OUT-TOEING AND IN-TOEING
In-toeing is when the feet point inward instead of straight and is often called “pigeon-toed.” Out-toeing means the feet point outward instead of straight, a condition often called “duck feet.”
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Out-Toeing and In-Toeing
Most people point their feet straight ahead or slightly outward. However, some people’s feet point inward. This musculoskeletal condition is known as in-toeing. In-toeing is a condition that affects infants and children and is characterized by an inwardly rotated foot or feet or, less frequently, an outwardly rotated foot or feet (sometimes called out-toeing). Doctors may also refer to this as a lower extremity rotational problem, which can result from abnormalities in the growth or alignment of the upper legs, lower legs, or feet. On the other hand, the vast majority of such issues appear simply as physiological variations during normal periods of development. As a result, a child may appear pigeon-toed, or one or both feet may appear splayed outwards. In-toeing can appear at any age, from birth to adolescence, depending on the actual reason.
Out-Toeing
As they learn to use their newfound ability to walk, some toddlers walk with a duck-footed gait, also known as out-toeing. This means they walk with their toes pointed outward instead of forward. Out-toeing can also appear for the first time in adolescents, teenagers, or adults. It’s not always a cause for concern, but it’s important to understand the distinction between a normal duck-footed gait and a condition that affects how you walk.
In-Toeing
This occurs when one or both of a child’s feet turn in while walking. Children’s knees can also turn in. Pigeon toe is a common condition in children. It usually appears between the ages of 2-3 years. It usually gets better gradually as children gain strength and control. Several conditions can cause pigeon toes. For example, foot conditions such as Metatarsus Adductus or clubfoot can cause the condition. It can also be caused by problems with shin or thigh bone alignment. Children with pigeon toes may trip or fall frequently. They may also run in an unusual manner, with their feet swinging out as they run. Unless severe, pigeon toe is usually painless.
QUESTIONS AND ANSWERS
What causes out-toeing (or in-toeing) in my child?
Out-toeing (toes pointing outward) or in-toeing (toes pointing inward) can be common variations in the way children walk as they develop. It may be due to the positioning of the hip, foot, or leg bones. In many cases, these gait patterns are considered normal and tend to resolve on their own as the child grows. However, sometimes these gait abnormalities can be related to underlying musculoskeletal issues. A doctor can perform an examination and provide insights into the specific cause and whether further evaluation or intervention is needed.
Should parents call the doctor if their child walks by out-toeing (or in-toeing) and will it resolve on its own?
Most cases of out-toeing or in-toeing do not require treatment as they often improve with time and as the child’s musculoskeletal system matures. However, if the gait abnormality is persistent, or if it is causing pain, discomfort, or difficulty with activities, the doctor may recommend treatment. Treatment options may include physical therapy, orthotics, specialized footwear, or, in rare cases, surgery. The doctor will provide guidance on whether intervention is necessary and the most appropriate course of action.
What can we do to address or improve my child's out-toeing (or in-toeing)?
In many cases, children do outgrow out-toeing or in-toeing as they grow and develop. Parents can encourage healthy physical activity and ensure that their child wears supportive and properly fitting shoes. Regular check-ups with the doctor can help monitor the child’s progress. If the gait abnormality persists or worsens, the doctor can provide guidance on additional steps to support the child’s development and ensure their musculoskeletal health.
It’s important to remember that the specific questions and concerns may vary based on the child’s age, the severity of the gait abnormality, and the individual circumstances. The doctor will tailor their responses to address the unique needs and conditions of the child with out-toeing or in-toeing.
When it comes to children and their medical conditions, parents need to think of the very best — Medical City Children’s Orthopedics and Spine Specialists is a group of doctors and surgeons who specialize in children’s health.
Causes of Out/In-Toeing
It is sometimes caused by tibial torsion. If your baby’s hips were pressed in the uterus, with the tibia rotating outwards, they may have out-toeing as a toddler. As a toddler, they may have been pigeon-toed if their hips were pressed and their tibia rotated inwards. Other less common causes of out-toeing include the following:
Have flat feet
This is due to the absence of a foot arch. This can sometimes result in children’s out-toeing.
Cerebral palsy
Some people with CP experience out-toeing in one or both legs as a result of muscle imbalances.
Legg-Calves-Perthes syndrome
Legg-Calves-Pertes Syndrome causes bone death in the hip joint’s ball. This disease causes less blood flow to the hip joint. The joint degrades as a result of bone death. Even after the body heals and replenishes the area with blood, the ball joint may not return to the same shape. Out-toeing may occur if the joint change causes decreased hip mobility.
Pigeon toes develop in the womb for many children. Due to a lack of space in the uterus, some babies develop in a position that causes the front part of their feet to turn inward. This is known as Metatarsus Adductus. Pigeon toes can develop as leg bones grow during the toddler years in some cases. Internal tibial torsion, which is present by the age of two, may cause in-toeing. A turning-in of the femur, or thighbone, in a child aged 3 or older is known as medial femoral torsion. Femoral anteversion is another term for this. Girls are more likely than boys to develop medial femoral torsion.
