Contents
Out toeing
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.
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.
Speak with your doctor if you’re concerned about the way your child walks. For a small number of kids, gait abnormalities can be associated with other problems. For example, out-toeing could signal a neuromuscular condition in rare cases.
Have your child evaluated by a doctor if you notice:
- Out-toeing that doesn’t improve by age 3
- Limping or complaints of pain
- One foot that turns out more than the other
- Developmental delays, such as not learning to talk as expected
- Gait abnormalities that worsen instead of improve
Your doctor can then decide if more specialized exams or testing should be done to make sure that your child gets the proper care.
My parents said that our pediatrician should have put our child in braces to correct the 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.
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.
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.
Out toeing cause
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) in older children and adolescents.
- Perthes disease also known as Legg-Calve-Perthes – because of decreased hip rotation, some patients with Perthes disease may present with out-toeing.
- Cerebral palsy – 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.
Out toeing 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.
Out toeing diagnosis
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.
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.
Out toeing 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 slipped capital femoral epiphysis, Perthes disease or cerebral palsy that are causing the out-toeing.
Out toeing prognosis
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.
Will my child walking improve?
As most kids get older, their bones very gradually rotate to a normal angle. Walking, like other skills, improves with experience, so kids will become better able to control their muscles and foot position.
In-toeing and out-toeing gets better over time, but this happens very gradually and is hard to notice. So doctors often recommend using video to help parents track improvement. Parents can record their child walking, and then wait about a year to take another video. This usually makes it easy to see if the gait abnormality has improved over time. In most cases, it has. If not, parents should speak with their child’s doctor to discuss whether treatment is necessary.
In the past, special shoes and braces were used to treat gait abnormalities. But doctors found that these didn’t make in-toeing or out-toeing disappear any faster, so they’re rarely used now.
