If you have already had one child’s foot looked at for a curved shape, skewfoot can be confusing, because it looks similar to the more familiar metatarsus adductus at first glance. Parents in Singapore often notice it while fitting shoes or watching an early walker, where the front of the foot points inward but the heel does not sit the way a simple in-curved foot usually does. The inner border of the foot can trace an “S” or “Z” as the eye travels from heel to toes.
That double curve is the whole point of skewfoot. The forefoot is adducted (turned inward) while the hindfoot is in valgus (rolled outward), so the foot bends one way at the front and the opposite way at the back, giving the serpentine or “Z-foot” shape. This is what separates it from metatarsus adductus, where only the forefoot curves in and the heel stays neutral. Because the hindfoot is involved, skewfoot can be mistaken for a flatfoot as well, and it can be flexible or rigid. Getting the classification right early is what decides whether a foot is monitored, supported, or referred onward, so an accurate assessment matters more here than with a straightforward in-curved forefoot.
Symptoms of Skewfoot
Skewfoot is a shape diagnosis more than a painful one in young children, so the signs are mostly what a parent sees rather than what the child complains of. The combination below, especially the forefoot and heel pointing in opposite directions, is the pattern that sets it apart.
- A “Z” or serpentine shape to the foot: looking at the sole, the forefoot curves inward while the heel and back of the foot angle outward, so the inner border traces an S or Z rather than a single smooth C.
- Forefoot turned inward (adducted): the front of the foot points toward the midline, the same finding seen in metatarsus adductus.
- Hindfoot rolled outward (valgus): the heel tilts outward and the inner arch looks lower or collapsed, which is the feature metatarsus adductus does not have.
- A crease on the inner border of the foot: a soft-tissue crease can appear where the forefoot bends inward, as in other in-curved foot shapes.
- In-toe walking once the child is up and moving: the adducted forefoot can point the foot inward during gait, so skewfoot is one of the foot-level contributors to an in-toed pattern.
- Difficulty fitting shoes: the shoe upper may wrinkle on the inner side at the forefoot while the heel counter does not grip well, reflecting the two opposing curves.
- Flexible in many cases, rigid in others: in a flexible foot the forefoot can be guided closer to straight with gentle handling, while a rigid foot resists correction and holds the Z-shape.
Pain is uncommon in the early years. When an older child or adolescent with a rigid skewfoot does report discomfort, it tends to sit under the inner arch or the ball of the foot, where the opposing curves change how load passes through the foot.
Causes of Skewfoot
Skewfoot sits at the more complex end of the in-curved-foot spectrum, and its exact origin is not always clear. It can appear on its own or emerge in a foot that started as metatarsus adductus, and in some children it follows earlier treatment for another foot shape.
What Causes Skewfoot?
- Congenital positioning. As with metatarsus adductus, tight positioning in the womb during late pregnancy is thought to hold the forefoot inward, with the hindfoot component developing as part of the same structural pattern.
- A more complex variant of forefoot adduction. Skewfoot is often described as forefoot adduction combined with a hindfoot that has rolled into valgus, so the two segments of the foot end up curved in opposite directions rather than the forefoot alone.
- Evolution from a treated or persistent metatarsus adductus. In some children a hindfoot valgus becomes apparent later, sometimes after casting for an in-curved forefoot, revealing a skewfoot pattern that was harder to see in infancy.
- Association with generalised ligament laxity. A more mobile, flexible foot type can allow the hindfoot to drift into valgus while the forefoot stays adducted, contributing to the serpentine shape.
- Neuromuscular influence in a minority. Uncommonly, an underlying neuromuscular condition affecting muscle balance around the foot can produce or accompany a skewfoot pattern, which is one reason a careful assessment is worthwhile.
Who Carries a Higher Baseline Risk?
- Children with a history of metatarsus adductus, particularly where a hindfoot valgus appears later.
- Babies who were in a breech position or came from a pregnancy with limited room, such as a multiple pregnancy or low amniotic fluid.
- Children with a family history of paediatric foot conditions.
- Children with generalised joint hypermobility or ligament laxity.
