Dr. McIntyre often gets referrals for children who either walk with their feet turned in toward one another or turned out away from one another excessively. Often these are normal in the course of pediatric gait development but sometimes can be significant enough to need treatment through physical therapy or be an indication of a greater problem. In this blog Dr. McIntyre will go over pediatric in-toeing and out-toeing, when it is normal, when to seek consultation or treatment for your child, and how its treated in the clinic.
What is in-toeing?
In-toeing or pigeon toed is a gait pattern where a child’s toes point inward toward one another when standing, walking, or running. Generally mild in-toeing is a normal finding in gait development when the child is between 2-5 years of age and typically grows completely out of the presentation by 8 years old at the latest. In-toeing generally does not cause issues if mild, but if excessive, there is the potential for increased fall/injury rate, decreased balance, clumsiness of movement and pain in hips, knees, and feet. Skeletal causes relate to underlying skeletal changes that are typically seen in children and for the most part are part of normal gait development. Non-skeletal causes include muscle imbalances, weakness, and co-morbidities.
Skeletal Causes
Demonstrates all three causes of in-toeing.
Femoral Antetorsion: internal twisting of the femur (thigh bone) resulting in the rest of the lower extremity turning inward toward each other - sometimes including presentation of knock-kneed (or valgus). We are born with ~ 40d of antetorsion. By the time we reach adolescents, it decreases to 10-15d. In-toeing from femoral antetorsion is seen most typically between ages 2-4. It worsens when running or with fatigue at the end of the day. Femoral antetorsion resolves itself developmentally without intervention ~ 99% of the time. Studies have shown braces, special shoes, etc do not help speed up the position of the femur or change the natural progression of boney development.
Internal/medial Tibial Torsion: Internal rotation of the tibia (lower leg bone) causing the foot to turn in even though the knees are pointed straight. At birth we have 0-5 degrees of internal torsion of the tibia compared to the fibula. By 2 years old we should have 10-15d of external torsion and by 5 years of age into adulthood we have 23-30d of external torsion. Typically in-toeing from this cause is seen as soon as the child starts walking and may persist to the age of 4. Again, studies show intervention does not change the natural progression of boney development.
Metatarsus Adductus: a convexity of the lateral (outside) aspect of the foot: i.e. the forefoot curves medially (inward) causing the feet to look turned in even though the rest of the lower extremity alignment is neutral. Thought to be caused by decreased intrauterine space, most children have a flexible metatarsus adductus meaning it is correctible to neutral. 90-95% of children reduce their presentation naturally and their feet straighten out without intervention. In some cases a straight lass shoe (no curve in the shoe) can be worn to help promote the neutral alignment of the feet.
Non-skeletal causes:
Hip and core weakness: lack of good hip control can lead to the whole leg turning in and the in-toe presentation. Children may also toe-in to help stabilize their standing posture if their core is weak- using their ligaments and skeletal system to stay in an upright posture. Potentially may also be related to children who have lower tone from a genetic condition or other developmental issue.
Flat feet: the collapse of your child’s arch causes an internal rotation moment from the ground up on their lower extremity. This may lead to in-toeing presentation as a compensation for their flat feet.
Neurologic conditions: Children with spasticity may present with in-toeing from spastic medial (inside) leg muscles.
What is out-toeing?
Out-toeing or duck walking is a gait presentation where a child’s toes point excessively away from one another. Having 4-10 degrees of out-toeing is a normal presentation for all ages during walking especially into adolescents and adulthood. While excessive out-toeing is typically not an issue, sometimes it can cause increased stress on the hip, knee, and ankle and potentially lead to pain or difficult with dynamic activities like running and jumping. Causes are similar to in-toeing but reversed in-terms of torsion.
Skeletal Causes:
Femoral Retrotorsion: the femur (thigh bone) is rotated out leading the rest of the lower extremity to turn out.
