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Conditions

Out-Toeing

Introduction

Out-toeing is when your child’s foot points outward instead of straight ahead when he or she runs or walks. While out-toeing is often normal and will correct on its own, there are some conditions that cause out-toeing that are serious. Out-toeing is much less common than in-toeing and can occur in older children. Out-toeing can also run in families.


Description

Out-toeing may be due to twists in the bone in the hip, thigh bone (femur), shin bone (tibia), or foot. While some of these are normal variations, a thorough history and examination are needed to make sure there is not a more serious problem.

Common causes of out-toeing:

External rotation contracture of the hip – During pregnancy,  both of the baby’s hips are flexed up and rotated outward to fit in the mother’s womb. This position is known as hip external rotation (the feet are pointed inwards).  This external rotation contracture present at birth usually goes away on its own when the child starts walking.

External tibial torsion – This is when the shin bone (tibia) is twisted outward. Similar to the external rotation contracture of the hip, external tibial torsion is also usually due to positioning of the baby in the womb. However, unlike an external rotation contracture of the hip, external tibial torsion usually does not improve and may even get worse as the child grows. Splints, braces, special shoes, or chiropractic manipulation do NOT improve external tibial torsion.

Flat feet – flat feet (link) occur when there is no arch in the foot. This can give the appearance of out-toeing. Flexible flat feet are normal in babies and toddlers. Out-toeing from flat feet usually improves on its own without treatment.

Less common causes of out-toeing

Femoral retroversion – This is when the thigh bone (femur) has a twist outward compared to the hip. This is more often seen in obese children. It can also be seen in slipped capital femoral epiphysis (SCFE) (link) in older children and adolescents.

Legg-Calve-Perthes (LCP)  – because of decreased hip rotation, some patients with LCP may present with out-toeing.

Cerebral palsy (CP)  – muscle imbalance in the legs of children with Cerebral Palsy can lead to out-toeing. This is usually seen on one leg only, not both. A thorough history and physical exam may reveal signs of possible Cerebral Palsy, and referral to a neurologist or physical medicine and rehabilitation specialist is usually needed.
 

Symptoms

Many children with out-toeing have no pain or functional problems.  Frequently, families notice that the child stands, walks, or runs with the feet point outward.  Depending on the reason for the out-toeing, some children may limp and/or have pain in the hip, thigh, knee, or foot.


Examination

Your doctor will take a thorough history, especially regarding birth history and developmental milestones. Any history of pain or limping should be discussed. The physical exam will include watching your child walk and run, and checking range of motion of the hips, knees, ankles, and feet. He or she will also do a neurologic examination to check muscle tightness, nerve / muscle function, and coordination.  


Other Studies

If the history and physical examination are consistent with out-toeing as normal development in your child, no other studies are needed. If your doctor finds anything concerning, he or she may order x-rays or refer your child to a specialist.


Treatment

Treatment is dependent on the underlying diagnosis that is causing the out-toeing. Normal developmental out-toeing can be followed by your child’s pediatrician or family doctor. Occasionally, external tibial torsion or femoral retroversion may require surgery to untwist the bones if the out-toeing causes pain, limping, knee cap (patella) problems, or severe problems with walking and running when the child is older. It is important that your child’s doctor evaluates your child to make sure that there are not other serious things like SCFE (link), LCP (link), or CP (link) that are causing the out-toeing.


Outcome

Even though normal developmental out-toeing may not completely correct with growth, almost all children are pain free and can participate in sports and activities. Although patients with external tibial torsion and femoral retroversion may have an increased risk of hip or knee pain, long term functional problems only occur in about 1 in 1,000 children (Ref – Staheli L “Rotational problems in children.” Instructional Course Lecture 1994; 43: 199-209.)
 

Q.  Will my child’s walking improve?

For most children, as they grow, the twist in the leg bones will gradually untwist. Also, your child’s muscle control and balance will get better as he or she gets older. Normal developmental in-toeing and out-toeing tends to improve with growth, so it can take a long time to see improvement – it’s like watching grass grow! It can be helpful to take a video of your child walking once a year so you can compare and see the gradual improvement.
 

Q. My parents said that our pediatrician should have put our child in braces to correct the in-toeing / out-toeing. But our doctor said we didn’t need to?! Who is right?

When your parents were growing up, doctors used special shoes, braces, and even cables to correct in-toeing / out-toeing. However, studies have now shown that the in-toeing / out-toeing improves on its own, and the shoes and braces didn’t make it happen any faster.
 

Q. When should I take my child to a doctor for in-toeing / out-toeing?

Your child should see a doctor if in-toeing / out-toeing does not improve by kindergarten, if there is pain, limp, developmental delay, or the walking is getting worse. Out-toeing in only one foot in an is very worrisome in teenagers for a problem in the hip, particularly if there is also hip, thigh, or knee pain - if this is the case your child should be evaluated with x-rays immediately.
 

Q. My toddler trips a lot because of in-toeing. When should I be worried?

Many toddlers who do in-toe also trip! Remember, toddlers are learning to walk, and they do not yet have the muscle control, balance, or coordination to keep up with their busy lives. The in-toeing may make this seem worse. As your child becomes stronger and more coordinated, the tripping will improve.