Parents always worry about their children’s walking patterns. Children sometimes display unusual leg or foot positions, and the most common ones are pigeon toed and bow legged. These differences in alignment look striking, but they are usually benign and tend to improve with time.
In this article, we are going to look into what it means to be pigeon-toed or bow legged, what factors contribute to these conditions, and the options available for treatment if intervention becomes necessary.
What is Pigeon Toed (Intoeing)?
When a child is pigeon toed, it simply means that the feet point inward when standing or walking instead of straight ahead. This is what is known to be intoeing, a quite common phenomenon occurring in the earlier stages of developing a child.
Parents might identify the condition once their child is taking his initial steps. When a child has pigeon-toed, it would be worrisome to find that the toes are pointing towards each other but it is true that pigeon-toed does not cause pain nor hinder the gait of children.
How Prevalent is Intoeing in Children?
Intoeing is a common occurrence in toddlers. Most babies and toddlers naturally walk with their feet turned slightly in during the first few years. As children strengthen and coordinate better with age, the condition typically resolves on its own without requiring any conscious correction.
Effect of Pigeon Toed on the body
Children with a pigeon-toed alignment will, upon examination of the feet or their movement, tend to demonstrate a visible medial rotation. Such deformity tends not to be symptomatic for discomfort, even though it often seems visible and present.
This could, at times, sometimes contribute to their propensity to experience falls when playing or running; more so because over time and especially if they are persistent with their medial turn, they have an increased propensity towards developing fractures, such as stress fractures and arthritis.
Causes and Contributing Factors for Pigeon Toed
The main cause of pigeon-toed alignment is a misalignment of bones or joints in the lower limb. Health care practitioners generally term this as “pigeon toes” when the inward angling of the feet is linked to one or more of the following underlying factors:
Metatarsus Adductus:
This is a congenital condition characterized by a curve in the midfoot where the toes turn inward, giving the foot a characteristic “C” shape. It is most commonly seen in infants under 12 months. Factors such as a breech position in the womb, reduced amniotic fluid (oligohydramnios), or a family history of the condition can increase the likelihood of developing metatarsus adductus.
Inward Tibial Torsion:
This occurs when the shinbone (tibia) rotates inward and usually emerges between ages 1 and 3. Sometimes, if it rotates too far, it appears as bow legs, but the problem is with how the shinbone turns inward. This condition usually self-corrects by age 5.
Femoral Anteversion:
In this case, the femur which is the thigh bone is rotated medially relative to the hip. Such may result in the knees remaining parallel even when the foot is properly aligned. Femoral anteversion is sometimes hereditary and sometimes also due to fetal positioning in the womb. The condition is often observed between 3 to 6 years of age, and usually improves with time as the child grows.
Rare Associations and Adult Cases
While most pigeon toe cases resolve by themselves, sometimes, an associated underlying medical condition might result in a persistence of intoeing. These include such medical conditions like cerebral palsy, club foot, also known as talipes equinovarus, abnormalities of the hip joint, or unusual skeletal malformations like skewfoot. Sometimes, in adults, if the condition persists, it can be due to persisting metatarsus adductus or going on condition of femoral anteversion.
Diagnosis and Management of Pigeon Toed
Parents typically notice that their child’s feet point inward when the child is standing, walking, or even at rest. The condition is usually apparent during routine check-ups with a pediatrician. Healthcare providers pay attention to the angles of the feet, ankles, knees, and hips during both standing and dynamic activities like running.
unless the misalignment persists or presents with other concerning symptoms, X-rays are not required.
Treatment Options for Pigeon Toed
Since most children get better with time, active treatment for pigeon toes is not always required. However, when intervention is deemed necessary, options include:
Physical Therapy and Exercises:
Certain exercises and stretches will enhance muscle strength and coordination to assist in the correction of the inward turn. A physical therapist may be ordered to help correct alignment.
Serial Casting:
For more severe cases of metatarsus adductus that do not improve with conservative measures, a series of casts might be applied. This technique gradually stretches the muscles and ligaments to encourage proper alignment. While effective, casting requires careful maintenance to prevent skin irritation or other issues.
Surgical Intervention:
Seldom, especially when inward tibial torsion is drastically impairing function in older children, is surgery advised. Procedures such as osteotomy—breaking a bone and realigning it—can correct this malalignment. Surgery is largely reserved for severe cases that do not respond to other treatments.
What are Bow Legs (Genu Varum)?
