In-Toeing and Out-Toeing in Children

It takes time and practice for toddlers to learn how to walk. During this exciting time, sometimes they will stand and walk with their toes and feet turned inward or outward, conditions known as being pigeon-toed (in-toeing) or duck-footed (out-toeing).

At Banner Children’s, our caring team can help. Learn how in-toeing and out-toeing gait (walking) patterns may affect your child, what to watch for and treatment options.

What is the difference between in-toeing and out-toeing?

In-toeing, or being pigeon-toed, is a gait pattern where one or both feet turn inward instead of straight when a child walks or runs.

An out-toeing (duck-footed) gait pattern is just the opposite. Out-toeing means one or both feet point outward instead of straight when walking or running.

Both conditions are common in young children learning to walk and usually will not affect their ability to walk, run or play later in life. These gait patterns usually improve on their own but should still be looked at by your child’s health care provider.

What causes in-toeing and out-toeing?

These conditions usually happen because the bones in the leg turn inward or outward. The root causes are not always clear, but it is believed they are caused by the baby’s foot position in the womb or from family history.

Common causes for in-toeing include the following:

• Femoral anteversion: This happens when a child’s thighbone (femur) in the hip joint has a twist and turns inward. This causes the child to stand with their kneecaps and toes pointed in and to sit in a “W” shape with their knees bent and their feet flared out behind their body. As the child grows, the rotation usually corrects itself.
• Internal tibial torsion: This happens when a child’s shinbone (tibia) has a twist and turns inward. In almost all children the shinbone will correct itself and untwist, but it could take several years.
• Metatarsus adductus (curved foot): This is when the foot is curved inward. It can look slightly like a clubfoot but is very different. This condition usually corrects on its own after birth but may require treatment.

Common causes for out-toeing include the following:

• Hip contracture: Rotated hips on a baby can cause hip tightness and their toes to point outward. It usually goes away on its own when the child starts walking.
• External tibial torsion: This occurs when the shinbone is twisted outward. It is usually seen in late childhood and teenage years and affects one leg.
• Flat feet: This occurs when there is no arch in the foot, which can give the appearance of out-toeing. It usually improves on its own without treatment.
• Femoral retroversion: This is when the thigh bone has a twist and turns outward. It is not as common as femoral anteversion, but is more often seen in overweight children or teenagers with hip problems like slipped capital femoral epiphysis.

What are the symptoms of in-toeing and out-toeing?

The most noticeable sign of in-toeing or out-toeing is how your child’s feet are pointed when they stand, walk or run.

Most children with both conditions have no pain or functional problems. Sometimes, children who in-toe are clumsy and trip a lot. Depending on the reason for out-toeing, some children may limp and/or feel sore in one or both hips, thighs, knees or feet.

How are in-toeing and out-toeing diagnosed?

Your child’s health care provider will ask about your child's medical history, including any pregnancy or birth issues that may offer clues about the condition.

They will check your child's lower limbs, including the feet, ankles, legs and hips. They will also watch your child walk and run to check their gait and range of motion in their hips, knees, ankles and feet.

In rare circumstances, your child’s provider may also recommend imaging tests, such as X-rays, or additional neurological testing.

How is the treatment for in-toeing and out-toeing?

Your child’s treatment will depend on their condition, age, and other factors. In general, treatment may not be necessary as many of the common causes usually happen in a growing child and fix themselves over time.

Some conditions, like external tibial torsion and femoral retroversion/anteversion, may require orthopedic surgery to untwist the bone. However, surgery is usually only recommended for older children if the rotation is causing them pain or issues with walking and running.

Other basic treatments that may help correct inward and outward rotations include special shoes (orthotics), braces or casts and physical therapy exercises to help correct the gait pattern.

What is the long-term outlook for children who in-toe or out-toe?

Most children who in-toe or out-toe lead healthy, active and pain-free lives and can participate in most sports and recreational activities.

For parents, here are some important points to remember:

• Walking ability: In most cases, in-toeing or out-toeing does not affect a child's physical abilities. Most children simply develop their own walking style as they grow.
• Sports participation: Most children with these conditions can engage in any sport or activity that they like. Your child’s health care provider will let you know if your child has any restrictions.
• Developmental milestones: Meeting milestones like crawling, standing and running is more important than foot alignment. In-toeing or out-toeing do not necessarily mean your child has a long-term problem.

As a parent, patience and positive reinforcement will go a long way toward building your child’s confidence as they learn to walk and outgrow in-toeing or out-toeing. If pain or other problems come up, talk to your child’s health care provider.

How we care for pediatric conditions at Banner Children’s

Contact Banner Children's if you notice problems with how your child stands, walks or runs. Our pediatric orthopedic specialists offer your child complete care to cover all of their needs. We will explain all treatment options to help you choose what’s best for your child.