A- uptodate- Approach to the child with out-toeing 2022

Approach to the child with out-toeing

Author:
Scott B Rosenfeld, MD
Section Editor:
William A Phillips, MD
Deputy Editor:
Diane Blake, MD
Literature review current through: May 2024.
This topic last updated: Jul 15, 2022.
INTRODUCTION — Out-toeing is a rotational variation of the lower
extremity where the feet or toes point away from the midline during gait
(figure 1).

Out-toeing is one of the most common anatomic musculoskeletal variations

encountered by pediatric primary care providers and a frequent reason for
referral to a pediatric orthopedic surgeon. However, most children with out-
toeing have variations of normal lower-extremity development that will
improve spontaneously and can be monitored by the primary care provider.

This topic will provide an overview of lower-extremity rotational

development, common causes of out-toeing, pathologic causes of out-
toeing that must be excluded, and an approach to the evaluation and
management of the child with out-toeing. In-toeing is discussed separately.
(See "Approach to the child with in-toeing".)
NORMAL PHYSIOLOGIC ALIGNMENT — An understanding of the
normal growth and development of the lower extremity is essential in
evaluating a child's rotational alignment and helps to elucidate the
mechanism of out-toeing. Rotational alignment of the lower extremity is
determined by the alignment of the foot, the rotation of the tibia in relation to
the transcondylar axis of the femur (tibial torsion), and the rotation of the
neck of the femur in relation to the transcondylar axis of the femur (femoral
anteversion) (figure 2). In-toeing and out-toeing may be accentuated
between six months and five years, when children are developing their
walking and coordination skills [1]. Normal growth and improved
coordination typically lead to spontaneous resolution of rotational variations
(table 1).
Intrauterine positioning has an important influence on the rotational
alignment of the legs. At the seventh week of gestation, the lower limb
rotates medially (internally), followed by external (lateral) rotation of the
upper leg. For the remainder of gestation, the tibiae and feet are medially
(internally) rotated, and the hips and femora are laterally (externally) rotated,
resulting in an external rotation contracture at the hip joint (figure 3) [2].
Normal newborn posture reflects intrauterine positioning. The hips are
flexed and externally rotated, with the patellae pointing outward. The tibiae
and feet remain relatively internally rotated, but this is overshadowed by the
external rotation contracture at the hip [3]. Out-toeing due to external
rotation contracture of the hip usually resolves by the time the child begins
walking [4].
COMMON CAUSES OF OUT-TOEING — The most common causes of
out-toeing are external rotation contracture of the hip, external tibial torsion,
and femoral retroversion (table 2). Concomitant occurrence of these
conditions is uncommon.
External rotation contracture of the hip — The normal intrauterine position of
flexed and externally rotated hips results in an external rotation contracture
of the hips. This causes out-toeing when the young child is lying down as
well as when they begin to stand and walk. When combined with physiologic
tibia vara, hip external rotation contracture may accentuate the appearance
of bowed legs. External rotation contracture of the hip is typically bilateral
and symmetrical.

Characteristic examination features include:

●Bilateral and symmetrical out-toeing

●When standing and walking, both the patella and feet point away from
the midline (external foot progression angle and external patella
progression angle) (see 'Observation of gait' below)
●Increased hip external rotation compared with internal rotation
(see 'Focused examination of the lower extremities' below)
Out-toeing due to external hip rotation contracture usually resolves around
12 months of age when the child begins to walk [5]. The management of
external rotation contracture of the hip is discussed below. (See 'External
rotation contracture of the hip' below.)
External tibial torsion — External tibial torsion is likely a result of intrauterine
positioning but is usually discovered in late childhood (four to seven years of
age) or early adolescence [6]. It may be more common in preterm infants
secondary to prone positioning in the neonatal period [7]. It is often
unilateral and is more common on the right side [6].

