In-toeing and Out-toeing in Children

Patient information — Dr Christopher Spelman, Orthopaedic Surgeon

Overview

In-toeing (“pigeon toes”) and out-toeing describe feet that point inwards or outwards when a child walks. They are among the most common reasons parents bring a child to an orthopaedic surgeon, and the great majority are a normal part of development that corrects itself with growth. The purpose of assessment is reassurance, and to identify the small number of children who need further attention.

Where the rotation comes from

The direction the feet point is determined by rotation at three levels of the leg, and the usual cause changes with age:

●      Foot – metatarsus adductus, a curved-in shape of the foot, is common in babies and usually resolves in the first one to two years.

●      Shin (tibia) – internal tibial torsion is the most common cause of in-toeing in toddlers, and typically corrects by around age four to five.

●      Thigh (femur) – increased femoral anteversion (an inward twist of the thigh bone) is the usual cause in older children, often most obvious around age three to six, and generally improves through to about age eight to ten. Out-toeing is usually caused by external rotation at the hip or thigh.

When to seek assessment

Most in-toeing and out-toeing needs no treatment. Features that do warrant review include:

●      Rotation that affects only one leg (asymmetry)

●      Rotation that is severe, painful, or getting worse rather than improving with age

●      A child who is not meeting developmental milestones, or who has other health concerns

●      Frequent tripping that is not improving, or a family history of persistent deformity

Assessment and treatment

Assessment involves watching the child walk and measuring the rotation at each level (the “rotational profile”). Reassuringly, the evidence is very consistent that isolated in-toeing and out-toeing correct with normal growth in almost all children. Special shoes, braces, inserts and exercises do not change the natural course and are not recommended. Surgery to rotate the bone (a derotation osteotomy) is reserved for the rare child with a severe, persistent deformity that causes genuine functional problems, usually after the age of about eight to ten when spontaneous correction is complete.

Summary

In-toeing and out-toeing are usually a normal, self-correcting part of growing up and need only reassurance and time. Braces and special shoes do not help. Assessment is worthwhile mainly to confirm the diagnosis and to pick up the uncommon child who is outside the normal pattern. Dr Spelman can examine your child’s rotational profile and advise accordingly.