• See Also
  1. Out-toeing
  2. Medial Tibial Torsion
  3. Femoral Anteversion
  4. Metatarsus Adductus
  5. Pediatric Leg Disorder
  6. Pediatric Limp
  7. Gait Evaluation in Children
  • Definitions
  1. In-Toeing (Pigeon-Toed)
    1. Foot Internal rotation (long axis) relative to the line of progression (movement when walking)
  • Epidemiology
  1. Common finding in age <6 years (up to 25 to 30% of children)
    1. Most cases are benign in this age group (80 to 95%)
  • Differential Diagnosis
  1. Intoeing encases several underlying leg abnormalities
  2. Intoeing may occur at any level down leg kinetic chain
    1. Hip: Medial Femoral Torsion (Femoral Anteversion)
    2. Leg: Medial Tibial Torsion (Internal Tibial Torsion)
    3. Foot: Metatarsus Adductus
  3. Intoeing causes by age (most common causes)
    1. Infant (age <1 year): Metatarsus Adductus
    2. Toddler (age 1 to 3 years): Internal Tibial Torsion
    3. Child (age 3 to 6 years): Femoral Anteversion (usually bilateral)
  • Approach
  1. Step 1: Evaluate gait and rotational profile (Torsional Profile)
    1. See Foot Progression Angle (Gait Rotational Angle)
    2. Confirm In-Toeing with Out-toeing
    3. Level of abnormality may be apparent by gait
  2. Step 2: Evaluate hip rotation
    1. See Hip Rotation Evaluation in Children
    2. Limited lateral hip rotation (less than -10 to 20)
      1. Medial Femoral Torsion
  3. Step 3: Evaluate Thigh to Foot Angle
    1. Negative angle suggests Medial Tibial Torsion
  4. Step 4: Evaluate for foot deformity
    1. Curved foot suggests Metatarsus Adductus
  5. Step 5: Evaluate for toe deformity
    1. Great toe abducted suggests searching toe
  • Management
  1. Foot rotation changes overtime as bone grows (up to age 10 to 15 years)
  2. Age <6 years
    1. Intoeing is present in up to 30% of children age <6 years and benign in up to 95% of cases
    2. No referral needed if symmetric and painless (reassure parents)
  3. Referral Indications
    1. Asymmetric or painful findings
    2. Age >6 years with angulation >2 SD from normal
  • References
  1. Schmale (2003) AAFP Board Review, Seattle
  2. Baird (2025) Am Fam Physician 111(2): 125-39 [PubMed]
  3. Rerucha (2017) Am Fam Physician 96(4): 226-33 [PubMed]