Out-toeing is a common condition in toddlers and young children in which the foot turns outward, and is the opposite to in-toeing (see our previous blog). It can cause children to trip and appear clumsy when walking and running. Often, an out-toeing gait can cause a condition called paediatric pes planus (flat feet in children) and lead to other lower leg complaints. There are three common causes of out-toeing, which can occur in isolation or a combination of all three.

External Tibial Torsion

Occurs when the large lower leg bone (tibia) is turned outward relative to the knee joint. In most kids from the age of 4, it is normal for the knee to be straight and the feet turned slightly outward. However, excessive external rotation will result in an abnormal gait and pain. 

External Femoral Torsion

Occurs when the large thigh bone (femur) is turned outward relative to the hip joint. This will cause the knee to turn outward and likely lead to the feet also turning outward. 

Flat Feet

Depending on the severity of your child’s flat feet, they may also display an out-toeing appearance of the lower leg. When the arch of your foot collapses it causes the forefoot to turn outward, leading to an out-toeing of the lower leg. 

Signs and Symptoms 

• One or both feet turned outwards
• Knees may point outwards
• ‘duck’-footed appearance 
• Flat-footed appearance 
• Clumsy gait when walking and running 

Pain is not commonly noted with children who display an out-toeing gait, however they may note tightness in various muscle groups (particularly around the hip, calf and into the foot). 

Examinations

Our podiatrists take a thorough history regarding birth history and developmental milestones. Physical examinations include a thorough gait analysis including walking and running, and range-of-motion of various joints. We examine each muscle group thoroughly and if required, perform a neurologic examination to determine any muscular tightness, nerve function and coordination. If the history is consistent with out-toeing as normal development, no further testing is required. In special circumstances, x-rays may be required to determine any bony pathology. 

Treatment 

Treatment is dependent on the underlying cause for the out-toeing. In normal developmental out-toeing, the child usually grows out of it by 10 years of age. Occasionally, external tibial torsion and external femoral torsion may require surgery to untwist the bones in severe cases. 

Footwear, bracing and physical therapy can help to provide pain relief, along with either over-the-counter or custom-orthotics if indicated.