What is in-toeing (pigeon toes) in children?
In-toeing — commonly called pigeon toes — is one of the most frequent gait concerns we see in our paediatric clinic: one or both feet point toward the midline when a child walks. Vivian Chen, Canadian Certified Pedorthist, C. Ped (C), at ROKAB Pedorthic Clinic explains it from a biomechanics perspective: in-toeing is not a problem with the toes themselves, but with lower-limb alignment. The toes are simply where it shows up — the cause may be in the forefoot, the lower leg, or the thigh, and it needs to be located by age and examination.
Three causes of in-toeing in children, by age
There are three common causes of in-toeing, and each is typical at a different age.
Metatarsus adductus is the most common cause in infants. The heel is in a normal position but the forefoot curves inward, giving the outer border of the foot a bowed shape. It is most commonly identified in infancy and usually resolves on its own as the baby grows [1].
Internal tibial torsion is the most common cause of in-toeing in toddlers. The foot itself looks normal, but the toes turn in while the knees still point forward. It usually improves with growth [1].
Increased femoral anteversion is the most common cause of in-toeing in children aged 3–8, and the most common cause overall. These children often sit in a W position, and the in-toeing becomes more noticeable when they run or get tired. Femoral anteversion can reach 40 degrees in newborns and decreases to about 15 degrees in young adulthood; most cases resolve spontaneously by age 8 [1].
So the same in-toeing can have a different cause at a different age: under 1 year, look first at the forefoot; ages 1–3, look at the lower leg; after age 3, look at the thigh and sitting posture. Looking only at the toes is how the location gets missed.
How biomechanics connects the hip, knee and foot
How biomechanics connects the hip, knee and foot is the key to understanding in-toeing. Walking direction is set by the foot progression angle — the angle between the foot and the direction of travel — and that angle is the sum of rotation at the hip, the tibia and the foot [1]. When the femur is excessively anteverted, the whole limb rotates inward: the hip turns in, the kneecap faces inward, and the foot follows, so the toes point toward the midline. That is why the knees and the toes should be checked together — they reveal where in the chain the rotation sits.
The same chain explains two things parents often notice. First, W-sitting: children with increased femoral anteversion often prefer sitting with their knees forward and lower legs splayed behind, because that position accommodates the inward hip rotation [1]. Second, tripping: with the foot turned in, the swinging foot crosses closer to the stance leg, so the child catches their own feet, especially when running or tired. Neither the W-sitting nor the tripping is a habit to be corrected by scolding — both follow from the alignment.
This is also why assessment looks at the whole limb rather than the foot alone: hip rotation range, tibial torsion, foot shape, gait and lower-limb alignment together locate the level of the problem, and that location decides what, if anything, needs to be done.
How to check in-toeing at home: two things to look for
When we assess in-toeing in clinic, we look at two things, and parents can watch for the same two at home.
First, whether the toes and the knees point in the same direction: with the child barefoot, standing and walking, watch from the front and behind — when the toes turn in, do the knees point forward or turn in as well, and do the kneecaps face inward? If the knees point forward and only the toes turn in, the cause is more likely in the forefoot or lower leg; if the knees turn in too and the child favours W-sitting, the thigh deserves closer attention.
Second, gait stability: does the child trip over their own feet often, fall more easily than peers when running, show worse in-toeing when tired, complain of foot or leg pain, or start avoiding walking and running? Like we do in our assessments, look at the whole picture rather than a single step.
When does in-toeing improve? What age is normal?
The natural history of in-toeing is generally reassuring. An expert summary from Practical Pediatrics notes that 30% of 6-year-olds have in-toeing, compared with fewer than 5% of adults, and that it gradually improves, usually by age 8–10 [2]. A 2026 review likewise found that the three most common causes — femoral anteversion, internal tibial torsion and metatarsus adductus — usually resolve on their own [1]. For younger children with no symptoms, symmetrical in-toeing and a mild presentation, observation with periodic review is usually the right approach; recording a short walking video every few months is more reliable than watching every day.
4 signs your pigeon-toed child should be assessed
Four situations warrant a timely assessment rather than continued waiting:
- In-toeing on one side only, or in-toeing that is getting worse.
- Frequent falls that already affect running and daily activities.
- A foot that cannot lie flat on the ground when walking, or pain.
- In-toeing that is still marked after age 8 with no sign of improvement.
Do in-toeing corrective shoes or orthotics work?
In these cases, we do not recommend buying a so-called corrective shoe first. The review states clearly that orthotics, wedges or special shoes do not alter the natural history of femoral anteversion [1] — for that type of in-toeing, a corrective shoe is not the answer. There is no single age by which in-toeing should be "corrected." Most children improve by age 8–10; if it remains marked after age 8, it should be assessed.
Whether a child needs custom orthotics or custom orthopaedic shoes is decided after assessment: at ROKAB, we combine the examination, gait analysis, joint range of motion, lower-limb alignment and 3D foot scanning to locate the cause before recommending a plan. Our in-toeing orthopaedic shoes and custom orthotics are designed one by one from assessment findings — not prescribed simply because in-toeing is present.
Whether a child needs custom orthotics or custom orthopaedic shoes is decided after assessment: at ROKAB, we combine the examination, gait analysis, joint range of motion, lower-limb alignment and 3D foot scanning to locate the cause before recommending a plan. Our in-toeing orthopaedic shoes and custom orthotics are designed one by one from assessment findings — not prescribed simply because in-toeing is present. Learn more about our custom orthotics and custom orthopaedic shoes, or book an appointment for a paediatric gait assessment.
Frequently asked questions about in-toeing
Is in-toeing normal in children?
Yes, in-toeing is common in childhood. About 30% of 6-year-olds walk pigeon-toed, and most improve on their own by age 8–10 [2].
At what age should in-toeing be corrected?
There is no single age by which in-toeing must be corrected. If it is still marked after age 8, or if any of the four signs above are present, it should be assessed.
Do orthotics help pigeon toes?
Orthotics and special shoes do not change the natural course of femoral anteversion, the most common cause of in-toeing [1]. Whether orthotics or orthopaedic shoes are appropriate depends on the cause found in assessment.
Why does my child keep tripping?
With the foot turned in, the swinging foot crosses closer to the stance leg, so the child catches their own feet — especially when running or tired. Frequent tripping that affects daily activities is one of the signs to get assessed.
Does W-sitting cause in-toeing?
W-sitting does not cause in-toeing. Children with increased femoral anteversion often prefer W-sitting because that position accommodates the inward hip rotation [1].
References
[1] Angular and Rotational Lower Limb Alignment Variations in Children: Practical Guidance for Paediatricians. Medicina, 2026, 62: 1499. DOI: 10.3390/medicina62081499.
[2] Reassurance, observation recommended for intoeing in children. MDedge, Practical Pediatrics.
This article is general health education and does not replace an in-person assessment, diagnosis or treatment recommendation for your child.