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In-Toeing and Out-Toeing

Whether your baby rises from a crawl with a shaky first step or a full-on sprint across the living room, chances are you'll be on the edge of your seat. But remember - a child's first steps usually aren't picture perfect. But for some little ones, there are certain conditions that can make walking more difficult, like in-toeing and out-toeing. In those cases, Cook Children's orthopedic specialists are here to help.

What causes in-toeing or out-toeing?

Most toddlers toe-in or -out because of a slight rotation, or twist, of the upper or lower leg bones.

Tibial torsion, the most common cause of in-toeing, occurs when the lower leg bone (tibia) tilts inward. If the tibia tilts outward, a child will toe-out. When the thighbone, or femur, is tilted, the tibia will also turn and give the appearance of in-toeing or out-toeing. The medical term for this is femoral anteversion. In-toeing can also be caused by metatarsus adductus, a curvature of the foot that causes toes to point inward.

Why some kids develop gait abnormalities and others don't is unclear, but many experts think that a family history of in-toeing or out-toeing plays a role. So, if you toed-in or -out as a child, there's a chance that your child could develop the same tendency.

Also, being cramped in the womb during pregnancy can contribute to a child in-toeing or out-toeing. As a fetus grows, some of the bones have to rotate slightly to fit into the small space of the uterus. In many cases, these bones are still rotated to some degree for the first few years of life. Often this is most noticeable when a child learns to walk because if the tibia or femur tilt at an angle, the feet will too.

Does walking improve?

As most kids get older, their bones very gradually rotate to a normal angle. Walking, like other skills, improves with experience, so kids will become better able to control their muscles and foot position.

In-toeing and out-toeing gets better over time, but this happens very gradually and is hard to notice. So doctors often recommend using video clips to help parents track improvement. Parents can record their child walking, and then wait about a year to take another video. This usually makes it easy to see if the gait abnormality has improved over time. In most cases, it has. If not, parents should speak with their child's doctor to discuss whether treatment is necessary.

In the past, special shoes and braces were used to treat gait abnormalities. But doctors found that these didn't make in-toeing or out-toeing disappear any faster, so they're rarely used now.

What if walking doesn't improve?

Speak with your doctor if you're concerned about the way your child walks. For a small number of kids, gait abnormalities can be associated with other problems. For example, out-toeing could signal a neuromuscular condition in rare cases.

Have your child evaluated by a doctor if you notice:

  • In-toeing or out-toeing that doesn't improve by age 3
  • Limping or complaints of pain
  • One foot that turns out more than the other
  • Developmental delays, such as not learning to talk as expected
  • Gait abnormalities that worsen instead of improve

The doctor can then decide if more specialized exams or testing should be done to make sure that your child gets the proper care.

We're here to help.

If your child has been diagnosed, you probably have lots of questions. We can help. If you would like to schedule an appointment, refer a patient or speak to our staff, please call our offices at 682-885-4405.

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