Characteristic examination features include:

 ●When standing and walking the foot points outward relative to the
patella (external foot progression angle) (see 'Observation of
gait' below)
●The medial malleolus is anterior to the lateral malleolus (with the child
seated with the thigh directly in front of the hip joint and the knee
pointed straight ahead) (see 'Focused examination of the lower
extremities' below)
●In the prone position the thigh foot angle is external (figure 4)
(see 'Focused examination of the lower extremities' below)
Since normal development of the tibia causes external rotation, external
tibial torsion often does not improve spontaneously, and out-toeing due to
external tibial torsion may worsen over time. Despite this, external tibial
torsion rarely causes pain or functional abnormalities. Problems associated
with external tibial torsion may include difficulty in parallel skiing [8],
patellofemoral instability, and patellofemoral pain [9]. Knee pain from
external tibial torsion is most common when associated with increased
femoral anteversion (also known as "miserable malalignment," "torsional
malalignment syndrome," or "malignant malalignment syndrome") [6,10,11].
(See "Patellofemoral pain", section on 'Malalignment'.)
Femoral retroversion — Femoral retroversion is a rare cause of out-toeing. It
is associated with increased external rotation and decreased internal
rotation at the hip joint. It is more commonly observed in obese children [6].
Characteristic examination features include:
●Bilateral and symmetrical out-toeing
●External foot and patella progression angles (see 'Observation of
gait' below)
●Increased hip external rotation compared with internal rotation
(see 'Focused examination of the lower extremities' below)
Femoral retroversion may be associated with osteoarthritis [12], stress
fracture [13], and slipped capital femoral epiphysis [14]. (See "Evaluation
and management of slipped capital femoral epiphysis (SCFE)".)
UNCOMMON PATHOLOGIC CAUSES OF OUT-TOEING — Uncommon,
pathologic causes of out-toeing may include slipped capital femoral
epiphysis (SCFE), Legg-Calvé-Perthes disease (LCP, idiopathic
osteonecrosis of the hip), and neuromuscular disorders. Although these
etiologies are uncommon, they must be considered in the evaluation of a
child with out-toeing because they do not resolve spontaneously and may
result in long term disability. They can generally be excluded through
history, physical examination, and radiographs.
SCFE and LCP may result in proximal femoral deformity causing a
derangement in hip rotation with resultant out-toeing. Children with SCFE or
LCP most commonly have limited hip internal rotation. They may present
with acute or chronic pain in the hip, thigh, or knee with a limp and out-
toeing, which is usually unilateral. Examination may demonstrate painful
range of motion of the hip with decreased internal rotation and increased
external rotation. Anteroposterior and frog leg (lateral) pelvis radiographs
should be obtained in children with suspected SCFE or LCP. Referral to an
orthopedic surgeon is also warranted in such children. (See "Approach to
hip pain in childhood", section on 'Legg-Calvé-Perthes and secondary
avascular necrosis' and "Evaluation and management of slipped capital
femoral epiphysis (SCFE)", section on 'Evaluation'.)
Mild hemiplegic cerebral palsy rarely may present with an out-toeing gait
[15]. Spasticity secondary to cerebral palsy may result in over-pull of the
evertors of the foot, which may cause an asymmetric, unilateral out-toeing
gait. Asymmetry is a red flag. The history may reveal perinatal problems or
abnormal developmental milestones. Examination may demonstrate
spasticity of the gastro-soleus, hamstrings, peroneal muscles, and hip
adductors [16]. Such findings should prompt referral to a specialist (eg,
neurologist, physical medicine and rehabilitation specialist) for evaluation for
cerebral palsy. (See "Cerebral palsy: Classification and clinical features".)
CLINICAL PRESENTATION — The presenting complaints for a child with
out-toeing may include concerns about appearance of the legs or foot,
excessive falling, awkward running style, and uneven shoe wear.
EVALUATION — The objectives of the evaluation are to identify caregiver
concerns (eg, cosmesis, frequent falling, permanent disability, interference
with sports performance), identify the cause of out-toeing, and exclude
pathologic etiologies. The history and physical examination usually are
sufficient to achieve these goals.
History — Important aspects of the history include:
●Birth history, including gestational age and complications (prematurity
may be a clue to cerebral palsy or external tibial torsion).
●Developmental milestones (delayed milestones may be a clue to
cerebral palsy).
●Early hand preference (preference for one side before three years of
age may be a sign of hemiplegia) [16,17].
●Family history out-toeing (femoral retroversion and external tibial