Genu varum, otherwise referred to as bow legs, describes an apparent curvature of the lower limbs inwards at the knee. While the child’s legs are separated during standing due to the lower leg’s apparent curving outward from the thigh, this characteristic feature is generally observed during the walking period, when it might even be combined with intoeing.
Bow legs in babies and young children are common. For most of the cases, the bowing is a part of normal development, and most children correct it by age 18 months. However, when the curvature persists beyond this period, there could be an associated problem that calls for medical investigation.
Causes and Contributing Factors for Bow Legs
Many cases of bow legs are physiologic genu varum, a normal developmental phase. Temporary bowing can result from the position of a fetus in cramped conditions in the womb. However, when bowing continues past toddler years, many causes can be identified:
Blount’s Disease (Tibia Vara)
This growth disorder results in abnormal pressure on the growth plate of the upper part of the shinbone (tibia). This disease is more common in overweight children, those who begin walking early, or those from specific ethnic groups.
Nutritional Deficiencies – Rickets:
Rickets is caused by less vitamin D or calcium and causes bones to be softer, weaker, and more prone to bowing of the legs. Fortunately, rickets is very uncommon in developed countries because of fortified foods and supplements but is more common in regions with nutritional deficiencies.
Genetic Conditions and Bone Dysplasias:
Other forms of dwarfism, as well as other diseases involving the bones during development, include achondroplasia. In addition, improper healing from fractures or the presence of bone dysplasias, a form of congenital malformations, may cause the deformity.
Environmental Causes:
The presence of toxins such as overexposure to fluoride or lead poisoning is a known cause of bone deformities, such as bow legs. However, this is a less common cause of the condition.
Identifying and Diagnosing Bow Legs
The classic finding of bow legs is that when the feet and ankles are held together by a child, there is an easily palpable gap between the knees. Though it is worse with walking, there is little pain or mobility problems associated with the condition. Most children who have bow legs also have intoeing because the inward foot is turned in as compensation for the outward leg bend.
Diagnostic Evaluation
A thorough evaluation is recommended if the child is more than 2 years old and the bowing persists. Healthcare providers typically begin with a detailed physical examination and a review of the child’s medical history. In some cases, the following tests may be used:
Measurements and Observations:
The doctor will examine the extent of curvature and observe the child’s gait. They may assess the leg angles and evaluate the flexibility of the joint.
Imaging Tests:
There is more often than not the use of X-rays to provide an image that better clarifies the existence of abnormalities in the bone structure, especially those that could be responsible for causing the curvature.
Laboratory Tests:
Blood tests may be performed to determine whether deficiencies in vitamin D or calcium contribute to the condition, particularly when rickets is suspected.
Managing and Treating Bow Legs
For most infants and toddlers with bow legs, the condition is a temporary phase of normal growth. In these cases, the child’s legs will gradually straighten on their own without any medical intervention. Healthcare providers often recommend regular monitoring to ensure that the curvature diminishes over time.
Bracing or Splinting:
For some instances, like the early stages of Blount’s disease, the use of a leg brace or splint can guide the bone growth into the right direction. This conservative option may work quite well provided that it starts early on.
Orthotics and Special Diabetic Footwear:
In certain situations, special shoes for orthotic appliances are advised to offer more support and, therefore ensure proper alignment of the legs as one walks.
Nutritional management:
When bow legs are due to rickets, correcting the underlying nutritional deficiency is crucial. This typically involves supplementing the diet with vitamin D and calcium to strengthen the bones.
Surgical Options
In rare cases where conservative measures do not yield the desired results, or if the bowing is causing functional problems, surgical intervention may be considered. Two common surgical techniques are:
Guided Growth Procedures:
This process involves the insertion of a small metal plate or staple on the growth plate of an affected bone. This, in turn, slows down the growth on one side, while the other catches up to gradually correct the alignment of the bone.
Tibial Osteotomy:
This surgery involves cutting and reshaping the shinbone to correct the curvature. The bone is then held in place with internal hardware such as plates and screws or an external frame until it heals in the proper alignment.
Conclusion
It is normal for parents to feel anxious when they notice that their child’s feet or legs are not perfectly aligned. However, conditions such as pigeon toes and bow legs are common and usually temporary. For pigeon-toed children, the inward turning of the feet is most often related to the alignment of bones in the foot, shin, or thigh. In the case of bow legs, the curvature of the lower legs is outward and usually a normal developmental stage that corrects itself with time.
