In-toeing (“pigeon-toeing”) is a rotational variation of the lower extremity where the feet or toes point toward the midline during gait (figure 1). Out-toeing is a rotational variation of the lower extremity where the feet or toes point away from the midline during gait (figure 1).
In-toeing and out-toeing are among 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 in-toeing or out-toeing have variations of normal lower-extremity development that will improve spontaneously and can be monitored by the primary care provider.
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. The most common causes of out-toeing in children are external rotation contracture of the hip, external tibial torsion, and femoral retroversion. These rotational variations are seen in normal, healthy children, and rarely persist into adolescence. Although out-toeing rarely causes dysfunction, out-toeing due to persistent external tibial torsion may be associated with patellofemoral pain. History and examination generally are sufficient to distinguish common rotational variations from less common pathologic causes of in-toeing and out-toeing (eg, hemiplegic cerebral palsy). (See 'Evaluation' below.)
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
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 . Normal growth and improved coordination typically lead to spontaneous resolution of rotational variations (table 1).