Pediatric Orthopedic Surgeons treating Out-toing and In-Toeing

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.”

At Medical City Children’s Orthopedics and Spine Specialists, our expert Osteomyelitis Doctors are dedicated to diagnosing and treating Out-Toeing and In-Toeing in children, ensuring comprehensive care tailored to each patient’s needs. With advanced techniques and a compassionate approach, our team is here to help your child walk correctly.

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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.

Out-toeing is sometimes seen in young children as a normal part of keeping their balance while they are learning to walk. Most children with out-toeing will improve naturally as they grow older, but it’s important for children with persistent out-toeing to be evaluated for hip problems to rule out any underlying conditions.

In-Toeing

In-toeing, sometimes described as “pigeon toes,” often occurs when the lower leg bones (tibia) rotate inward. This is a common alignment variation in young children and often results from the natural position of a child’s legs while developing in the womb. Parents tend to notice in-toeing as their child begins to walk, with the toes pointing toward the midline rather than straight ahead.

The good news is that in-toeing due to internal tibial torsion usually improves naturally over time—many children outgrow it as their legs straighten with age, typically by about 6 years old. There’s no need for special shoes, braces, or bars (which were once suggested); comfortable, well-fitting footwear from brands like Stride Rite or New Balance works just fine. What matters most is that your child feels comfortable and confident as they move, whether they’re sporting sneakers, sandals, or boots.

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?

Seeking Medical Advice

Parents often seek medical advice for their child’s walking positions due to concerns about “rotational deformities,” such as out-toeing or in-toeing. These conditions frequently prompt consultations with orthopaedic surgeons, physiotherapists, or podiatrists for specialized assessments. The unusual walking patterns naturally raise questions about whether intervention is necessary to ensure healthy development.

It’s important to note that most cases of out-toeing or in-toeing do not require treatment, as they often improve with time as the child’s musculoskeletal system matures. For example, children with out-toeing should be evaluated for hip problems to rule out underlying issues, but the majority will get better as they get older. Similarly, in-toeing—commonly seen in toddlers and young children—tends to resolve as the child grows and develops strength and coordination.

However, if the gait abnormality is persistent, or if it is causing pain, discomfort, or difficulty with activities, the doctor may recommend treatment. Some signs that further evaluation might be needed include:

The abnormal walking pattern does not improve or worsens over time
The child experiences pain, frequent tripping, or difficulty keeping up with peers
There is a family history of musculoskeletal disorders
The child’s walking pattern is noticeably asymmetric

Treatment options may include:

Physical therapy
Orthotics
Specialized footwear
Surgery (in rare cases)

The doctor will provide guidance on whether intervention is necessary and the most appropriate course of action. By understanding the potential need for specialized assessment and treatment, parents can make informed decisions about their child’s health and well-being.

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.

Understanding W-Sitting and Its Impact on Child Development

W-sitting is a position in which a child sits on the floor with their buttocks positioned on the ground, and their knees bent, causing the legs to splay out to the sides, resembling the letter “W”. This posture is commonly adopted by children due to its stability and comfort, making it easy for them to sit and play without much effort.

Impact on Muscle Development:

W-sitting can contribute to muscle imbalances in the hips and legs. This position may limit the activation of core muscles and restrict the rotation of the trunk, potentially leading to weaker core and hip muscles over time.

Children with femoral anteversion often display certain habits and movement patterns. For instance, they may prefer to sit with their legs folded under them in a “W” shape—this is especially common in preschoolers around age three. Walking or running with their knees and feet turned inward is often noticeable as well. These behaviors are typically a normal part of development and often become less pronounced as a child gets older, usually improving on their own by the age of eight.

Causes of Out-Toeing and 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-Pertes Syndrome: This 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.

Additionally, out-toeing can be related to a condition called femoral retroversion, where the thigh bone (femur) is rotated outward. This is another reason children may walk with their feet turned out, especially in the early years. 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. 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 or femoral anteversion. Girls are more likely than boys to develop medial femoral torsion.

In-toeing (Femoral Anteversion)

Femoral anteversion occurs when the bone in the upper leg (the femur) is rotated inward. This inward twist is a normal part of growth and development and is most commonly noticed around the age of 3. Children with femoral anteversion often prefer to sit in the “W” position, with their legs folded under them. While this posture may look unusual, it’s important to know that femoral anteversion typically improves on its own, often up until about 8 years of age. There are no shoes or braces that have been shown to help correct this condition. Instead, most children gradually outgrow it as their bones develop and their gait matures.

Out-Toeing and In-Toeing 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.

Out-Toeing and In-Toeing Diagnosis

Diagnosing in-toeing (pigeon-toeing) or out-toeing in children begins with a thorough clinical evaluation by a pediatrician or pediatric orthopedic specialist. The doctor starts by taking a detailed history, asking about the child’s developmental milestones, any family history of gait abnormalities, and the onset or progression of the toeing pattern. During the physical exam, the physician observes the child’s gait while walking or running, noting the foot’s orientation—whether the toes point inward (in-toeing) or outward (out-toeing).

They assess the range of motion in the hips, knees, and ankles, looking for underlying causes like femoral anteversion (inward twist of the thigh bone), tibial torsion (twist of the shin bone), or foot deformities such as metatarsus adductus. The doctor may also evaluate for associated conditions, such as Legg-Calvé-Perthes syndrome, which can contribute to out-toeing due to hip joint changes, or cerebral palsy, which might affect overall alignment and muscle control.