- Children with a known neuromuscular condition affecting the lower limb.
A higher baseline risk does not mean the deformity will be severe or rigid. It means an assessment is worthwhile so the foot can be graded as flexible or rigid and separated from a simple flatfoot or forefoot curve early.
Conditions Commonly Mistaken for Skewfoot
The serpentine shape overlaps with several other paediatric foot patterns, and some of them are managed very differently. The distinctions below are what a paediatric assessment works through.
Metatarsus adductus
This is the closest and most common point of confusion. In metatarsus adductus only the forefoot curves inward and the heel sits in a normal position, giving a single “C” to the inner border. Skewfoot adds a hindfoot rolled outward into valgus, so the foot bends in two opposing directions and traces a “Z”. Skewfoot also tends to present later and to be more rigid than a typical flexible metatarsus adductus.
Flatfoot
Because the hindfoot rolls outward and the inner arch looks low, skewfoot can be read as a simple flat feet in children pattern. The difference is the forefoot. A flexible flatfoot has a collapsed arch and outward heel but a forefoot that points straight ahead, whereas skewfoot pairs that hindfoot valgus with an inward-turning forefoot. Missing the forefoot component is the usual reason a skewfoot gets labelled as flatfoot.
In-toe walking from higher up the leg
In-toe walking can come from the hip (femoral anteversion) or the shin (internal tibial torsion) rather than the foot. A child may walk with the feet turned in even when the forefoot itself is not adducted, so the in-toeing is coming from the rotation of the leg rather than the shape of the foot.
Congenital vertical talus
Congenital vertical talus is a rigid deformity where the sole of the foot is rounded outward into a rocker-bottom shape, with the hindfoot fixed in a downward and outward position. It is stiffer and more structurally severe than skewfoot, and it typically needs early specialist-led treatment. It is grouped here because both involve a hindfoot that is not sitting in a neutral position.
Clubfoot (talipes equinovarus)
Clubfoot involves the whole foot turning inward and downward with a rigid hindfoot pointed down and in, the opposite hindfoot direction to skewfoot. It is usually recognised at birth and needs early correction with the Ponseti method. It is listed here because both are congenital shape deformities, but the hindfoot points in opposite directions, which is a key differentiator on examination.
Treating and Preventing Skewfoot
Care for skewfoot starts with classification, not correction. The first job is to confirm the diagnosis, separate it from metatarsus adductus and flatfoot, and grade whether the foot is flexible or rigid, because that single finding drives everything that follows. A flexible skewfoot that guides toward straight with gentle handling is monitored and supported, while a rigid or severe skewfoot that holds its shape is where onward referral for casting or a surgical opinion belongs. The honest framing is that the more corrective end of skewfoot treatment, serial casting and any surgery, is led by paediatric orthopaedics, and the podiatry contribution is accurate assessment, footwear and orthotic support, gait review, and monitoring over time.
Conservative treatment
For flexible cases and for ongoing support, conservative measures are matched to the child’s age and how the foot is loading.
- Footwear guidance: soft, flexible footwear that does not force the forefoot, along with advice on shoe shape and fit. In mild persistent forefoot adduction, straight-last or reverse-last shoes are sometimes suggested to discourage the inward forefoot position.
- Passive stretching for the flexible forefoot: where the forefoot is flexible, a parent-delivered stretching routine taught during the assessment can gently guide the front of the foot toward a straighter position, typically worked into daily nappy changes or dressing in younger children.
- Custom foot orthoses: in older children where a hindfoot valgus is contributing to in-toeing, tripping, or footwear difficulty, an orthosis can support the hindfoot and improve how load passes through the foot. The device is matched to the specific foot rather than used as a default.
- Paediatric supramalleolar orthoses: where more control of the hindfoot position is needed, a supramalleolar device that extends above the ankle can hold the rearfoot in a better-aligned position while the child grows.
- Monitoring as the child grows: a scheduled review to track whether a flexible foot is holding, improving, or stiffening, so that any move toward a rigid pattern is picked up early rather than late.