torsion run in families); the clinical course of these problems in a sibling
or parent may help to reassure the family about spontaneous resolution
and lack of long-term sequelae.
●Onset:
•At birth (external rotation hip contracture)
•When the child began walking (external tibial torsion [may worsen
after age three] or [rarely] hip dislocation)
•Noticed after age three years (femoral retroversion)
•During adolescence (slipped capital femoral epiphysis [SCFE])
●Clinical course (recent change may indicate pathologic cause).
 ●Unilateral or bilateral? Symmetric or asymmetric? Unilateral or
asymmetric out-toeing may be a red flag for external tibial torsion,
cerebral palsy, SCFE, or Legg-Calvé-Perthes disease.
●Associated complaints: pain or limp (red flags for pathologic
conditions); tripping or falling (may be an indication for referral if they
persist beyond the normal age of resolution and are severe and
disabling).
●Perceived difficulties caused by out-toeing (must be addressed during
management). (See 'Management of common causes' below.)
Examination — The examination serves to exclude pathologic causes of
out-toeing, pinpoint rotational contributions, and identify associated angular
problems (eg, bow legs). The examination should include observation of
gait, focused examination of the lower extremity, and neurologic
examination. In some cases, evaluation of the parental rotational profile also
may be helpful.
Observation of gait — If the child is ambulatory, the child's gait should be
observed as the child walks toward and away from the examiner [2]. The
presence or absence of a limp should be noted.
The foot progression and patellar progression angles should be noted.
These angles describe the alignment of the foot and patella, respectively, as
they relate to the direction that the patient is moving. An external foot
progression angle describes a foot that points away from the midline as the
patient walks forward (figure 1). An external patellar progression angle
describes a patella that points away from the midline as the patient walks
forward. External rotation hip contracture, external tibial torsion, and femoral
retroversion generally have external foot and patellar progression angles,
although the patellar progression angle may be neutral in external tibial
torsion (table 2).
The child should also be observed while running [6,18]. Running may
accentuate neurologic dysfunction and rotational variations. Unilateral limp
while walking or running should raise suspicion of pathologic causes of out-
toeing.
Focused examination of the lower extremities — Examination of the rotational
alignment of the lower extremities is best done with the patient lying prone
on the examination table [1]. The caregivers should be encouraged to stand
with the examiner next to the patient so that they can appreciate the findings
as the examination is performed. The examination should progress through
the three main sites for rotational variations: foot, tibia, and femur/hip. This
can be accomplished by making the following measurements:
●Thigh-foot angle – The thigh-foot angle is measured with the knee
flexed and the ankle dorsiflexed so that the plantar surface of the foot is
parallel to the ceiling. Allow the foot to fall into a neutral position. A
visual line is approximated along the long axis of the thigh and a
 second line along the long axis of the heel. The angle between these
two lines is the thigh-foot angle (figure 4). If the line of the heel points
away from the midline relative to the thigh, it suggests external torsion
of the tibia. If the line of the heel points toward the midline relative to
the thigh, it suggests internal torsion of the tibia.
Normal values for the thigh-foot angle were determined in a study of
1000 limbs of 500 subjects (all White) ranging in age from <1 to 70
years [19]. The average thigh-foot angle at birth is -5 degrees (internal)
and increases to 15 degrees (external) at maturity.
●Hip rotation – Hip rotation is measured with the knees flexed (figure
5). Internal rotation is measured by rotating the leg away from the axis
of the body (rotating the hip internally). External rotation is measured
by rotating the leg towards the axis of the body (rotating the hip
externally).
Normal values for hip rotation were determined in a study of 1000 limbs
of 500 subjects (all White) ranging in age from <1 to 70 years (figure 5)
[19]. The average amount of internal hip rotation during childhood
ranges between 40 and 50 degrees. The average amount of external
hip rotation during childhood ranges between 40 and 70 degrees.
Patients with femoral retroversion will have increased external rotation
(to almost 90 degrees) and very little internal rotation [16]. Conversely,
patients with increased femoral anteversion may have as much as 90
degrees of internal rotation, allowing the legs to rotate flat against the
examination table. Similarly, they will have a decreased amount of
external rotation, often only to neutral.