If the physical exam raises concerns, the doctor may order imaging to confirm the diagnosis and rule out more serious conditions. X-rays of the hips, legs, or feet can reveal structural abnormalities, such as excessive femoral anteversion or tibial torsion, while an MRI or CT scan might be used in complex cases to assess soft tissue or cartilage involvement, particularly if a condition like Legg-Calvé-Perthes is suspected. The doctor also measures rotational profiles, such as the degree of internal or external hip rotation, to quantify the severity of the misalignment.

In most cases, in-toeing or out-toeing is benign and resolves naturally as the child grows, but persistent or severe cases may require monitoring or intervention, especially if they impact function or cause pain. This comprehensive approach ensures an accurate diagnosis and guides appropriate management.

Out-Toeing and In-Toeing 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. Orthotic inserts are an effective, inexpensive solution for retraining your muscles and regaining a normal gait. They help stabilize the heel and keep your foot aligned, preventing it from turning outward as you walk.

If your duck feet condition is due to an injury or weakened muscles, orthotics offer additional support and comfort. This can be crucial in addressing discomfort during walking. Moreover, these inserts play a preventative role by potentially healing or preventing plantar fasciitis, which can occur due to a flattening arch.

By incorporating orthotic inserts into your footwear, you take a proactive step towards improving foot health and overall walking mechanics.

Stretching and Exercising

Improving a duck feet gait requires a consistent routine of stretching exercises that target the right muscles. Spending just 20 minutes each day on these stretches can help limber up muscles, avoid soreness, and guide you towards a realigned gait. By focusing on the same foot and leg stretches often used to treat plantar fasciitis, you can make significant progress.

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.

These wall stretches are crucial in loosening up the calf muscles, thus providing support for correcting your gait.

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.

Regularly rolling a tennis ball under your calves can relieve tension and prepare your legs for the transition to a healthier gait.

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.

Incorporating these piriformis stretches will not only enhance flexibility but also support the alignment needed to improve a duck feet walk. Consistent practice of these exercises can significantly contribute to a more aligned gait, helping you walk with better posture and confidence.

Shoes or Braces for Femoral Anteversion?

When it comes to femoral anteversion—a condition where the thigh bone turns inward—it’s natural to wonder if a special pair of shoes or a high-tech brace might speed things along. The reality is, there aren’t any shoes, orthotic devices, or braces that have been shown to correct this particular alignment. Despite what the latest catalog or website might promise, neither orthopedic shoes, inserts, nor popular brands like Dr. Scholl’s or Superfeet will change the natural development of femoral anteversion.

Most children with femoral anteversion are first noticed around age 3, and many may also prefer to sit in the classic “W” position. While this posture might raise eyebrows, it’s usually harmless and part of a normal growth pattern. In most cases, femoral anteversion improves on its own, often resolving significantly by the age of 8 as bones and muscles mature.

Instead of focusing on corrective footwear or braces, encourage active play and age-appropriate movement. Patience is key—the vast majority of kids outgrow the inward rotation without any lasting issues.

How Massage Eases Discomfort from Altered Walking Patterns

Altering the way you walk can often lead to muscle tension and soreness. This discomfort usually arises because your muscles and joints are adjusting to the new movement patterns. Fortunately, massage therapy offers an effective remedy, providing multiple benefits that target the root of this discomfort.

Relaxes Tight Muscles

Massage helps to ease tight muscles, which is often a result of unusual strain when you change your gait. By focusing on muscle relaxation, massage practitioners can reduce tension, promoting a more natural movement.

Enhances Circulation

Improved blood flow is another crucial benefit of massage. With better circulation, your muscles receive more oxygen and nutrients, speeding up recovery. This means less pain and quicker adaptation to new walking patterns.

Myofascial Release Techniques

Myofascial release is a specialized technique used in massage therapy. It specifically targets the fascia, a connective tissue surrounding muscles. This release can help alleviate stiffness, offering relief from the stress placed on your body by changes in your gait.

Supports Flexibility and Range of Motion

Massages also increase flexibility and improve the range of motion in your joints. This can ease the transition to a new gait, making movements smoother and less painful. Whether you’re dealing with recent changes or preparing for a gait adjustment, incorporating massage into your routine can make a significant difference in managing and reducing discomfort.

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. This approach is often taken with young children since their bodies are still developing, and the alignment may naturally correct itself over time.

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. Daily stretching exercises, similar to those used for plantar fasciitis, can help in realigning the gait and strengthening the muscles. Spending just 20 minutes a day on simple exercises can make a noticeable difference.

Surgery

Surgery may be recommended if a bone deformity or slipped capital femoral epiphysis is discovered. This option is generally considered when other treatments have not yielded results or if the structural issue is severe.

Self-Care and Lifestyle Adjustments

In addition to medical treatments, consider incorporating some simple self-care practices into your daily routine. Paying attention to foot positioning while walking, standing, or resting can significantly impact your gait. Aim to keep your feet facing forward to encourage proper muscle alignment.

Orthotic Inserts

Using orthotic inserts in your shoes is another effective method for improving foot alignment. These inserts can stabilize the heel and support the arch, making it easier to maintain a correct gait. They are especially helpful if muscle weakness or injury contributes to duck-footedness.

Massage and Myofascial Release

To alleviate any muscle soreness from realignment efforts, consider regular massage or self-myofascial release techniques. These can help relax tight muscles and reduce discomfort as you adjust your walking pattern.

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 Dallas, Arlington, 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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