In-toeing walking is sometimes seen in kids and can be a cause for concern for many parents. While most of these cases resolve on their own, there can be long-term implications if the condition does not improve. There are several different levels that the leg and foot can turn inward, and each have their own treatment needs.
Simply put, an in-toe pattern of walking is when the foot turns toward the other foot when standing and walking, instead of remaining straight ahead or slightly outward. In this position, a child can have fatigue when walking, can appear clumsy, can scuff their toes, and can trip easily. The shoes will also have abnormal wear patterns.
The main causes of in-toeing are abnormal rotation of the thigh bone (femur), abnormal rotation of the shin bone (tibia), abnormal inward angulation of the metatarsal bones on the feet, as well as a neuromuscular disease called cerebral palsy.
Abnormal femur rotation can be caused by an abnormal position in the womb while developing, but it can also be affected by certain sitting and sleeping positions. In this condition, both the feet and the kneecaps point inward. About 85-95% of these cases do spontaneously correct themselves by age 8, although one study found that the majority of cases that do correct themselves do so only because the rest of the leg changes to accommodate the deformity, as opposed to the actual thigh bone rotation becoming normal itself. This rotation can be corrected with splints and braces that force the tissue outward. Surgery to derotate the bone is needed if the deformity persists past 8 years of age, and this usually involves a procedure to cut and rotate the thigh bone back into a proper position.
Abnormal tibia rotation is the most common cause of in-toeing. In this condition, the knee caps face forward but the feet point inward. The legs may also be bowed. This rotation is caused by cramping in the womb during development. It resolves more than 95% of the time by the age of eight. It can be corrected with splints and braces early during growth, and surgery is sometimes indicated to derotate the bone if it does not improve.
Abnormal position of the long bones in the foot called metatarsals occurs in 1 out of 1000 births. It can develop due to abnormal position in the womb, genetic factors, growth arrest of the bone, an abnormally large muscle on the side of the foot, abnormal tendon positioning, as well as belly sleeping after birth. About 85-90% of these cases resolve by one year of age, although 4-5% can persist into adulthood. This condition is called metatarsus adductus, and results in a c-shaped foot that has a concave inner side with a crease, as well as a convex outer side. This deformity can be treated with stretching, manipulation, and casting, as well as splinting, bracing, and specially pointed shoes. Surgery is performed if these measures do not correct the deformity, and the specific procedure depends on the age of the child. Children ages 2-6 can simply have soft tissue procedures that help the foot stretch into a proper position, while older children require a procedure to actually move the metatarsal bones back into a proper position.
Cerebral palsy is a brain disease that affects neurological and muscular function. It is actually a group of many different conditions that can result in abnormal movement, limb position, sensation, and cognitive impairment. There is no known cure, although limb deformities can be treated with braces or surgery.
In-toe walking, in general, is not uncommon among foot and leg deformities, but fortunately, most cases do resolve on their own. However, uncorrected or under-corrected cases can pose a risk for chronic leg strain and fatigue later in life. A simple exam by your podiatrist can identify the root cause of the abnormal rotation and can identify whether any further treatment is required.