Believe it or not, it’s a pretty common issue. Being pigeon toed or In-toeing during gait commonly begins during childhood and may continue into adult life if not addressed appropriately. There are a number of anatomical, physiological and biomechanical factors which may contribute to the visual appearance of an intoed foot. Additionally, being 
“pigeon toed” does not necessarily lead to injury or pain and this is why it may go untreated in some children and follow them into adulthood. That being said being able to educate a patient about the potential risks and benefits is an important factor in developing a management plan for the presenting complaint.
Although neurological conditions should not be completely ruled out, people who in-toe are commonly identified to have one of the three following conditions;
Internal Femoral Torsion: is where the thigh bone rotates inwards which then continued throughout the rest of the lower leg. The condition is common among young children and in most cases will correct itself however, exercises, much of which are designed to be a part of play can be used in an attempt to speed up the recovery from the pathology. Additionally, specialized shoes or orthotics can be used in an attempt to alter gait.
Internal Tibial Torsion: is where the “shin bone” rotates between the knee and ankle joint leading to inward turning of the foot. The condition commonly corrects itself without treatment by ten years of age.
Metatarsus Adductus: is the curving of the foot inwards as opposed to the naturally straight position. It is believed that this in-ward curving of the foot occurs as a result of the position of the child in the uterus. The condition is commonly treated with gentle massage but does sometimes require the use of casting to straighten the foot.
Pelvic Control: with an increased sedentary lifestyle becoming the norm, pelvic control and stability are quickly becoming a common cause of in-toeing in adults. From the day we begin kindergarten we are taught to be in a seated position (legs crossed) which can increase laxity within the ligaments of the hips. Additionally, as we move through school and then enter the work force, remaining seated becomes a significant part of life, reducing activation ability of the gluteal muscles.
Specific rehabilitation exercises can be used to develop activation, control and motor patterns of the gluteal muscles responsible for extension and external rotation of the hip.
Molloy, et al (2015) found that during unsuspected movement tasks a greater hip external-rotator strength lead to reduced frontal plane hip excursion and transverse plane knee excursion in female soccer players. The article gives moderate support to the theory that external-rotator strength contributes to the dynamic control of the lower limb. However, to date very little evidence has fully supported the theory and therefore it remains just that, a theory.
Dependent on the reason for the in-toed gait a number of interventions can be put in place to address the issue. The use of in-shoe devices such as functional orthotics to address biomechanical contributors to the presenting gait complaint. Additionally, exercises or games which aim to increase activation, control and strength of external rotators of the hips can be beneficial if the complaint is believed to be of proximal origin. In many cases it is not enough to address the issue from one place and a multidisciplinary approach is recommended.
Until Next Time,
Jackson McCosker
Director/ Chief Editor
REFERENCES
Malloy, P., Morgan, A., Meinerz, C., Geiser, C., & Kipp, K. (2015). Hip External Rotator Strength Is Associated With Better Dynamic Control Of The Lower Extremity During Landing Tasks. Journal Of Strength And Conditioning Research, 282 – 291.
Wegener, C., Hunt, A., Vanwanseele, B., Burns, J., & Rm, S. (2011). Effect Of Children’s Shoes On Gait: A Systematic Review And Meta-Analysis. Journal Of Foot And Ankle Research, 1 – 11.
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