Some children's feet turn in when they walk. This is called in-toeing or pigeon-toed walking and is part of normal development for many toddlers. It is one of the most common developmental conditions in children, affecting around one child in 10.

It is usually seen in both feet, but can occur in just one foot. In most children it is not a serious problem and usually corrects itself with time, often by the age of six to seven years. In a small number of children, it does not improve on its own and treatment may be needed.

What problems can occur?

Children who in-toe may trip slightly more often when they are younger, but this usually improves with time. Children with in-toeing can take part in sports and are no more likely to develop arthritis or back problems than other children. If you feel your child's in-toeing is getting worse, you should arrange a reassessment.

Many parents worry that their child will always walk with their feet turned in. However, this rarely happens. Once your child has been assessed and any serious or congenital conditions have been ruled out, some improvement can usually be expected as they grow.

What causes in-toeing?

In-toeing can be caused by a problem in one area, or a combination of four areas. The foot, the knee, the hip, and very often in conjuction with core stability.

Hip: Internal torsion, flexible joints and weak muscles

Children can be very flexible and some children have more movement at the hip in an internally rotated direction than in an externally rotated direction. This imbalance means their resting position is naturally more inwardly turned than another child's. This usually improves with age.

However, sitting in a W position, kneeling on the feet and sleeping on the tummy with the bottom in the air can have a significant effect on this problem. Failure to address these positions may mean the problem continues for longer.

Hip: Hamstrings

Tight hamstrings can also cause an in-toeing gait, with the kneecaps turning inwards. Sitting and sleeping positions may aggravate this. Growth spurts can often make the in-toeing appear worse.

Regular stretching exercises are usually enough to improve this.

Core stability

Children who have weakness in their back, hip and stomach muscles, known as the trunk postural muscles, may develop an in-toeing position.

When these muscles are weak and unable to actively stabilise and control movement, an in-toeing position can lock the joints of the back, hip and knee into a more stable position. In this situation, the body is compensating for weakness and this weakness needs to be addressed for the in-toeing to improve.

Important muscles around the hip control the inward and outward movement of the leg. If these muscles are weak, they tire quickly and the feet may begin to turn in. This is one reason why some children's in-toeing appears worse when they are tired towards the end of the day.

In-toeing can also be caused by a twist in the bone between the hip and the knee, known as the femur. This twist is normal and gradually unwinds during development. Any delay in this normal process can give the appearance of in-toeing.

In 90 per cent of children, the in-toeing gradually improves between the ages of seven and 14 years.

In persistent cases there is often a strong family history of in-toeing.

For the rare cases that do not improve, surgical correction remains a possibility. In practice, this is rarely necessary and is not normally considered in younger children because most children improve naturally.

Knee: Medial genicular position

This is most commonly noticed during the second year of life after a child has started walking. The feet turn inwards but the kneecaps (patellae) face forwards. The shin bone (tibia) is slightly internally rotated within the knee, causing the foot to turn inwards. The tibia may also appear bowed because the calf muscles are visible on the outside of the leg.

The in-toeing is often exaggerated by the bent-knee walking pattern of younger children and usually improves naturally as a child develops a more mature walking pattern.

Foot: Metatarsus adductus

Metatarsus adductus is a curve in the foot. If your child has this condition, you may notice it whilst they are still a baby. The curve in the foot is thought to develop before birth when the feet are pressed into this position inside the womb.

If the foot is flexible and can be gently moved into the correct position, treatment is not usually required. In 95 per cent of children, the feet straighten naturally as they grow.

Sometimes stretching exercises may be recommended. In a very small number of children, plaster casting may be needed to improve correction.

General advice

Children who in-toe often find it very easy to sit in the W position. We encourage children to avoid this position because it may delay or prevent the natural correction that occurs through growth and development.

Likewise, kneeling and sitting on the feet can also prevent the condition from correcting itself.

Kneeling on Feet

This is particularly important if the in-toeing is related to the knees.

Sleeping with the bottom in the air and the feet tucked underneath also encourages inward rotation of the legs.

Out-toed activities such as ballet may help improve an in-toeing gait that has become habitual.Depending on the age of the child, duck walking and frog jumping can be fun activities that may work in a similar way.

Core stability can be improved through:

• soft play
• trampolining
• dance
• martial arts
• playground activities.

Specific exercises can be prescribed if needed, depending on the age of the child.

All children trip and fall whilst learning to walk. This is not always caused by in-toeing. In-toeing should not affect your child's ability to walk, run, play or lead a normal life.

Bracing, twister cables and corrective shoes are not usually required. Many years ago it was believed that these treatments were helpful, but research has shown that they are not effective.

If you remain concerned, please seek reassessment.