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Chapter 61: In-Toeing and Out-Toeing in a Child

Wendi W. McKenna

Description of the Symptom

In-toeing and out-toeing postures may be seen during quiet stance or gait.1,2,3 These postures are recognized by an excessive bilateral or unilateral angulation of the foot longitudinal axis toward or away from a child's line of forward progression, respectively (Fig. 61-1). This chapter describes possible causes of in-toeing and out-toeing in a child.

FIGURE 61-1

Out-toeing bilaterally with left foot more affected than right.

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Special Concerns

  • Post-traumatic changes in lower extremity alignment or a painful limp

  • Progressive limp leading to refusal to walk with or without pain

  • Grossly asymmetric presentation of lower extremity alignment

  • History of multiple fractures

CHAPTER PREVIEW: Conditions That May Lead to In-Toeing and Out-Toeing in a Child
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CHAPTER PREVIEW: Conditions That May Lead to In-Toeing and Out-Toeing in a Child
T  Trauma
IN-TOEING OUT-TOEING
COMMON
Not applicable Slipped capital femoral epiphysis 1175
UNCOMMON
Not applicable Not applicable
RARE
Not applicable Not applicable
I  Inflammation
IN-TOEING OUT-TOEING
COMMON
Not applicable Not applicable
UNCOMMON
Not applicable Not applicable
RARE
Not applicable Not applicable
M  Metabolic
IN-TOEING OUT-TOEING
COMMON
Not applicable Overweight and obesity 1175
UNCOMMON
Not applicable Not applicable
RARE
Not applicable Not applicable
Va  Vascular
IN-TOEING OUT-TOEING
COMMON
Avascular necrosis of the femoral head (Legg-Calvé-Perthes disease) 1169 Not applicable
UNCOMMON
Not applicable Not applicable
RARE
Not applicable Not applicable
De Degenerative
IN-TOEING OUT-TOEING
COMMON
Not applicable Not applicable
UNCOMMON
Not applicable Not applicable
RARE
Not applicable Not applicable
Tu  Tumor
IN-TOEING OUT-TOEING
COMMON
Not applicable Not applicable
UNCOMMON
Not applicable Not applicable
RARE
Not applicable Not applicable
Co  Congenital
IN-TOEING OUT-TOEING
COMMON

Excessive femoral anteversion (torsion) 1171

Medial tibial torsion 1171

Metatarsus adductus 1171

Muscle imbalance or weakness 1172

Talipes equinovarus (clubfoot) 1172

Femoral retroversion (torsion) 1174

Lateral tibial torsion 1174

Muscle imbalance or weakness 1174
UNCOMMON
Not applicable Not applicable
RARE
Not applicable Bladder exstrophy 1173
Ne  Neurogenic/Psychogenic
IN-TOEING OUT-TOEING
COMMON
Cerebral palsy 1170 Cerebral palsy 1173
UNCOMMON
Not applicable Not applicable
RARE
Tethered cord syndrome 1173 Not applicable

Note: These are estimates of relative incidence because few data are available for the less common conditions.

Common Ages at Which In-Toeing and Out-Toeing Present in a Child
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Common Ages at Which In-Toeing and Out-Toeing Present in a Child
APPROXIMATE AGE CONDITION
Birth to 3 Years

Abnormal tibial torsion

Bladder exstrophy

Cerebral palsy

Excessive femoral anteversion (torsion)

Femoral retroversion (torsion)

Metatarsus adductus

Muscle imbalance or weakness

Overweight and obesity

Talipes equinovarus (clubfoot)

Tethered cord syndrome
Preschool (3–5 Years)

Abnormal tibial torsion

Cerebral palsy

Excessive femoral anteversion (torsion)

Femoral retroversion (torsion)

Metatarsus adductus

Muscle imbalance or weakness

Overweight and obesity

Tethered cord syndrome
Elementary School (6–11 Years)

Abnormal tibial torsion

Avascular necrosis of the femoral head ...

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