Out-toeing

Description

Out-toeing means the feet point outward when a child stands or walks. It is less common than in-toeing, and like in-toeing it is usually a normal variation that improves as the child grows. It can come from the hip, the shin, or the foot.

How it happens (the causes)

Just as with in-toeing, the direction the feet point is the sum of rotation at the hip, shin, and foot — here, turned outward:

• External rotation of the hip (infants) — many newborns out-toe because the hip has been held turned out in the womb. As the hip loosens over the first year or two of walking, this settles on its own.
• External tibial torsion (the shin) — the shinbone is rotated outward. Unlike internal tibial torsion, this tends to appear a bit later (around ages 4 to 7) and can persist, because the normal direction of growth is toward more outward rotation.
• Flexible flatfoot (the foot) — a foot that rolls inward can give an out-toed, turned-out appearance. Flexible flatfeet are common and usually painless and normal.

What matters — the one not to miss

Most out-toeing is a painless, symmetric, normal variant. The important exception is new out-toeing in a pre-teen or teenager, especially on one side and with hip, thigh, or knee pain or a limp. An outwardly rotated, painful leg in this age group is the classic look of a slipped capital femoral epiphysis (SCFE) — a hip condition that needs prompt evaluation. So while ordinary out-toeing is reassuring, out-toeing that is new, one-sided, or painful in an older child is not something to wait on.

How it is diagnosed

The cause is identified with the same rotational-profile examination used for in-toeing. X-rays are usually unnecessary for ordinary out-toeing, but the hip is imaged promptly if there is any concern for SCFE or another hip problem.

Treatment

For ordinary out-toeing, treatment is reassurance and observation — special shoes, braces, and inserts do not change the outcome. Infant hip-related out-toeing resolves as the child walks; flexible flatfeet rarely need anything. External tibial torsion that remains severe and causes real problems near the end of growth is occasionally corrected surgically, but this is uncommon.

Recovery and long-term outlook

Out-toeing from the infant hip position resolves in the first couple of years; most children walk, run, and play normally. The key is simply to keep an eye out for the painful or one-sided patterns that deserve evaluation.

When to call the doctor

Call promptly if an older child or teenager develops new out-toeing, particularly on one side or with hip, thigh, or knee pain, a limp, or difficulty bearing weight — this needs evaluation for a hip condition such as SCFE. Also call for pain, marked asymmetry, or worsening at any age.

Learn more

POSNA OrthoKids — Out-Toeing: orthokids.org

OrthoInfo (AAOS) — Intoeing: orthoinfo.aaos.org

This information is for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. For specific concerns about your child, consult a board-certified, fellowship-trained pediatric orthopaedic surgeon.