In-toeing (pigeon toes) in children: what's normal at each age, and when to see a GP

What in-toeing is

In-toeing (intoeing, pigeon toes, or being pigeon-toed) means a child's feet point inwards when they walk or run. The Association of Paediatric Chartered Physiotherapists (APCP) calls it one of the most common normal variants in children. It's usually in both feet but can be in one, and it looks more obvious when a child is tired or has very flexible joints.

The British Society for Children's Orthopaedic Surgery (BSCOS) says it can be present at birth or develop in young children, and parents often first notice it when a baby starts walking.

Sources 1, 2, 3

The three causes, by ageStrong evidence

Babies: metatarsus adductus. The front half of the foot curves inwards, so the outer edge looks like a half-moon, while the heel looks normal. It's thought to come from the baby's position in the womb.

Toddlers: internal tibial torsion. The shin bone is twisted inwards, so the feet turn in while the kneecaps point forwards. It's the usual cause in a child's second year.

School-age children, about 3 to 10: femoral anteversion. The thigh bone is twisted inwards at the hip, so the knees and the feet both point in. These children can turn their hips inwards a long way, and often find sitting in a W comfortable.

A child can have more than one, and all three can run in families. The APCP leaflet adds that tight hamstrings, or slightly weaker muscles on the outside of the hip that turn the leg out, can add to it. Clubfoot is different: a stiffer foot shape present at birth, treated from birth by a specialist team.

Sources 4, 5, 3, 1, 6, 7

How common it isMixed evidence

Figures depend on age and on how in-toeing is defined. In a survey of 1,134 children aged 3 to 6 in 26 nursery schools, 5.9% in-toed: 76% of them in both feet, with 2.4 girls to every boy, and 75% from the thigh bone and 25% from the shin. An NHS referral guide quotes up to 30% of children under 6.

For curved baby feet, one review gives 1 to 2 in every 1,000 births, and a later paper about 1 in 100 babies.

Sources 8, 9, 10, 11

How it's checked

A doctor or physiotherapist watches your child walk. Then, with your child lying on their front, they check how far each hip turns in and out, the angle of the foot against the thigh, and the shape of the foot: together, the rotational profile.

In a study of 1,000 normal legs, the inward twists of toddlers' shins and young children's thighs were the extremes of a normal developmental pattern, and in the vast majority needed no treatment. X-rays are rarely needed; one children's health site says doctors sometimes order them if they notice a problem.

Sources 4, 12, 13

What's normal at each ageEmerging evidence

Sources give different ages, so these are ranges, with who says what.

Curved baby feet: most straighten within the first year. The American Academy of Orthopaedic Surgeons (AAOS) says usually over the first 4 to 6 months, the American Academy of Pediatrics (AAP) before the first birthday, and an NHS referral guide by about 1; NHS leaflets say most improve by about 2 or 3. In 130 untreated curved feet followed for about 7 years, 86% were normal or only mildly curved and fully flexible, 10% were moderately curved but painless, and 4% stayed curved and stiff. The stiff ones couldn't be picked out before about 3.

A twisted shin bone: NHS leaflets and guides give different ages for when it usually corrects: by about 4 to 5 (the APCP leaflet), by 5 (an NHS referral guide), by 6 (Lincolnshire's leaflet) or by about 8 (the West Suffolk and East Sussex leaflets). AAOS says it almost always improves without treatment, usually before school age.

A twisted thigh bone: most noticeable at about 4 to 7 in the referral guide, at 5 or 6 for AAOS, and at 2 to 4 in the APCP leaflet. It usually corrects by about 8 (in 80% of children, the referral guide says), 10 (the APCP, West Suffolk and East Sussex leaflets) or 12 (Lincolnshire's). In a study that followed 30 in-toeing children to at least 15, the thigh bone's inward twist fell from an average of 42° to 28°, about 1.5° a year with a wide range, and the in-toeing went in all but 5.

BSCOS sums it up: in the vast majority of children younger than 10, in-toeing will almost always correct itself without casts, braces, special shoes, surgery or any special treatment, and where it doesn't, it very rarely causes symptoms. In-toeing can last into adult life, but rarely seems to cause major problems, a children's hospital says.

Sources 3, 5, 9, 14, 6, 15, 16, 1, 17, 2, 4

What in-toeing does and doesn't doEmerging evidence

In-toeing by itself doesn't cause pain, doesn't stop a child learning to walk, run and play, and doesn't lead to arthritis, AAOS and BSCOS say. In a small study using computed tomography (CT) scans, the thigh bone's twist was no different in 16 people with hip arthritis and 18 without. The APCP leaflet says children who in-toe are no more likely than anyone else to have back or hip problems or arthritis.