Other aspects of the lower-extremity examination that may be helpful in

identifying associated conditions and excluding pathologic causes of out-
toeing include:

●Assessment for associated angular variations (knock-knees are

associated with external tibial torsion) (see "Approach to the child with
bow-legs", section on 'Physiologic varus' and "Approach to the child
with knock-knees", section on 'Physiologic valgus')
●Decreased hip internal rotation that is painful or associated with a limp
(may indicate SCFE; other clues include unilateral out-toeing and hip,
thigh, or knee pain) (see "Evaluation and management of slipped
capital femoral epiphysis (SCFE)")
Parental rotational profiles — Femoral retroversion and external tibial
torsion tend to run in families. Assessment of the parents' rotational profiles
as described above may help to predict how the child is likely to be affected
as an adult [6]. Such information may help to reassure the family about the
lack of long-term functional problems. (See 'Management of common
causes' below.)
Focused neurologic examination — A focused neurologic examination is
important to exclude cerebral palsy. The minimal neurologic examination
should include (see "Detailed neurologic assessment of infants and
children", section on 'Tendon reflexes'):
●Upper- and lower-extremity reflexes.
●Ankle clonus.
●Measurement of popliteal angles to assess hamstring spasticity. The
popliteal angle is measured by flexing the hip and the knee to 90
degrees and then extending the knee up to the point of mild resistance
(figure 6). The popliteal angle is the angle between the tibia and the
extension of the femur. Values ≥50 to 55 degrees are considered
abnormal in children [20,21].
●Asking the child to walk on their heels and toes and to hop on each
leg. Heel walking demonstrates the ability to dorsiflex the ankle. Toe
walking and hopping help to evaluate the child's overall motor
coordination level (which varies with age).
Radiographs — Radiographs generally are not necessary in the assessment
of out-toeing. External tibial torsion and femoral retroversion, the most
common causes of out-toeing in infants and school-age children, are
diagnosed clinically. Patients with unilateral out-toeing, pain, and limp
should be evaluated for SCFE with anteroposterior and frog leg (lateral)
radiographs of the pelvis. (See "Evaluation and management of slipped
capital femoral epiphysis (SCFE)", section on 'Plain radiographs'.)
DETERMINING THE CAUSE — The cause of in-toeing is determined
according clinical features (eg, age group, foot and patellar progression
angles, laterality, associated clinical features, and natural history) (table 2).
Asymmetry, pain, or limp are red flags for uncommon pathologic conditions
(eg, slipped capital femoral epiphysis, Legg-Calvé-Perthes disease
[idiopathic osteonecrosis of the hip]) and neuromuscular disorders (eg,
cerebral palsy).
INDICATIONS FOR REFERRAL — Most patients with out-toeing can be
followed in the primary care office. Indications for referral include:
●Unilateral or asymmetric out-toeing associated with clinical findings
suggestive of neurologic disorder (refer to a pediatric orthopedic
surgeon, pediatric neurologist, or physical medicine and rehabilitation
specialist).
●External tibial torsion causing activity-limiting or cosmetically
unacceptable out-toeing in children ≥8 years (may be candidates for
derotational osteotomy; refer to an orthopedic surgeon with expertise in
rotational problems).
●Femoral retroversion causing activity-limiting or cosmetically
unacceptable out-toeing in children ≥11 years (may be candidates for
derotational osteotomy; refer to an orthopedic surgeon with expertise in
 rotational problems).
●Combination of external tibial torsion and increased femoral
anteversion ("miserable malalignment") associated with knee pain. This
alignment combination can cause patellofemoral pain and may require
tibial and femoral derotational osteotomies. (See "Patellofemoral pain".)
●Patients with hip, thigh, or knee pain who limp and have unilateral out-
toeing and radiographs suggestive of slipped capital femoral epiphysis
or Legg-Calvé-Perthes disease should be referred urgently to an
orthopaedic surgeon for treatment. (See "Evaluation and management
of slipped capital femoral epiphysis (SCFE)", section on
'Management'.)
MANAGEMENT OF COMMON CAUSES
Caregiver reassurance — The natural history of most rotational variations is
spontaneous resolution as the child grows and develops. The most
important (and usually only) intervention that is necessary for the majority of
children with out-toeing is reassurance that:
●Out-toeing is a common developmental variation related to
intrauterine positioning
●Although out-toeing may be associated with an increased risk of hip
or knee pain, treatment is only required if symptoms develop
●Even if out-toeing does not completely resolve, long-term functional
problems are rare (occurring in approximately 1 in 1000 children) [6]

