In-toeing means that a child's toes point inwards when walking or running [1][2]. It has three usual causes: a foot that curves inwards in babies, an inward twist of the shin bone in toddlers, and an inward twist of the thigh bone in older children [1][3]. In the vast majority of children younger than 8 it corrects by itself; special shoes, insoles, braces and exercises have not been shown to speed this up [1][2][3].
What is in-toeing and how do you recognise it?
In-toeing means that when a child walks or runs, the feet turn inwards instead of pointing straight ahead [1][2]. Parents most often notice it when the baby begins to walk; other members of the family may have it too [1][2].
In everyday speech, similar words are also used for a foot that rolls onto its inner edge with a flattened arch. This article is about the toes pointing inwards when walking; fallen arches are covered in the flat feet article in this guide.
If the foot itself is curved, its outer border is rounded [3]; if the twist is in the thigh bone, the knees as well as the feet point inwards [1]. In the usual forms the turn is mostly similar in both legs and does not limit movement [3].
What causes in-toeing?
The twist in the bones changes with growth: in a newborn the twist of the thigh bone can be as much as 40 degrees and it falls to about 15 degrees in young adulthood; the shin bone is also turned inwards in infancy and turns outwards by the age of 5 [3].
There are three usual causes; which one is involved can mostly be told from the child's age [1][3][4]:
- Infancy: the foot curves inwards from its middle part to the toes (metatarsus adductus)
- Ages 1–3: the shin bone is twisted inwards (tibial torsion); this is the most common cause at these ages
- Ages 3–6 and primary-school age: the thigh bone is twisted inwards (femoral anteversion); this is the most common cause overall
In-toeing in babies: a foot that curves inwards
The foot bends inwards from its middle part to the toes; in some babies it is mild and flexible, in others obvious and rigid [1]. It improves by itself most of the time, usually over the first 4 to 6 months of life [1].
Babies aged 6 to 9 months with a severe deformity or very rigid feet may be treated with casts or special shoes; the success rate is high and surgery is rarely required [1]. According to the Pediatric Orthopaedic Society of North America (POSNA), braces or casts may be recommended if the foot does not improve during the first year [2]. Severe cases may partly resemble a clubfoot; clubfoot, however, is a separate and more severe condition that requires treatment soon after birth [1].
At what age do children grow out of in-toeing?
According to the American Academy of Orthopaedic Surgeons (AAOS), in the vast majority of children younger than 8, in-toeing corrects itself without casts, braces or surgery [1]. The twist in the leg bones gradually untwists with growth; muscle control and balance also improve with age [2].
The twist in the shin bone almost always improves without treatment, and usually before school age [1]; according to one review it usually resolves by 3 to 4 years of age and rarely persists beyond 6 [5].
The twist in the thigh bone is often most obvious at about 5 or 6 years of age and corrects by itself in most children as they grow older [1]; this happens during the primary-school years, over many years, and most cases resolve by the age of 8 [2][3].
How does a doctor assess in-toeing?
For the vast majority of children a history and physical examination are enough [2]. The doctor asks about the birth, developmental milestones, when the in-toeing started and how it has changed, and pain [2][3].
The child is watched walking barefoot; then, with the child lying face down, the rotation of the hip, the angle between the thigh and the foot, and the shape of the foot are examined to tell whether the turn lies in the foot, the shin bone or the thigh bone [3]. Muscle tightness and coordination are also checked [2].
X-rays are not needed for most children; they are requested when another disorder is suspected, when there is no improvement, or when the turn affects one side only [3][4]. If the findings fit the child's age, follow-up at intervals of 6 to 12 months is sufficient [3].
Shoes, insoles, exercises and "W" sitting
Leaving aside the curved foot of infancy, none of the sources read recommends special shoes, insoles, braces or exercises for in-toeing. According to the AAOS, splints, special shoes and exercise programmes do not help in tibial torsion, and special shoes, braces and exercises do not help in femoral anteversion [1]. According to POSNA, studies have shown that in-toeing improves on its own and that shoes and braces did not make this happen any faster; nor does chiropractic manipulation [2].
According to one review, orthotics, shoe inserts and exercises have no proven effectiveness in the usual forms of in-toeing; orthotics and special shoes do not alter the natural course and may have negative psychological effects [3][4]. Other reviews likewise report that there is minimal evidence to support orthotics and braces and that physical therapy has not been proven effective [5][6].
There are small studies of insoles: in a randomised trial of 11 girls aged 7 to 10, a specially shaped insole or a shoe raised along its outer edge was followed after four weeks by a measured improvement in the angle between the foot and the direction of walking; the authors state that longer and larger studies are needed to reach a conclusion [7].