Potentially associated with Slipped Capital Femoral Epiphysis (SCFE) which is ruled out via an x-ray and is a serious medical condition. SCFE is a condition where the head of the femur slips off the neck of the femur. Seen primarily in males during early adolescents
Legg-Calve-Perthes (LCP) may also cause toe-out. This is a condition where the head of the femur stops getting blood supply and the bone begins to die or become necrotic. This is also ruled out via x-ray and is a serious medical condition. Primarily seen in boys ages 6-10.
Tibial External/Lateral Torsion: the tibia (lower leg bone) rotates outward causing the foot to turn out as well.
Flat feet: the collapse of the arch sends the toes out to the side in compensation for the arch position. The “too many toes sign” is a good indicator that potentially flat feet are leading to your child’s out-toeing presentation.
Demonstrates flat feet causing out-toeing posture.
Non-Skeletal Causes:
Neurologic conditions: like cerebral palsy can lead to out-toeing just like in-toeing. The spasticity changes their gait pattern and causes different muscle tightness.
Breech Birth/External rotation contracture: Sometimes when an infant is in the womb with their legs flexed up and turned out they may start life with tightness that keeps their legs turned out. This typically diminishes as soon as they start weight bearing and walking independently.
Does my child need treated?
In all likelihood the answer is NO! Most typically developing children will naturally develop a mature gait pattern and their rotation of their leg will normalize as they age. However, if the gait pattern is causing pain, excessive tripping/falling, or difficulty with keeping up with peers or learning new motor/coordination skills then likely your child will benefit from physical therapy intervention. If your child has a co-morbidity that could lead to spasticity or low tone that may affect their gait pattern you child will likely greatly benefit from therapy.
Spontaneous in-toeing or out-toeing:
Did you child just start in or out-toeing spontaneously without a gradual increase in presentation? Are they limping and complaining of pain either in their hip or knee?
If this is the case, then I highly recommend visiting your pediatrician ASAP. LCP and SCFE (mentioned above) are serious conditions of the pediatric hip and need medical intervention.
Physical therapy to the rescue!
Physical therapy will work to address the gait pattern your child presents with through a variety of interventions. PT goals are typically not to completely eliminate the gait pattern as it may be from a boney alignment issue that will self correct over time. PT goals are traditionally to decrease any pain associated with the pattern, promote age appropriate balance, strength, and functional mobility skills, and decrease tripping/falling to prevent other injury from occurring secondary to the gait pattern.
Strengthening
In both gait presentations children tend to present with weakness in their hips, core, and other leg muscles. PT focuses on strengthening those muscles found to be weak during initial evaluation to promote better control of a neutral leg alignment.
Stretching
Obviously tightness is involved with either gait presentation. During your initial assessment your physical therapist will determine if your child has any tight muscles and give you exercises to help stretch them
Examples:
Butterfly stretch for in-toeing to help lengthen adductors and internal rotators of the hip
Piriformis stretch for out-toeing to help length the external rotators of the hip
Orthotics
A taping technique to promote neutral alignment from in-toeing
Research on orthotic interventions such as foot plates etc is not favorable for use to help with in-toeing or out-toeing
However, if the orthotics are just to treat the flat foot presentation that may be a contributing factor to your child’s gait pattern then they are recommended and at the minimum will not negatively effect the gait pattern.
However it is important to note that most young children present with a typical and normal pes planus until ~ the age of 4. Children under 4 bear weight through their entire foot and the medial arch does not start to develop until ~ 4-5 years of age. Your physical therapist will determine if your child’s feet are more pes planus than is typical and if they would benefit from orthotics.
Re-training gait and functional movements
The meat and bones of physical therapy!
Use of visual cues and verbal cues to help during specific exercises
Use of manual therapy techniques like wrapping or taping to promote improved alignment during exercises
Games that encourage playing with correct alignment working on balance and neutral alignment during gross motor and coordination skills.
For in-toeing especially recommendation to have your child sit criss/cross applesauce instead of W-sitting which may be their preferred method.
If your child is a pigeon or duck walker, likely they don’t need medical intervention just observation and your reassurance that your child will continue to develop normally. If you are concerned consult your pediatrician or a pediatric physical therapist for a recommendation on whether or not they need skilled intervention.