Symptoms
Out-toeing can give the impression that a child is waddling from side to side. You might notice that your child’s knees appear to point outward as well. Out-toeing is usually not associated with pain or discomfort. It also usually does not impair a child’s ability to walk, run, or be mobile in any way. Out-toeing may appear more visible when a child runs rather than walks. Parents may also notice that their child’s shoes are wearing out or have visible scuff marks on the outer edges. Doctors examine the feet in Adults for out-toeing by standing naturally with their feet about 1 foot apart. If the toes point outward rather than straight ahead, you are most likely duck-footed.
Internal tibial torsion may not appear until your child begins to walk. With each step, you may notice that one or both of their feet turn inward. Although signs of medial femoral torsion may appear after the age of 3, they are usually obvious by the age of 5 or 6. In many cases, your child’s foot and knee both turn in as he or she walks. It may also appear even when your child is standing still. Children with medial femoral torsion frequently sit with their legs flat on the floor and their feet out to either side in the shape of a “W.” Out-toeing is a condition that is related to out-toeing. It refers to feet that point outward. The causes of Out-toeing and in-toeing appear caused by the same bone development issues.
Diagnosis
Doctors ask about a child’s growth and development during well-child checkups. They will analyze the bones and strength of the child’s legs and feet, as well as observe the child walking. If they notice a problem, they may request X-rays.
Treatment
In general, no treatments are required because the common causes listed are normal variations in a growing child. Children who have in-toeing or out-toeing have no restrictions in their activities, which range from simple outdoor games to competitive sports. While rotational problems may cause some early difficulties for both children and parents, parents can expect their children to live normal, active, and healthy lives. At-home treatment can often resolve out and in-toeing. Parents may try the following home remedies.
Retrain Your Stance
Increase your awareness of how you position your feet when walking or standing. Out and in-toeing can be alleviated or reduced by doing so.
Use Orthotic Inserts
Look for orthotic inserts that provide arch support and lift. These may aid in heel stability and alignment.
Stretching and Exercising
Stretching exercises for the hamstrings and hips can help without in-toeing. Here are some easy stretches you may practice at home.
Wall Stretches
- Position a footstand or several thick books approximately 2 feet away from a wall.
- Stand on the footstand, allowing your heels to fall off the back edge
- You’re in the right place if your arches are supported but your heels aren’t.
- Lean against the wall and support your body with your hands. Your hands should be shoulder-length against the wall, and your arms should be fully extended.
- Lift one foot at a time up and down, stretching the foot and calf.
Tennis Ball Roll
- Take a seat on the floor, your legs outstretched in front of you.
- Roll a tennis ball back and forth under your calf for about 2 minutes.
- Increase the stretch by flexing your foot while rolling the ball.
- If your leg feels tight, tender, or sore, roll the ball on the outside of it.
- Repeat with the opposite leg.
- Do this several times a day.
Piriformis Stretches
- Lie down on your back and bend your knees so that your feet are about hip-width apart on the floor.
- Cross one leg over the other, pressing the ankle into the thigh just above the knee.
- Gently press down with your ankle for 60 seconds.
- A slight stretch should be felt throughout the thigh, hip, and lower back.
- Repeat on the opposite side.
Treatments for Duck/Out Toes
Your doctor may recommend the following medical treatments for duck-footedness:
Watchful waiting
If your child is under the age of six, their doctor may advise them to wait and see if the condition resolves on its own.
Physical therapy
A physical therapist can assist in the supervision of exercises that may retrain the legs and feet or reduce pressure and tightness in the hips.
Surgery
Surgery may be recommended if a bone deformity or slipped capital femoral epiphysis is discovered.
Treatments for Pigeons in-Toes
Without treatment, children with mild or moderate toeing tend to outgrow the problem. It may take a few years, but the bones will eventually align themselves. Infants with severe Metatarsus Adductus may require a series of casts on their affected foot or feet for several weeks. This does not usually occur until a baby is at least six months old. The casts are intended to correct alignment before your child begins to walk.
Our doctors may show stretches and massage techniques to assist the baby’s bones in growing in the correct direction. In most cases, no casts, braces, or special shoes are required for tibial torsion or medial femoral torsion. The issues simply require time to resolve. Night braces and a variety of other devices were once recommended for children with pigeon toes. However, these were not ineffective. If there has been no significant improvement by the age of 9 or 10, surgery may properly align the bones. The very first reason parents choose Medical City Children’s Orthopedics and Spine Specialists for their children is because we are experts in children’s health.
Parents should want their child treated by experts and we will provide that expertise. Our doctors and surgeons do it all the time in our Arlington, Dallas, Flower Mound, Frisco, and McKinney, TX offices. Finally, to obtain the very best diagnosis and treatment, we invite parents to give us a call to make an appointment for their child.
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Footnote:
National Library of Medicine: Out-Toeing and In-Towing Children
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