When reassuring the family, it can sometimes be helpful to explain that the
approach to management has changed over time. This is of particular
importance when there is a family history of out-toeing. Parents and
grandparents may recall a time when rotational variations were considered
serious problems and were treated with interventions now known to be
ineffective (eg, special shoes, orthotics). A brief explanation of how our
understanding of these problems has evolved can help reassure families.

To demonstrate the benign nature of out-toeing, one simple exercise is to

have the family member sit down in a public place and observe people
walking past. They will notice considerable variation in the direction that
people's feet point when they walk.

External rotation contracture of the hip — The natural history of out-toeing

due to hip external rotation contracture is that of spontaneous resolution.
External rotation contracture of the hip is present in less than 5 percent of
children by age 18 months [4]. Treatment includes observation and
caregiver reassurance that external rotation contracture of the hip is
physiologic and resolves spontaneously.
External tibial torsion — Although external tibial torsion may increase with
growth, it rarely becomes problematic before late childhood or adolescence.
Symptoms and sequelae may include difficulty parallel skiing, patellofemoral
instability, patellofemoral pain, knee arthritis, and osteochondritis dissecans
of the knee [3,6]. When combined with increased femoral anteversion
("miserable malalignment syndrome"), patients may develop patellofemoral
pain and instability.
Most children with external tibial torsion can be managed with observation
and caregiver reassurance that long term sequelae are rare. Bracing and
splinting are ineffective. Derotational tibial osteotomy is the only effective
treatment but should be reserved for patients with knee pain, severe
cosmetic and functional deformity, and an external thigh-foot angle greater
than 40 degrees [6].
Femoral retroversion — Femoral retroversion is unlikely to resolve
spontaneously. Bracing and twister cables are ineffective in correcting the
version of the femur. Derotational osteotomy may be indicated in patients
with hip pain, severe gait disturbance, or cosmetic deformity.
SUMMARY AND RECOMMENDATIONS
●Causes of out-toeing – The most common causes of out-toeing in
children are related to intrauterine molding and often resolve
spontaneously through normal growth and development. These include
(table 2):
•External rotation contracture of the hip – Physiologic external
rotation contracture of the hip is caused by intrauterine positioning
and present in children from birth until they begin to walk. External
rotation contracture of the hip is characterized by external foot and
patella progression angles, increased external rotation, and
decreased internal rotation. It usually resolves when children begin
to walk. (See 'External rotation contracture of the hip' above.)
•External tibial torsion – External tibial torsion is external (lateral)
rotation of the tibia in relation to the transcondylar axis of the
femur. It may be associated with prematurity and prone
positioning. It is characterized by an external foot progression
angle and neutral or external patella progression angle, and
medial malleolus even with or anterior to the lateral malleolus.
External tibial torsion usually does not correct spontaneously and
may increase with growth. Although most patients with external
tibial torsion remain asymptomatic, there may be an increased risk
of patellofemoral pain or instability and knee arthritis. Symptomatic
patients may require derotational osteotomy. (See 'External tibial
torsion' above.)
