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How To Deal With In-Toeing And Out-Toeing In Children

Many a times, we find an abnormality in the walking trait of infants or children. It may develop from the time they started walking or even in the later years. Some children walk with their feet facing inwards or outwards instead of pointing straight. This phenomenon is referred to as in-toeing and out-toeing and they are extremely common.

However, most of the parents do not have an idea about the condition and are not quite sure if medical intervention is necessary or not. In this article, we will tell you everything you need to know about in-toeing and out-toeing in children, and how to deal with the condition.

What Is In-Toeing?

In-toeing in children is often referred to the feet of the child pointing inwards rather than straight. This may be quite noticeable while walking or running. This is quite a common complaint of parents whose kids may have started walking quite recently. This condition is also referred to as pigeon toe. It often happens due to a slight rotation or twist in the upper or lower leg bones [1] . Contrary to popular belief, in-toeing cannot be called a physical deformity as most of the cases have been known to resolve on their own with time.

Here are three common reasons of in-toeing in children.

1. Femoral anteversion: Known as the twisting of the femur bone of the leg, the femoral ante version is the most common cause of in-toeing in children. The condition in which the bone tends to twist towards the midline of the body is the main cause of in toeing. This is most often recognised by the inward pointing kneecaps and is known to resolve on its own with age [2] .

2. Tibial torsion: This is often recognisable as bow legs. Though it is common for the shin bone to twist a little to accommodate place in the uterus, the condition is said to resolve on its own after the child birth. If the lower legs still remain bend after the child has started walking, it may lead to in-toeing.

3. Metatarsus adductus: This is a condition where the middle part of the child's feet to the toes is bending inwards [3] . The bend in the foot is known to be caused due to intrauterine positioning. This condition is quite different from club foot as it is not very rigid and is known to resolve on its own.

What Is Out-Toeing?

Out-toeing is the exact opposite of in-toeing. It is the condition where the feet of the child is pointed outward in quite an abnormal manner. Although in-toeing is quite common, not many cases of out-toeing are known. Also, this condition usually affects children a little older. Some of the cases of out-toeing have also been known to be caused due to some serious underlying condition. Out-toeing in children is usually hereditary and runs in families.

Here are some common causes of out-toeing in children.

1. External rotation contracture of the hip: The hips of the foetus usually rotate outward in order to fit in the mother's womb. However, after birth, the hips are known to slip back into position [4] . If this is not resolved by the time the child starts walking, it can cause out-toeing.

2. External tibial torsion: This happens when the shin bone is twisted outwards. Although this condition is also due to the position of the foetus in the womb, the condition is not known to resolve on its own and medical intervention becomes necessary [5] .

3. Cerebral palsy: Children with cerebral palsy are known to have muscle imbalances, especially in the legs. A complete neurological diagnosis is needed in order to rule out the fact that the out-toeing in a child may be caused due to the onset of cerebral palsy [6] .

Diagnosis Of In-Toeing And Out-Toeing

In-toeing and out-toeing in children are usually diagnosed by a physical examination. The consulting doctor will examine the gait of the child [4] .

However, further examination in the form of an X-ray is needed only if the doctor deems necessary. This is usually in the case of out-toeing where the condition may be due to an underlying cause [8] .


In each of the three cases of in-toeing, there is no treatment necessary as the condition is known to resolve on its own [7] . If the child develops gait problems a bit later in life, it may be due to obesity. The excess weight on the delicate bones of the child's legs may cause gait problems [11] . Therefore, if your family has a history of obesity, it may be wise to keep your toddler's weight in check.

However, certain out-toeing cases such as external tibial torsion may not improve on its own and may need medical intervention. Usually a surgery is required to untwist the bones, if the out-toeing is causing limping or knee cap problems [8] .

There are certain cases where the child experience slight pain while performing activities that put extra pressure on the legs. While these problems may not be serious enough to require surgery, they may use braces or special shoes for support. Additionally, physiotherapy can also be performed in order to correct the child's gait [7] .

In-toeing and out-toeing in children usually resolves on their own. However, the condition is said to be hereditary to some degree. If you have in-toed or out-toed as a child, there are high chances of your child carrying the same problems. In such cases, ancient techniques of massaging the soft bones of newborn babies is definitely said to help straighten the bones [12] .

Will In-Toeing And Out-Toeing Cause Any Problems To Children In The Future?

Children with gait problems like in-toeing and out-toeing do not suffer any major problems in the future. As the conditions tend to resolve on their own, these children grow up as normal individuals capable of carrying out all sporting activities. Apart from a few problems with regards to out-toeing mentioned earlier in the article, other gait problems may just be a part of childhood that your child will just grow out of eventually [9] .

When To See A Doctor

If you have noticed your child in-toeing or out-toeing, there is nothing for you to worry about, unless there are complains of pain while walking, swollen feet or painful knees. You may only visit a doctor if your child isn't capable of walking or running without any pain. All the other cases of gait problems do not require a medical consultation at all [10] .

View Article References
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  2. [2] Faulks, S., Brown, K., & Birch, J. G. (2017). Spectrum of diagnosis and disposition of patients referred to a pediatric orthopaedic center for a diagnosis of intoeing.Journal of Pediatric Orthopaedics,37(7), e432-e435.
  3. [3] Li, Y. H., & Leong, J. C. Y. (1999). Intoeing gait in children.
  4. [4] Pitkow, R. B. (1975). External rotation contracture of the extended hip. A common phenomenon of infancy obscuring femoral neck anteversion and the most frequent cause of out-toeing gait in children.Clinical orthopaedics and related research, (110), 139-145.
  5. [5] Pitkow, R. B. (1975). External rotation contracture of the extended hip. A common phenomenon of infancy obscuring femoral neck anteversion and the most frequent cause of out-toeing gait in children.Clinical orthopaedics and related research, (110), 139-145.
  6. [6] Inan, M., Altintaş, F., & Duru, I. (2009). The evaluation and management of rotational deformity in cerebral palsy.Acta Orthop Traumatol Turc,43(43), 106-112.
  7. [7] Uden, H., & Kumar, S. (2012). Non-surgical management of a pediatric “intoed” gait pattern–a systematic review of the current best evidence.Journal of multidisciplinary healthcare,5, 27.
  8. [8] Lofterød, B., & Terjesen, T. (2010). Changes in lower limb rotation after soft tissue surgery in spastic diplegia: 3-dimensional gait analysis in 28 children.Acta orthopaedica,81(2), 245-249.
  9. [9] Weseley, M. S., Barenfeld, P. A., & Eisenstein, A. L. (1981). Thoughts on in-toeing and out-toeing: twenty years' experience with over 5000 cases and a review of the literature.Foot & ankle,2(1), 49-57.
  10. [10] Terminology, O. (2003). Lower extremity abnormalities in children.Am Fam Physician,68(3), 461-468.
  11. [11] Mueller, S., Carlsohn, A., Mueller, J., Baur, H., & Mayer, F. (2016). Influence of obesity on foot loading characteristics in gait for children aged 1 to 12 years.PloS one,11(2), e0149924.
  12. [12] Loi, E. C., Buysse, C. A., Price, K. S., Jaramillo, T. M., Pico, E. L., Hansen, A. B., & Feldman, H. M. (2015). Myofascial structural integration therapy on gross motor function and gait of young children with spastic cerebral palsy: a randomized controlled trial.Frontiers in Pediatrics,3, 74.
Story first published: Tuesday, May 7, 2019, 16:45 [IST]