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Approach to the child with out-toeing

INTRODUCTION

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 [1]. Normal growth and improved coordination typically lead to spontaneous resolution of rotational variations (table 1).

                     

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Literature review current through: Nov 2014. | This topic last updated: Mar 28, 2014.
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References
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  1. Schoenecker PL, Rich MM. The lower extremity. In: Lovell and Winter's Pediatric Orthopaedics, 6th ed, Morrissy RT, Weinstein SL (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1158.
  2. LeDamany P. La torsion du tibia, normal, pathologique, experimentale. J Anat Physiol 1909; 45:598.
  3. Staheli LT. Lower limb. In: Fundamentals of Pediatric Orthopedics, 4th ed, Lippincott Williams & Wilkins, Philadelphia 2008. p.135.
  4. Pitkow RB. External rotation contracture of the extended hip. A common phenomenon of infancy obscuring femoral neck anteversion and the most frequent cause of out-toeing gait in children. Clin Orthop Relat Res 1975; :139.
  5. Johnston CE. Disorders of the leg. In: Tachdjian's Pediatric Orthopaedics, 4th, Herring JA (Ed), Saunders, Philadelphia 2008. p.973.
  6. Staheli LT. Rotational problems in children. Instr Course Lect 1994; 43:199.
  7. Katz K, Krikler R, Wielunsky E, Merlob P. Effect of neonatal posture on later lower limb rotation and gait in premature infants. J Pediatr Orthop 1991; 11:520.
  8. Winter WG Jr, Lafferty JF. The skiing sequelae of tibial torsion. Orthop Clin North Am 1976; 7:231.
  9. Turner MS, Smillie IS. The effect of tibial torsion of the pathology of the knee. J Bone Joint Surg Br 1981; 63-B:396.
  10. Scherl SA. Common lower extremity problems in children. Pediatr Rev 2004; 25:52.
  11. Karol LA. Rotational deformities in the lower extremities. Curr Opin Pediatr 1997; 9:77.
  12. Tönnis D, Heinecke A. Diminished femoral antetorsion syndrome: a cause of pain and osteoarthritis. J Pediatr Orthop 1991; 11:419.
  13. Giladi M, Milgrom C, Stein M, et al. External rotation of the hip. A predictor of risk for stress fractures. Clin Orthop Relat Res 1987; :131.
  14. Pritchett JW, Perdue KD. Mechanical factors in slipped capital femoral epiphysis. J Pediatr Orthop 1988; 8:385.
  15. Muscular Affectations of the Muscular System. In: Clinical Pediatric Orthopaedics: The Art of Diagnosis and Principles of Management, Tachdjians, MO (Eds), Appleton and Lange, Stamford 1997. p.381.
  16. Tachdjian MO. The knee and leg. In: Clinical Pediatric Orthopedics: The Art of Diagnosis and Principles of Management, Appleton and Lange, Stamford 1997. p.87.
  17. Tachdjian MO. Generalized affectations of the muscular skeletal system. In: Clinical Pediatric Orthopedics: The Art of Diagnosis and Principles of Management, Appleton and Lange, Stamford 1997. p.369.
  18. Bruce RW Jr. Torsional and angular deformities. Pediatr Clin North Am 1996; 43:867.
  19. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am 1985; 67:39.
  20. Katz K, Rosenthal A, Yosipovitch Z. Normal ranges of popliteal angle in children. J Pediatr Orthop 1992; 12:229.
  21. Kuo L, Chung W, Bates E, Stephen J. The hamstring index. J Pediatr Orthop 1997; 17:78.