In "W" sitting the child sits with the knees bent and the feet out behind and to the sides; it is common in children with femoral anteversion [1][2]. This position does not cause the twist and there is no need to discourage it [5]; it has not been found to be associated with developmental dysplasia of the hip, and there is no scientific evidence that it leads to hip dislocation or loss of function [6].
What problems can in-toeing lead to?
According to the AAOS, in-toeing by itself does not cause pain and does not lead to arthritis [1]. According to the POSNA guide for doctors, femoral anteversion has not been found to be associated with osteoarthritis (degenerative joint disease) of the hip or knee, and an inward twist of the shin bone is not a risk factor for it either; femoral anteversion is, however, associated with knee pain, particularly together with an outward twist of the shin bone [4].
Most children with in-toeing learn to walk, run and play sports just like other children [2]. Many toddlers who in-toe also trip and fall often; POSNA explains this by the fact that muscle control, balance and coordination are not yet developed at this age [2]. Mild clumsiness is common with femoral anteversion [3].
In-toeing in adults is outside the scope of this article; the sources read contain no separate assessment or treatment advice for adults.
When is surgery considered for in-toeing in children?
Surgery is very rarely needed in children who have no other disorder; it may be considered if the twist is still present during the middle-school years and causes problems with tripping or walking [2].
According to the AAOS, surgery for the shin bone may be done in a child who is at least 8 to 10 years old and has a severe twist that causes significant walking problems; for the thigh bone it is usually not considered unless the child is older than 9 or 10 and has a severe deformity that causes tripping and an abnormal gait [1]. In the operation the bone is cut and rotated into the correct alignment [1][4]. Children with a nerve and muscle disorder such as cerebral palsy are more likely to need surgery [4].
When not to wait
In-toeing is most often a normal stage of growth; in the following situations, however, see a doctor without waiting [1][2][3]:
- There is pain, swelling or a limp
- The in-toeing affects one leg only
- It is increasing or the walking is getting worse
- There is no improvement by kindergarten age (the year before primary school)
- It appeared after the age of 8, or suddenly in adolescence
- Walking and other developmental milestones are delayed
- The hip is stiff, or in a baby the foot is too rigid to be straightened by hand
- It gets in the way of sport or everyday activities
Frequently asked questions
- Does in-toeing in children correct by itself?
- In most children, yes: in the vast majority of children younger than 8 it corrects by itself without casts, braces or surgery [1]. The improvement comes with growth, over years [2].
- Should I buy insoles or corrective shoes for in-toeing?
- For the usual in-toeing that comes from a twist in the bone, the sources do not recommend them: special shoes and braces do not make it improve faster [1][2], and insoles and orthotics have no proven effectiveness [3]. One small, short study measured a change in foot angle with insoles, but its authors state that larger studies are needed [7].
- Do exercises for in-toeing in children work?
- The AAOS reports that exercise programmes do not help [1]. According to reviews, exercises and physical therapy have likewise not been proven effective in the usual forms of in-toeing [3][6].
- How is in-toeing treated?
- In the usual forms, what is done is to follow the child's growth [2][3]. Casts or special shoes come into question for a baby with a severe or rigid curved foot, and surgery, rarely, for an older child with a severe twist that persists and disturbs walking [1].
- Does in-toeing cause arthritis or other problems later in life?
- In-toeing by itself does not cause pain and does not lead to arthritis [1]; most children walk, run and play sports like other children [2]. Femoral anteversion has been found to be associated with knee pain, particularly together with an outward twist of the shin bone [4].
This article is a general summary; diagnosis and treatment decisions are made by the doctor who examines you.
Sources
- Intoeing. American Academy of Orthopaedic Surgeons (OrthoInfo), n.d.. orthoinfo.org
- In-Toeing. Pediatric Orthopaedic Society of North America (POSNA OrthoKids), n.d.. orthokids.org
- Angular and Rotational Lower Limb Alignment Variations in Children: Practical Guidance for Paediatricians. Medicina (Vlaic J, et al.), 2026. pubmed.ncbi.nlm.nih.gov
- Torsional Problems (POSNA Study Guide). Pediatric Orthopaedic Society of North America (POSNA), n.d.. posna.org
- Lower Extremity Abnormalities in Children. American Family Physician (Baird DC, et al.), 2025. aafp.org
- Pediatric orthopedic mythbusters: the truth about flexible flatfeet, tibial and femoral torsion, W-sitting, and idiopathic toe-walking. Current Opinion in Pediatrics (Honig EL, et al.), 2021. pubmed.ncbi.nlm.nih.gov
- Effectiveness of gait plate insole and lateral sole wedged shoes on foot progression angle in children with in-toeing gait: A prospective randomized control trial. Gait & Posture (Parian S, et al.), 2024. pubmed.ncbi.nlm.nih.gov
This article is general information and does not replace an examination or imaging. If you have symptoms, see a doctor.