Children who in-toe may trip a little more at first, and this lessens as they grow. NHS Lothian's GP guidance says the tripping comes from the toes catching and is nothing to worry about, and the APCP leaflet says falling is part of learning to walk, not caused by in-toeing. In one blinded study of 100 school students, sprinters had more inward-turned shins on average than other students, and more of them in-toed when sprinting.

Sources 3, 2, 18, 1, 19, 20

When it isn't the usual kind, and look-alikes

In-toeing on one side, in-toeing with stiff or tight legs, late milestones, or in-toeing that appears suddenly needs checking for a nerve or muscle cause such as cerebral palsy: these are the signs NHS and children's hospital referral guides list. The NHS lists walking on tiptoes, stiff or floppy muscles and late sitting or walking among the possible signs of cerebral palsy.

Out-toeing (feet turning out) is also usually normal: new walkers often turn their feet out for balance, and an NHS children's hospital leaflet says both patterns are in most cases completely normal. But new out-toeing in an older child, especially with hip, thigh or knee pain, can be a slipped growth plate at the hip (a slipped upper femoral epiphysis), which has its own guide. Bow legs and knock knees have their own page, and flat feet that don't hurt have their own guide.

Sources 9, 4, 21, 22, 23

Time, and ordinary active playStrong evidence

UK and US children's orthopaedic bodies, NHS guidance and a children's hospital agree that in-toeing in young children needs no treatment beyond time. Children don't need their activities restricted, the APCP leaflet says.

The NHS asks children under 5 to be active for at least 3 hours a day, including an hour of energetic play for 3 and 4 year olds, and 5 to 18 year olds for an average of at least 60 minutes a day, with activities that strengthen muscles and bones across the week. Ordinary active play is the backbone of the plan below. It keeps children fit and confident, and it doesn't need to target the in-toeing.

Sources 2, 3, 5, 19, 4, 1, 24, 25

Shoes, insoles, braces, twister cables and night splints don't change itStrong evidence

There is no evidence that splints or special shoes help, and good quality, well-fitting shoes are all that's recommended, the APCP leaflet says. BSCOS says in-toeing corrects itself in the vast majority under 10 without casts, braces, special shoes, surgery or any special treatment.

The AAP says a night brace (shoes joined by a bar) hasn't proven effective, and that corrective shoes, twister cables, daytime braces, shoe inserts and back manipulation don't resolve in-toeing and may be harmful, because they interfere with normal play or walking; a child in a brace may also face unnecessary emotional strain from other children. KidsHealth says doctors found special shoes and braces didn't make in-toeing clear up any faster.

The trial evidence is old and thin. In 1976, wedges in children's shoes had no clinically useful effect on the walking angle, and the best device corrected only about a quarter of the in-toeing while it was worn. No modern trial exists.

Sources 1, 2, 5, 13, 26

Exercises and stretches can't untwist the bonesStrong evidence

NHS Lothian's GP guidance says insoles and exercises won't correct in-toeing, and neither will stretches. AAOS says splints, special shoes and exercise programmes don't help a twisted shin, and that studies have found special shoes, braces and exercises don't help a twisted thigh bone. The AAP lists exercises among the unprescribed treatments to avoid, and the West Suffolk and East Sussex leaflets say no specific exercises, braces or special shoes can correct a twisted shin or thigh bone.

Sources 19, 3, 5, 6, 15

What a physiotherapist may suggest for an older child who trips a lotEmerging evidence

The APCP leaflet, used by several NHS trusts, says tight hamstrings or slightly weaker hip muscles that turn the leg out can add to in-toeing; that a programme of stretches may help tight hamstrings; and that strengthening the hip muscles can help in some cases. It suggests out-toed activities (ballet, horse riding, martial arts, breaststroke swimming) and, as children get older, out-toed walking ('penguin walking') and walking along a straight line. One NHS trust's referral guide sends a child to physiotherapy for tripping and falling several times a day, weakness (for example, not being able to hold a bridge), in-toeing that starts suddenly or is on one side, or late milestones.

None of this has been tested in a trial, and none of it changes the bones: it's about how confidently a child moves. The doses in stage 2 are editorial.

Sources 1, 15, 27, 9

W-sitting: no harm shownEmerging evidence

Children with a twisted thigh bone often find sitting in a W comfortable, because their hips turn inwards easily. A 2024 systematic review found 7 studies, all of low level: two surveys that couldn't show cause and effect, a muscle study in adults, a narrative review, and one cohort that found no link with hip dysplasia. It concluded there is no scientific evidence to advise against W-sitting in children. That cohort, of 104 children having hip X-rays, found hip dysplasia in 9% of W-sitters and 10% of other children. A nursery-school survey found W-sitting more common in in-toeing children, but couldn't say which caused which.

