Pigeon toe, or in-toeing, is a condition where the feet turn inward instead of pointing straight ahead during walking or running. While it is a common and often self-correcting developmental variation in young children, its persistence into adulthood presents distinct challenges. When the inward rotation remains after skeletal maturity, it can lead to inefficient gait, increased risk of tripping, and secondary joint stress in the knees and hips. Adult in-toeing is typically structural, meaning the underlying cause is a fixed bony alignment that does not spontaneously resolve. Treatment focuses on managing resulting functional issues and pain through conservative methods or definitively correcting the underlying skeletal rotation through surgery.
Understanding the Anatomical Cause
Adult in-toeing is not a single condition but a result of rotational misalignment that can originate at three different levels of the leg. Identifying the precise anatomical source of the inward twist is necessary because it dictates the appropriate management strategy. The three primary structural causes are femoral anteversion, tibial torsion, and metatarsus adductus.
Femoral anteversion is a rotational deformity originating in the upper leg, where the thighbone (femur) is twisted inward relative to the hip socket. This excessive internal twist causes the entire leg, from the hip to the foot, to rotate inward, often leading to a gait pattern where the knees also face toward each other. The condition is sometimes referred to as excessive femoral torsion, and it is the most frequent cause of in-toeing that persists into late childhood and adulthood.
Tibial torsion involves the inward twisting of the tibia, or shin bone. In this case, the knee joint may point forward normally, but the lower leg and foot turn inward because of the twist in the tibia itself. This misalignment causes the foot to angle inward during walking, and the severity can vary significantly from a mild rotational difference to a pronounced deformity.
The third cause, metatarsus adductus, is confined to the foot, where the forefoot bends inward relative to the hindfoot, creating a bean-shaped appearance. This is a common congenital foot deformity that usually resolves early in life, but if the forefoot remains rigid and curved in adulthood, it contributes to in-toeing. Unlike the other two causes, which involve the long bones of the leg, metatarsus adductus is a local foot deformity.
Conservative Management Approaches
Conservative management for adult in-toeing is primarily aimed at improving gait efficiency, managing pain, and mitigating the secondary effects of the misalignment, rather than structurally correcting the bony twist. Physical therapy is a foundational component of this approach, focusing on strengthening the muscles that externally rotate the hip and stabilize the pelvis. Specific exercises, such as clam shells and hip abduction movements, target the gluteus medius and other external rotators to help pull the leg into a more neutral alignment during dynamic activities.
Gait retraining techniques are also employed to raise awareness of the foot’s position during walking and running. Patients are often coached to consciously focus on landing with the foot pointed forward, which encourages the use of stabilizing muscles and can minimize tripping. While this does not change the underlying bone structure, it can improve the functional walking pattern.
Custom-made orthotics and specialized footwear modifications play a significant role in managing symptoms and improving foot mechanics. Custom orthotics, particularly those incorporating a feature known as a gait plate, work by applying pressure to the forefoot to encourage external rotation during the push-off phase of the gait cycle. This angled design provides a mechanical assist to the walking pattern.
Footwear selection should prioritize shoes with a firm heel counter and adequate arch support to stabilize the ankle and prevent excessive inward rolling of the foot. In cases of metatarsus adductus, the orthotic helps accommodate the inward curve of the forefoot while ensuring proper weight distribution across the sole. Non-steroidal anti-inflammatory drugs (NSAIDs) may be recommended for short-term use to alleviate pain and inflammation that can arise from secondary joint stress in the knees or hips.
Surgical Options for Correction
Surgical intervention is considered when the structural rotational deformity is severe, causes chronic pain, or results in significant functional limitations, such as frequent falling or difficulty participating in daily activities. Since conservative methods cannot correct a fixed bony misalignment, surgery is the definitive option for achieving structural correction. A common threshold for considering surgery in femoral anteversion is a torsional angle greater than 25 to 30 degrees, especially when combined with symptomatic patellofemoral issues.
The primary surgical procedure used for structural correction is a derotational osteotomy, which involves cutting the affected bone and then rotating it to the correct alignment. The procedure performed is specific to the anatomical cause of the in-toeing identified during a comprehensive evaluation, which often includes a computed tomography (CT) scan to precisely measure the degree of torsion. For excessive femoral anteversion, a femoral derotational osteotomy is performed on the thighbone.
This surgery involves making a cut in the femur, and then rotating the bone segment outward to restore a more normal hip-to-knee alignment. Once the correction is achieved, the bone is stabilized with internal fixation, typically using a rod or a plate and screws, to hold the new position while the bone heals. A tibial derotational osteotomy is performed for cases of significant internal tibial torsion.
Recovery following a derotational osteotomy is a substantial process that requires a period of non-weight-bearing or protected weight-bearing. Patients typically use crutches or a walker for several weeks while the bone segment fuses in its new position. Post-operative physical therapy is essential to regain strength, range of motion, and a normalized gait pattern, with a full return to unrestricted activity often taking several months.