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Intoeing, Pandis Vasilios, Consultant Orthopaedic Surgeon, Corfu

Your child walks with his/her feet turned in or intoed. Some call this hen toeing or pigeon toeing. The problem appears to be in the feet but careful examination reveals that the whole leg, not just the foot, is turned in the way. The in-turning is at the hip. This may also give the appearance of knock- knees.

Many intoers seem rather clumsy and fall a lot. Intoers commonly have loose joints or "ligamentous laxity". It is easy to show by examination that the joints are loose and that the hips can be turned in more than out.


No. We know that one child in six is an intoer. It is more common than blue eyes or being left handed and no one would consider these conditions as a disease.


The loose ligaments mentioned above. The hip is a ball and socket joint. We don't know why, but every baby is born with its hips twisted to point partly forwards rather than directly in the way. Because the hip points partly forwards this allows it to be turned inward through a greater range than outward. When a child starts to walk the forward-pointing ball part of the hip is pressed up against the ligaments at the front of the joint. Pressure from these ligaments gradually corrects the forward twist of the hip, in the same way a brace corrects crooked teeth. However loose ligaments exert less pressure so children with loose joints correct the hip twist more slowly and less completely than the five out of six children with tight joints.


Yes and no. Some of the hip twist will correct over time, but most children will be able to turn their hip in more than out even as an adult. Indeed one or both parents will also be able to in-turn more than out since your child will almost certainly have inherited the tendency from them. Yet most parents would consider themselves normal.

Walking intoed is a habit. There is nothing to stop your child walking with their feet pointing forwards if they want to. It just happens to be easier to walk with the hip in the mid point of its range of movement than to one side. Many children improve with time to avoid being teased for walking intoed. However, they will tend to intoe when tired, not concentrating, running fast or when wearing heavy boots or shoes.


Many parents worry that their child is always falling and hurting itself. The in-turned foot may contribute to this but loose joints are also linked with clumsiness. Obviously children are always more clumsy than adults.

One reason for this is that the part of the brain which controls movement continues to develop up to age eight or so. This means that younger children do not have all the nerves necessary for movement control and are more likely to fall.

A second reason is that the way we tell where our bodies are positioned is by nerves in the ligaments, muscles and joints. As a child runs about and plays they program these nerves, rather like a computer, so they know exactly where each part of their body is at any one time. These nerves have to be re-programmed each time they grow. So when a child is growing they tend to be clumsier. Both of these apply to the intoer but, in addition, their loose ligaments mean that the messages going back to the brain are sloppier than are those in a child with tight ligaments. This explains why intoers are often more clumsy than other children.


This all sounds rather worrying but most intoers do not remain permanently clumsy. Indeed many intoers become above average sportsmen and women. Flexible joints are helpful for many sports. If you allow intoed children to run about, even if they fall a lot, they eventually develop more sensitive position-sense nerves than children who don't have to try so hard. The body does not accept second best if it can improve by extra practice. Eventually when these children stop growing, they find themselves at an advantage with more flexible joints and better position sense. This explains why many great athletes are intoers, as can be seen when they run fast. Indeed we think that the intoing gene may be positively selected because it is beneficial for the human race.


No. There have been several studies to see if physiotherapy or various shoe modifications will help correct intoing but none show any benefit beyond the normal improvement occurring anyway with age. Even Twisters that involve long steel rods from a waistband to the shoes do not help. Children forced to wear splints or special shoes are mercilessly teased, so these devices do more harm than good.


No. It is quite wrong to operate on a normal child. You wouldn't allow surgery for blue eyes or being left handed. Surgery can only correct intoing not the clumsiness. Surgery was done in bygone days but 15% (1 in 6) children had complications, occasionally even crippling the child. There has also been some worry that such surgery may predispose to early arthritis of the knee.


One thing you can do is to prevent your child from sitting splay-legged in the W shape. Many intoers do this. Sitting this way can slowly produce an outward twist of the shinbone, which not only looks ugly but also may cause problems later with knee pain. Once present, this twist can only be corrected by major and sometimes dangerous surgery. Sitting cross-legged or with the legs dangling down will prevent this problem.


Intoeing is a harmless normal variation that may be beneficial to the human race. Treatment cannot cure the intoeing but stopping your child from sitting splay-legged can prevent problems in the future.


10 Alexandras Avenue
49100 Corfu Greece

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