represent the appearance of treatment without the substance. However, if flat feet are contributing to the in-toeing presentation, arch-supporting orthotics can improve gait efficiency and reduce foot fatigue. We discuss this distinction honestly with families.

Reassurance Is Often the Best Medicine

Many families arrive having worried about their child’s in-toeing for months or years. Most leave with significant reassurance after understanding the normal natural history. If your child has in-toeing and you’re concerned, contact Balance Foot & Ankle for a comprehensive evaluation — we’ll give you an honest assessment and a clear plan.

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Balance Foot & Ankle — Howell & Bloomfield Township, MI

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Worried About Your Childs In-Toeing or Pigeon-Toed Walking?

In-toeing (pigeon-toed walking) is common in young children and usually resolves naturally. However, persistent or severe in-toeing may indicate metatarsus adductus, tibial torsion, or femoral anteversion that benefits from podiatric evaluation to ensure proper development.

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Clinical References

1. Staheli LT. Rotational problems in children. Journal of Bone and Joint Surgery. 1993;75(6):939-949.
2. Lincoln TL, Suen PW. Common rotational variations in children. Journal of the American Academy of Orthopaedic Surgeons. 2003;11(5):312-320.
3. Sass P, Hassan G. Lower extremity abnormalities in children. American Family Physician. 2003;68(3):461-468.