When conservative care isn’t enough
Skewfoot that is rigid, severe, or clearly worsening is beyond what footwear and orthoses can correct, and it warrants a paediatric orthopaedic opinion. Serial casting, where a series of casts is changed at intervals to gradually reposition the foot, is a specialist-led pathway that works best when started young. A smaller number of children with a fixed, symptomatic deformity that has not responded to conservative and casting approaches may be considered for surgical correction, usually later in childhood once growth allows. Where an underlying neuromuscular cause is suspected, that is investigated alongside the foot itself. Our role in these cases is to flag the foot early, support it appropriately, and coordinate the referral rather than to hold a foot that needs specialist input.
Have Your Child’s Skewfoot Assessed at Straits Podiatry
Paediatric foot conditions are seen at all three Straits Podiatry clinics in Buona Vista, Orchard, and Paya Lebar, where our podiatrists work with children of all ages. Straits Podiatry is part of Healthway Medical Group.
A skewfoot assessment includes a paediatric foot and gait assessment, grading of the forefoot and hindfoot to separate skewfoot from metatarsus adductus and flatfoot, a check of flexibility versus rigidity, hip and lower limb rotation screening where in-toeing is present, and footwear review. Where the foot is flexible, we can help with footwear guidance, a stretching plan, custom or supramalleolar orthoses, and a monitoring schedule. Where it is rigid or severe, we discuss the casting or surgical referral pathway openly and coordinate onward care.
If your child’s foot has a Z or serpentine shape, or you have been told it is a flatfoot but the forefoot also turns in, book a consultation for an assessment at any of our three Singapore clinics.
Frequently Asked Questions About Skewfoot
What is the difference between skewfoot and metatarsus adductus?
Both involve a forefoot that turns inward, but skewfoot adds a second curve. In metatarsus adductus only the forefoot is adducted and the heel sits in a normal position, so the inner border of the foot traces a single “C”. In skewfoot the forefoot is adducted and the hindfoot has rolled outward into valgus, so the foot curves in two opposite directions and traces a “Z” or serpentine shape. Skewfoot also tends to appear later and to be more rigid. Telling the two apart matters because they can be managed differently, and the only reliable way is a paediatric assessment of both the forefoot and the heel.
Is skewfoot the same as a flatfoot?
No, although they are easy to confuse. Skewfoot includes a hindfoot rolled outward and a low-looking inner arch, which is why it can be mistaken for a childhood flatfoot. The difference is the forefoot: a flexible flatfoot has a straight-pointing forefoot, whereas skewfoot pairs the hindfoot valgus with an inward-turning forefoot. If a child has been told they have flat feet but the front of the foot also curves in, it is worth having the forefoot checked so a skewfoot is not missed.
Will my child’s skewfoot correct on its own?
It depends on whether the foot is flexible or rigid, which is why grading it early is so useful. A flexible skewfoot may improve with growth, footwear guidance, and monitoring, in a similar way to a flexible in-curved forefoot. A rigid skewfoot is less likely to fully straighten without more active treatment, and it is the group where serial casting or a surgical opinion has more to offer. An assessment is the only way to know which side of that line a particular foot sits on, so the plan can either monitor with confidence or refer early.
At what age should skewfoot be assessed?
Sooner rather than later, ideally in the first year or two, or whenever the Z-shape is first noticed. Early assessment is not about rushing into treatment, since many flexible feet are simply monitored. It is about classification: confirming skewfoot rather than metatarsus adductus or flatfoot, grading flexibility, and picking up any rigid or worsening foot while the window for casting is still favourable. If a child is already walking with an in-toed gait or tripping, that is another good reason to have the foot looked at.
Does skewfoot need surgery?
Most children do not need surgery. Flexible skewfoot is generally managed with footwear, orthoses, and monitoring, and rigid cases are first considered for specialist-led serial casting. Surgery is reserved for the smaller number of older children with a fixed, symptomatic deformity that has not responded to conservative and casting approaches, and it is usually considered later in childhood once growth allows. That decision is led by paediatric orthopaedics, with podiatry supporting the assessment, footwear, and follow-up around it.