BSCOS says W-sitting will cause no harm. Some NHS physiotherapy leaflets still suggest encouraging cross-legged sitting instead, if it's comfortable, one NHS referral guide advises avoiding the W, and one leaflet says there's no evidence it's harmful but it might be wise to avoid it. The evidence is thin, but none of it shows harm, so this guide says: let your child sit however is comfortable. Cross-legged sitting is one option among many, and it never needs to be a battle.

Sources 28, 29, 8, 3, 2, 1, 6, 9

Curved baby feet (metatarsus adductus)Emerging evidence

Flexible curved feet: a systematic review found strong evidence for no treatment. In a randomised trial of 94 newborn feet, parents' stretching did no better than watching and waiting, and tended to do worse in moderate to severe feet; the authors recommend watching to 4 to 6 months and casting curves that persist. Some NHS leaflets still say gentle stretches or exercise may help: harmless if gentle, but not needed.

Stiff or persistent curved feet: the AAP describes a series of casts over 3 to 6 weeks if the curve persists after 6 months or is rigid, aiming to correct it before walking. AAOS says babies of 6 to 9 months with severe or very rigid feet may be treated with casts or special shoes with a high rate of success, and that surgery is rarely needed. A review of 11 studies found casts, braces and special shoes can all correct the curve, with fewer complications from some braces and shoes; in one series, an orthosis worn 23 hours a day improved 98 of 114 moderately to severely curved feet in babies aged 4 to 11 months. One NHS trust refers a foot that can't be gently corrected to straight, or isn't corrected by 12 months, to orthopaedics.

Sources 10, 30, 14, 6, 5, 3, 31, 11, 9

Surgery: very rarelyStrong evidence

Surgery is considered only for severe in-toeing still causing tripping and walking problems in an older child: at least 8 to 10 for a twisted shin and over 9 or 10 for a twisted thigh bone, AAOS says, and the AAP mentions it if in-toeing remains at 9 or 10. BSCOS calls it an enormous operation that is virtually never required. The operation cuts the bone and turns it.

The complication figures come from older series. Of 95 children who had a thigh-bone operation, all the bones healed and the twist was corrected, but 13 had serious complications, and the authors advised a much more conservative attitude; in the 52 followed for 9 years, the operation did remove the in-toeing. Of 52 shin-bone operations, 13% of those done high on the shin had serious complications, against none of those done near the ankle.

Sources 2, 3, 5, 32, 33, 34

Checking a baby's curved foot (written steps)

From the AAP, AAOS, the NHS clubfoot page, an NHS referral guide and a trial, with our suggestion marked.

• 1. Look at the sole. In metatarsus adductus the front half of the foot turns in and the outer edge curves like a half-moon, while the heel looks normal.
• 2. Gently hold the heel and see whether the front of the foot straightens. A foot that straightens easily is flexible, and most of these straighten by themselves, usually within the first year.
• 3. A foot that is stiff, can't be straightened, also points down, or feels tight when you gently move it: show your health visitor or GP. Clubfoot, a different and stiffer foot shape, is treated from birth by a specialist team.
• 4. If the curve is still there at about 6 months, or the foot is stiff, a specialist may use a series of casts over 3 to 6 weeks, or special shoes, ideally before your baby walks. One NHS referral guide refers a curved foot that isn't corrected by 12 months.
• 5. Stretches: in a randomised trial of 94 newborn feet, parents' stretches did no better than watching and waiting. If your health visitor or physiotherapist shows you one, keep it gentle and stop if your baby is unsettled (our suggestion).

Sources 5, 3, 7, 9, 30

Watching it change (written steps)

KidsHealth suggests a short video once or twice a year, because change is slow and hard to notice. The details are our suggestions.

• 1. Once or twice a year, film your child walking towards you and away from you on a flat floor. Shorts and 10 to 20 steps make it easier to see (our suggestion).
• 2. Compare each video with the last one rather than watching day to day: change is slow and hard to notice.
• 3. Take the videos to your GP if the in-toeing seems to be getting worse or is on one side only (our suggestion).

Source 13

Sitting, shoes and play (written steps)

From BSCOS, the APCP leaflet and the AAP, with our suggestions marked.

• 1. Let your child sit however is comfortable, including in a W: the British Society for Children's Orthopaedic Surgery says it will cause no harm. If you'd like to offer other positions, the physiotherapists' leaflet suggests cross-legged sitting if it's comfortable; long-sitting and side-sitting are fine too (our suggestion).
• 2. Ordinary, good quality, well-fitting shoes. No special shoes, inserts, wedges, twister cables or night braces.
• 3. No activity needs restricting. Ballet, horse riding, martial arts and breaststroke swimming are good fun, and the physiotherapists' leaflet says they may help an in-toeing walk.
• 4. Try not to keep correcting how your child walks. The American Academy of Pediatrics warns that braces and other unproven treatments can get in the way of play and cause unnecessary emotional strain (our suggestion, from its advice).

Sources 2, 1, 5