Case Study: Treating In-toeing in a Primary School-Aged Child

Treating In-toeing in a Primary


  • 7-year-old healthy, happy and active young girl
  • Mum concerned with Lily’s pigeon-toeing
  • Had hypermobility and hip dysplasia at birth

Lily’s mum first brought her in to see us because she was concerned about her pigeon-toeing (in-toeing). She wanted to understand why it was happening and if everything was ‘normal’. She noticed the in-toeing was more prominent when Lily was tired, and that she was occasionally tripping during running


When Lily was born, she had hip dysplasia in both hips, as well as hypermobility in her joints. Hip dysplasia is when the top of the femur does not sit snuggly in the hip socket, making it vulnerable to being repeatedly dislocated.

Hypermobility describes having naturally flexible joints that can move easily beyond the ‘normal’ range.


We performed a kids foot and leg assessment on Lily, which included testing her muscle strength, the range of motion in her joints, visually examining her gait (not on the treadmill) and a physical assessment. These assessments are designed to be fun and easy for kids. We noted that she had:

  • Very hypermobile joints with excessive hip movement
  •  Very pronated (flat) feet when standing
  • Mild in-toeing
  • Internally rotated knees


We diagnosed Lily with hypermobility with in-toeing. The in-toeing was partly resulting from her pronation and subsequent internal rotation of her legs, with her muscles having adapted to this position over time. This means that Lily had become stronger when in the pigeon-toed stance.

The good news is that her hips were fully capable of the external rotation needed to walk “normally”.



While in-toeing on its own is not typically painful, it can cause a clumsy or uncoordinated gait, repeated tripping and falling, and an inability to run as fast and keep up with other kids on the sports field. Repeated falling can be painful and may make kids hesitant to partake in physical activities.


The goal of Lily’s treatment is to promote a good, healthy range of motion in her hips, so she can develop normal muscle strength and function that will keep her feet facing forwards.

Lily’s treatment has started with strong arch supports to reduce her pronation, and therefore reduce the internal rotation of the leg. We discussed with Lily and her mum the positions that encourage the feet and legs to turn in, like W sitting, which must be avoided. We also discussed the positions that will encourage the hips to rotate outwards, which is the position that we want to encourage.


We will be reviewing Lily’s progress every six months as she grows, making adjustments to our treatment program as we go.

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