Internal rotation of the feet, known as "In-toe Gait," is a very common finding in children aged one to four years old (beginning with walking) and is characterized by the foot being placed on the ground in a position that is slightly directed inward toward the center of the body. The foot is well-placed on the ground, and the condition is usually painless and almost always symmetrical.
When the lower limb rotates around its axis in a way that the foot turns toward the other foot, it is called "internal rotation." When the rotation around the axis moves the foot away from the other foot, it is called "external rotation." The first condition is more common.
Internal foot rotation can result from an abnormality in the hip joint, shin, or foot. Increased hip rotation can cause the foot to turn inward towards the other foot. The cause may be a structural abnormality of the bones and joints or a problem with muscle contractions that lead to holding the foot in such a position without bone abnormalities. Various diseases can also cause internal foot rotation, although it is not as common.
In most cases, internal rotation does not interfere with crawling, so everything appears normal from the side. It is only when the child stands that the feet appear slightly turned towards each other. The condition becomes more prominent when the child begins to walk because the act of lifting the foot accentuates the internal rotation. At this stage, a concern may arise, and parents may notice that "the child falls a lot." (Sometimes they even recall that the older child had a similar issue or one of the parents or relatives, and it resolved on its own, so they might avoid going to the doctor).
Most cases of internal foot rotation in children are normal. Babies are born with significant internal rotation of the feet (for various reasons), and the entire leg goes through a gradual process of external rotation until the age of around seven. Most children of primary school age and beyond walk with slight external rotation (as the phenomenon of internal rotation alternates with external rotation over time). In a minority of cases, there is a genuine problem with the hip joint, thigh bones, shin, or foot. In these cases, internal rotation is not corrected during growth, and orthopedic intervention is usually required.
It is worth noting that treatments such as orthopedic shoes and various devices have been very successful because they provide treatment for a "problem" that would resolve even without treatment. Nowadays, we try to avoid treating this condition as much as possible because it almost always resolves on its own. We only treat cases where there is a genuine problem that is not expected to improve with the child's growth.
Summary:
If during the examination, the orthopedic doctor suspects that the condition is not within the range of normal internal rotation that some children have at this age, the doctor will conduct further evaluation. Even if no treatment is given, it is recommended to follow up after about a year (if the internal rotation is still present).
This explanation is general and does not replace a personalized explanation by the treating doctor. For any questions, you can contact Dr. Ehud Lebel via email at lebel@szmc.org.il.