One of the most common reasons for referral to pediatric orthopedics is related to angular deformity and variations of the lower limb. Most the children, when they start to walk have a tendency to walk with their feet pointing inwards, commonly known as pigeon-toed gait or intoeing in children. Many children may continue to walk with similar gait patterns well in their teenage years.
The medical terminology of this type of gait pattern is intoning and is caused by rotational variation anywhere in the lower extremity causing the foot to point inwards.
Should I be concerned about intoeing in children?
Children go through various stages of development during their growth areas that cause a variety of changes in the alignment of their lower limbs. It may be helpful to be familiar with the normal growth and development of the child’s lower extremities.
Children are usually born with the tendency of their lower limbs to point inwards. Newborns have their thigh bone facing forwards causing a natural tendency of the hips to be rotated inwards, this slowly decreases over time as the child grows, even the lower leg bones have an inherent bowing inwards which straightens out over time. As such mentoring can be considered as a part of the normal development of the child.
What are the different reasons for intoeing in children?
There are 3 main contributory factors of intoeing in children affecting different parts of the lower limb and these are mainly determined by the age of the child.
Age 18 months and younger: The most common condition in children younger than 18 months is metatarsus adductus, it may be noted more in girls than boys and is attributed to the position of the baby in the womb of the mother.
In the metatarsus adductus, the forefoot is pointing inwards making the foot appear bean-shaped. If the outer edge of the foot is carefully observed it may appear C-shaped.
Age 18 months to 3 years: The tibia is normally internally rotated at birth, a term called internal tibial torsion but this angulation varies greatly. Internal tibial torsion is most frequently bilateral and may be present with other causes of intoing. The child’s kneecap may be noticed to be facing outwards whereas while seated the child may be noticed to have an inwards bowing of the lower legs.
Age 3-8 years: The position of the thigh bone is the 3rd most common cause of intoeing in children, although the condition may be present in infancy it is more pronounced after the age of 3 with the average age of diagnosis being around 3-6 years.
At birth, the upper portion of the thigh bone is internally rotated to around 40 degrees and as the child matures it derogates to around 15 degrees.
What to expect for intoeing in children?
Parents should be reassured that the bulk of the causes of intoeing in children are secondary to conditions that resolve over time and that the majority of the cases are managed by observation.
Metatarsus adductus usually resolves by the age of 2 years and any presence is not associated with any residual dysfunction.
Tibial torsion spontaneously resolves by the age of 5 years and it is uncommon to develop any chronic issues even in case of persistence. In rare cases, it may be of cosmetic concern or may cause functional disability, a surgical procedure that involves cutting the bone and rotating it to a straighter plane.
The natural course of femoral anteversion is also spontaneous resolution by the age of 11 years.
What can I do to improve my child’s pigeon gait?
It is important to have supportive shoes, and proper sitting and sleeping posture should be encouraged which involves avoiding sitting in a W- W-shaped manner which hinders the natural. the course of femoral anteversion, the child instead should be encouraged to sit in a crisscross pattern.
While sleeping it is best to avoid lying on your tummy with hips and knees bent(the natural womb position of the baby).
When to seek medical advice?
If the child reaches the age where they would have outgrown tibial torsion or femoral anteversion and are limiting the child’s function then surgical correction may be an option though it should be kept in mind that even presistence of this pattern of gait type may be quite normal.
On rare occasions intoeing in children may be secondary to pathological abnormality such as club foot, cerebral palsy, or spina bifida.