•Femoral retroversion – Femoral retroversion is a rare cause of
out-toeing. It is characterized by a decreased angle of rotation of
the femoral neck in relation to the transcondylar axis of the femur;
gait with outward facing feet and knees; and increased hip external
 rotation and decreased internal rotation. Femoral retroversion
does not improve spontaneously and may be associated with hip
or knee arthritis, stress fracture, and slipped capital femoral
epiphysis (SCFE). (See 'Femoral retroversion' above.)
●Pathologic causes of out-toeing – Pathologic conditions that must
be considered in the evaluation of a child with out-toeing include SCFE,
Legg-Calvé-Perthes (LCP) disease (idiopathic osteonecrosis of the
hip), and neuromuscular disorders. Among these, SCFE is the most
important to exclude. Anteroposterior and frog leg (lateral) radiographs
of the pelvis should be obtained in children with unilateral out-toeing
associated with hip, thigh, or knee pain and decreased internal rotation
of the hip. Children with radiographs suggestive of SCFE should be
urgently referred to an orthopedic surgeon. (See 'Uncommon
pathologic causes of out-toeing' above and 'Evaluation' above
and "Evaluation and management of slipped capital femoral epiphysis
(SCFE)".)
●Management of common causes of out-toeing – Most children with
rotational variations of the lower extremity can be followed in the
primary care office. The most important aspect of management of
rotational causes of out-toeing is caregiver reassurance that most
"deformities" correct spontaneously and that, even in persistent cases,
adverse long-term sequelae are rare. Nonoperative interventions (eg,
shoe inserts, braces, twister cables, casting) are ineffective in the
treatment of internal and external tibial torsion, increased femoral
anteversion, and femoral retroversion. These interventions should be
avoided. (See 'Management of common causes' above.)
●Indications for referral – Indications for referral for out-toeing include
external tibial torsion and femoral retroversion associated with severe
cosmetic or functional problems, hip pain, or knee pain; unilateral out-
toeing associated with limp, hip pain, or knee pain; and out-toeing with
concern for SCFE or LCP. (See 'Indications for referral' above.)
Topic 15691 Version 16.0
References

1 : Schoenecker PL, Rich MM, Gordon JE. The lower extremity. In: Lovell
and Winter’s Pediatric Orthopaedics, 7th ed, Weinstein SL, Flynn JM (Eds),
Wolters Kluwer Health, Philadelphia 2014. p.1261.

2 : La torsion du tibia, normal, pathologique, experimentale

3 : La torsion du tibia, normal, pathologique, experimentale

4 : 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.

5 : 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.

6 : Rotational problems in children.

7 : Effect of neonatal posture on later lower limb rotation and gait in

premature infants.

8 : The skiing sequelae of tibial torsion.

9 : The effect of tibial torsion of the pathology of the knee.

10 : Common lower extremity problems in children.

11 : Rotational deformities in the lower extremities.

12 : Diminished femoral antetorsion syndrome: a cause of pain and

osteoarthritis.

13 : External rotation of the hip. A predictor of risk for stress fractures.

14 : Mechanical factors in slipped capital femoral epiphysis.

15 : Mechanical factors in slipped capital femoral epiphysis.

16 : Mechanical factors in slipped capital femoral epiphysis.

17 : Mechanical factors in slipped capital femoral epiphysis.

18 : Torsional and angular deformities.

19 : Lower-extremity rotational problems in children. Normal values to guide

management.

20 : Normal ranges of popliteal angle in children.

21 : The hamstring index.

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