News From The PT

“Pigeon Toes”and Tripping in your Preschooler

What could be the cause of my new walker toddler’s feet turning in?

Tibial torsion is an inward twisting of the shin bones, causing the child’s feet to turn inward. This positioning is also sometimes called “pigeon toed” and it is actually commonly seen in toddlers. When children are first learning to walk, tibial torsion can create an in-toeing and bowed leg appearance. Pigeon-toed walking is a normal part of learning to walk, both due to bony alignment of the tibias and also to allow a child to feel more stable in standing. Development of stronger hip muscles (specifically the hip extensors/buttocks muscles) helps to create more stability and better alignment of the feet and leg through standing and weight bearing. This also effects proper bony development in hips and legs.

Is this something we need to address?

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Tibial torsion often improves with time. As the child grows, walking often becomes more and more normal, and tibial torsion is many times no longer significant by 5-6 years of age. 

In addition, tibial torsion does not lead to arthritis or any other health problems later in life. Tibial torsion can be associated with tripping over toes during walking and running due to foot positioning. When this becomes a safety concern or when it doesn’t improve with time and practice walking, it can be important to address. 

What should we do? 

Specific treatment is determined by your child’s health care providers based on child’s age, overall health, medical history, severity of condition, and other factors. A pediatric physical therapist, orthopedist or rehabilitation doctor may take a closer look at your child’s feet, legs and hips and perhaps even take an x ray of their hips. A child’s foot musculature continues to develop for up to age 4-5 years and bony formation continues up to age 7-8. In very young children with lower tone or ligamentous laxity, there might be significant “collapse” of the foot to the inside edge, most easily seen from looking at back view of the heel in standing. One can also see from the top view of the foot in standing, that the toes might tend to drift towards the little toe side. In this situation, the muscles of the foot could apply forces to the many bones of the foot creating atypical bony alignment. If this persists past the age of bony maturation in the foot, this flattened position of the foot will occur into adulthood. If this flatfoot position is significant, then orthotics might be prescribed to allow the foot to work through a dynamic pattern of walking and running in correct alignment. This creates optimal muscle activation, efficiency and bone growth. To address the pediatric flexible flatfoot, there are many types of orthotics from simple shoe inserts with arch supports or SMOS (supra malleolar orthotics). One can check with your child’s pediatrician or pediatric specialist to see what might be best for your child.

- Lisa Swenson, PT, C/NDT and Anne Ziegltrum, PT, DPT

1.    Children’s Hospital of Philadelphia Website:
2.    Boston Children’s Hospital Website:

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