May 30, 2024

In-toeing gait is usually attributed to metatarsal adductus (in infants), internal tibial torsion (in toddlers), and femoral ante version (in children <10 years)

The child walks with foot will turn inwards instead of pointing straight ahead


  1. Excessive femoral anteversion
  2. Internal tibial torsion
  3. Metatarsal adductus

Excessive femoral anteversion:

The angle between the neck of the femur and shaft in the sagittal plane internally rotated

The commonest cause of in-toeing is between 3-8 years

The angle is about 40° at birth and decreases when the child starts walking.

In a disease that affects a child’s ability to walk, the child continues to have a high angle of anteversion

It reaches normal (about 17°) by age of 8 years.

Clinical Features

  • May presents with apparent genu valgum, may lead to patellofemoral problems
  • W position upon sitting
  • Patella is facing inward (During gait)
  • Awkard running style and frequent falls
  • The examination will show that hip IR exceeds hip ER
    • IR > 70° (n=20°-60°)
    • ER <20° (n=30°-60°)

Child with this problem classically sits with legs in ‘W’ shape

Anteversion degree


  • No treatment required
  • Usually resolved spontaneously around the age of 8
  • Brace and orthotics don’t change the natural history of the disease

Femoral derotational osteotomy (rarely needed): If the condition does not improve by age of 9. ( Not functional but for cosmesis)

Internal Tibial Torsion

Inward rotation of the shaft of the tibia

Most common cause of in-toeing

Normal finding in the newborn: due to intrauterine position

The commonest cause of in-toeing gait:- Usually seen in infants, aged 2-3

Diagnosed by a negative femoral thigh angle > 15° (n=0,+20)

> 15 ° transmalleolar angle

Internal rotation of tibia causes pigeon-toed gait


  • No treatment is required , patient reassurances
  • Usually resolves spontaneously around the age of 6
  • Bracing and orthotics don’t change the natural history of the disease
  • If the condition does not improve by the age of 8 (Supramalleolar derotational osteotomy)

Metatarsal adductus

Adduction and inward rotation of the forefoot (tarsometatarsal joint) in relation to the hindfoot

Usually seen in 1st year of life


Heel bisector method (Beck, 1983)

NormalHeel bisector angle through 2/3 toe web space
Mild Heel bisector angle through 3 toe
ModerateHeel bisector angle through 3/4 toe web space
SevereHeel bisector angle through 4/5 toe web space

Clinical Features

The foot has a curved lateral border rather than the straight one

It May be associated with other conditions related to uterine malposition (DDH and torticollis)

In-toeing gait


  • Most infants will improve without interference
  • Observation is recommended in the first 6 months of life with stretching exercises
  • If the condition persists beyond 6 months and the deformity is rigid, serial casting or bracing may be required
  • Surgery is rarely indicated
    • Lateral column shortening and medial column lengthening if patient older than 5 years old (mixed result)