In-Toeing / Out-Toeing

MARYLAND PEDIATRIC ORTHOPAEDIC CENTER, L.L.C.
Phone (301) 829‐2552 Fax (301) 829‐9588
Mt. Airy Office Mt. Washington Pediatric Hospital
1502 South Main Street #307 1708 W. Rogers Avenue
Mt. Airy, MD 21771 Baltimore, MD 21209
In‐Toeing / Out‐Toeing
Andrew J. Abramowitz, M.D.
In-toeing and out-toeing are frequent causes for visits to the pediatric orthopedist
for infants and children. Rotation of the legs cause a wide range of normal
variations in children’s feet so that most cases of excessive in-toeing or out-toeing
are variations of normal in infants and children. These rotational variations are
often a cause of concern for family members and occasionally cause minor
difficulties for children. In order to be sure that the in-toeing or out-toeing is a part
of normal development, the child must be evaluated thoroughly to establish a
reason for the toes pointing in or out. A thorough history is taken to make sure
that:
there is no family history of hip or foot problems
there were no problems with the pregnancy
the child is developing normally, and
there are no muscle problems or recent trauma.
Occasionally, leg rotational problems can be a marker for an underlying medical
disorder such as cerebral palsy, limb length differences, hip disorders, or
angulations of the limb.
The majority of children’s feet point straight ahead or slightly outward. Children
whose feet point inward are said to be “in-toeing” or “pigeon toed”. In the vast
majority of children, in-toeing will go away without any treatment. In the past,
braces were used to treat in-toeing, but recent studies have shown that braces offer
no advantages. The normal progression of rotational growth in the lower
extremity leads to correction in most cases of in-toeing by age 6 to 8. In a small
percentage of children, the in-toeing does not completely resolve; but most of these
children will cope just fine without any difficulties in their activities of daily
living. Rarely does a child with unresolved in-toeing need surgical treatment to
correct the problem. There is no evidence that in-toeing leads to arthritis or causes
clumsiness. In fact, many of our best track and field athletes are pigeon toed.
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Occasionally, in-toeing may cause problems with shoe wear, but braces, special
shoes, or inserts do not correct the problem.
There are three causes for in-toeing:
metatarsus adductus, the child’s feet bend inward from the middle part of
the foot. This is typically caused by the position of the baby in the uterus.
tibial torsion, the child’s lower leg twists out of normal alignment, and
femoral ante version, the child’s thigh bone turns inward.
The metatarsus adductus can be mild, moderate, or severe. In mild feet, the foot
can be overcorrected passively. These feet usually resolve by the age of 2 years.
In moderate feet, the foot can be passively corrected so that the lateral border is
straight, but it cannot be overcorrected. These feet also usually improve on their
own in the majority of cases, and occasionally may
need special shoes to help obtain and maintain the
correction. Both mild and moderate feet also respond
well to stretching to help get the foot straighter. This
is usually shown to the parents by the doctor and can
be done at home at bath time. Stiff feet cannot be
stretched so that the outside border of the foot is
straight. These feet may be treated with a series of casts to help stretch the feet,
followed by special shoes to maintain the correction. Rarely, surgery may be
necessary if casting fails or if the deformity recurs during growth and the child has
functional problems as a result.
Internal tibial torsion is an inward twist of the tibia bone. This
is usually noticed when the child begins to walk. Inward
twisting is normal in many babies and often corrects by the
age of 1. However, the inward twist is slower to correct in
some children and these are the ones that usually present to the
doctor. In about 90% of patients the inward twist slowly
corrects itself by about ages 4-6. As the child begins to walk
with tibial torsion it frequently causes tripping and falls;
however, as the child grows and muscles develop, they are
better able to cope with the in-toeing until it ultimately
resolves in most cases.
Studies have shown that bracing does not speed up the
correction of inward tibial torsion, so most doctors do not
prescribe any treatment other than observation. In about 10% of patients the tibial
torsion does not correct, but most children function perfectly well and there is no
evidence that tibial torsion causes arthritis or functional problems in the long run.
In the rare case that the torsion does not resolve by age 6 to 8 and the child does
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have a functional problem as a result of the torsion, the treatment is to cut the bone
and rotate it outward so the feet point straight. Very few children without
neuromuscular problems need this surgery, therefore careful discussion with the
doctor is necessary before pursuing surgery.
Femoral anteversion, an excessive inward twist of the upper thigh bone at the hip
region, is usually noticed between ages 2 to 4. All
children are born with some inward twist of the thigh
bone. As the children grow, the ligaments around the
hip tighten causing the anteversion to resolve during
the first few years of life. In some children, these
ligaments never completely tighten up and when the
child starts to walk they can become even looser,
causing the hips to rotate further inward. This causes
the in-toeing to be noticed between ages 2 and 4.
Most cases of femoral anteversion resolve
spontaneously by the time the child is between 6 and
8 years old. Once again, it has been shown that
special shoe wear and braces do not improve on the
natural resolution of the deformity, and may actually cause problems such as
discomfort and poor self esteem. A few children will not resolve their anteversion
but most function fine without any problems. In the rare case that the anteversion
does not resolve by age 6 to 8 and the child does have a functional problem as a
result of the torsion, the treatment is to cut the bone and rotate it outward so the
feet point straight.
Out-toeing is much less common than in-toeing. The most typical presentation is
within the first or second year of life. Most children are born with external rotation
contractures of the hips and this resolves shortly after walking begins. In those
children in whom the resolution is slower, out-toeing is the result when they first
start walking. This will almost always resolve within a year from the onset of
walking. Out-toeing may also be caused by outward twisting of the tibia or femur
bone, and is not usually seen in normal children, but is more common in those with
neuromuscular abnormalities. As with in-toeing, bracing and shoe wear are not
helpful in resolving the deformity. Occasionally, a normal child will have outtoeing
from tibial or femoral outward twisting that does not resolve by the end of
the first decade. This may cause functional difficulties. If this is the case, surgery
can be done to cut the bone and rotate to a more normal position. This is also
rarely necessary.
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