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Approach to the child with out-toeing

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: Jan 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.)

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