In-toeing (Pigeon-Toed) and Out-Toeing (Duck-Footed)

Overview

What are in-toeing and out-toeing?

In-toeing means the feet turn toward each other (instead of pointing straight ahead) when a child walks or runs. Also known as being pigeon-toed, in-toeing is actually a normal stage in childhood development. In more than 95% of children with in-toeing, the lower limbs gradually rotate out on their own until about 10 years of age. At this point, the adult shape of the legs is set and no further improvement can be expected. In-toeing almost always gets better on its own and doesn't pose a problem during childhood – or adulthood.

Out-toeing, or being duck-footed, means the feet point outward instead of straight ahead when a child walks or runs. It can also be a normal part of development. However, because the lower limbs tend to rotate further outward with growth, out-toeing may stay the same or become more pronounced as the child matures.

Symptoms of in-toeing and out-toeing

In severe cases, the rotation of the legs and feet is so extreme that the child has difficulty running, playing and participating in normal childhood activities. Out-toeing is more likely to cause problems than in-toeing. In fact, in-toeing may be a functional advantage – athletes tend to be pigeon-toed more often than the general population.

In addition, children may perceive severe in-toeing or out-toeing as embarrassing or unattractive, which can have negative effects on body image and self-esteem. While it may be more widely accepted to treat these conditions for functional reasons, we believe appearance concerns need to be factored into treatment decisions as well.

Causes of in-toeing and out-toeing

In-toeing and out-toeing are often caused by a slight rotation of the upper or lower leg bones. This can occur for several reasons.

In-toeing may be caused by:

• Metatarsus adductus. Some babies are born with the front of one or both feet turned inward, giving the foot a C shape. This is usually due to the baby's position in the uterus, and it generally goes away on its own by the baby's first birthday.
• Internal tibial torsion. In this condition, the tibia (commonly known as the shinbone) rotates inward. It's usually detected after age 1, once the child begins to walk. Most kids outgrow it by age 5.
• Femoral anteversion. This is when the thigh bone, or femur, rotates inward. It's usually diagnosed after age 3 and improves as the child grows.

Out-toeing may be caused by:

• External rotation contracture of the hip. This is caused by the baby's natural position in the womb, with hips flexed and turned out. It usually self-corrects when the child starts walking, around 1 year of age.
• External tibial torsion. This is when the shinbone (tibia) turns outward. It's also caused by the baby's position in the womb, but unlike external rotation contracture of the hip, it usually doesn't improve as the child grows.
• Femoral retroversion. This is when the femur (thigh bone) turns outward. It usually doesn't get better on its own.
• Flatfoot. Having flatfoot (when the feet have low or no arches) can make it look as if a child is out-toeing. This generally improves without any treatment.
• Other conditions. Although it's rare, out-toeing can be caused by other disorders, such as slipped capital femoral epiphysis, Legg-Calvé-Perthes disease  and cerebral palsy.

Treatment of in-toeing and out-toeing

Because in-toeing corrects itself in 95% of children by the time they’re 10 years old, those who have it are simply observed, usually by their pediatricians, until they reach that age. This allows normal development to take its course, while the provider keeps a lookout for potential problems.

If significant in-toeing or out-toeing persists, you may want to consult a pediatric orthopedic surgeon.

Surgery for in-toeing and out-toeing

A surgical procedure called rotational osteotomy is the only intervention that can alter alignment of the lower limbs in a child with in-toeing or out-toeing. Braces, special shoes and physical therapy aren't effective.

In a rotational osteotomy, the thigh bone (femur) or bones of the lower leg (tibia and fibula) are cut and rotated so that the feet align properly. Metal implants – typically pins or a plate and screws – keep the bones in place while they heal in their new orientation.

Rotational osteotomy is a major operation. Possible complications include:

• Bleeding and infection. These risks are commonly associated with orthopedic operations.
• Implant failure. The metal implants can dislodge from the bone. If this happens, the correction is lost and the implants must be replaced.
• Injury to the hip’s blood supply. While this is uncommon (affecting well under 10% of kids who undergo surgery), it can have devastating consequences to hip function, including painful arthritis and stiffness.

Although surgery is the only way to change severe in-toeing or out-toeing, the benefits must be carefully weighed against the risks for each child.