Clinical features of common causes of out-toeing in children

	External rotation contracture of the hip	External tibial torsion	Femoral retroversion
Description	Physiologic contracture related to intrauterine positioning	External (lateral) rotation of the tibia relative to the transcondylar axis of the femur	Decreased angle of rotation between the axis of the femoral neck and the transcondylar axis of the femur
Most common age group	Birth to one year	Late childhood, early adolescence	Older than three years
Foot progression angle	External	External	External
Patellar progression angle	External	Neutral or external	External
Evaluation	Increased external hip rotation; decreased internal hip rotation*	Thigh foot angle^¶ is external (positive)	Increased external hip rotation; decreased internal hip rotation*
Laterality	Usually bilateral and symmetrical	Often unilateral with the right side more often affected	Usually bilateral and symmetrical; when unilateral, the right side is more often affected
Other clinical features		Medial malleolus anterior to lateral malleolus when seated with thigh directly in front of hip joint and the knee pointed straight ahead May be associated with knock-knees May be associated with prematurity and prone positioning	Rare More commonly seen in obese children May be associated with slipped capital femoral epiphysis
Natural history	Usually resolves by 12 months	Usually does not correct spontaneously; may worsen over time, but rarely causes problems or sequelae (eg, patellofemoral pain or instability, arthritis of the knee)	Does not improve spontaneously May be associated with hip or knee arthritis, stress fractures, and slipped capital femoral epiphysis

* Hip rotation is measured with the child prone and the knees flexed. To assess external hip rotation, the lower leg is rotated toward the axis of the body; to assess internal rotation, the lower leg is rotated away from the axis of the body. Refer to UpToDate content on out-toeing in children for details.
¶ The thigh-foot angle is measured with the child prone, the knee flexed, and the ankle dorsiflexed so that the plantar surface of the foot is parallel to the ceiling. 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. Refer to UpToDate content on out-toeing in children for details.

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Clinical features of common causes of out-toeing in children