The following patient information sheet is meant to help patients and family better understand a specific pediatric orthopaedic condition. It is not meant to be comprehensive, and only reflects one viewpoint. This page does not replace a medical evaluation by a pediatric orthopaedic surgeon, and your own surgeon may have a different approach to your condition.


What are intoeing and outtoeing?

Intoeing and outteoing are terms used to describe children who walk with their feet turned inwards or outwards.

What causes my child to intoe or outtoe?

The position of the foot is a reflection of the position of the thigh (femur bone), shin (tibia bone) and foot itself. Any of these three regions can be rotated (or twisted) to influence the ultimate foot position. To compensate, children will often rotate through their hips to try to keep their feet pointed straight ahead. Their ability to do this is lessened when they are tired and running, and oftentimes these are the situations where the foot positioning is noticed.

Intoeing is generally caused by femoral anteversion, internal tibial torsion or metatarsus adductus. Femoral anteversion is a twist in the femur or thigh bone. Although it is present at birth, it oftentimes does not present until toddler age because it is masked by natural outward tightness in the hips. The image to the right demonstrates a child with femoral anteversion.

Internal tibial torsion is a twist of the tibia or shin bone, and is generally noticeable just as the child starts to walk. Metatarsus adductus is a turn in the foot itself, and is generally seen at birth.

Outtoeing is most often caused by external tibial torsion or flat feet. External tibial torsion is the opposite of internal tibial torsion. Older children with flat feet can have a outtoeing appearance as the foot collapses. Click here for a more detailed description of flat feet.

How is the diagnosis of intoeing or outtoeing made?

The cause of intoeing and outtoeing is determined based on a careful physical exam. This is generally best done with the child lying face down. Many toddlers are too anxious for such a position, in which case they can still be examined sitting in the lap of a parent.

X-rays are not necessary to make a diagnosis of intoeing or outtoeing. In some cases x-rays are useful to ensure that there are not any other bony issues.

What treatments are available for intoeing and outtoeing?

In general, the causes of intoeing tend to improve with age. For femoral anteversion, most do not recommend bracing, but do advise the avoidance of “W” sitting, which is thought to prevent the child from improving with growth. The image to the right shows an example of W sitting. For internal tibial torsion, the general recommendation is also against bracing, although I will occasionally use a bar and shoe construct for nighttime and nap use in severe cases. In some children with metatarsus adductus the foot becomes stiff, in which case a series of casting and then bracing may be necessary. Uncommonly, foot osteotomy may be necessary when the child is older.

For external tibial torsion, the twist in the bone can improve but does so less commonly than with internal tibial torsion.

If your child has persistent deformity and develops pain or functional limitations, then surgical correction may be recommended. Again, this is rare, but may be beneficial particularly in cases of combined femoral anteversion and external tibial torsion. Physical therapy is generally attempted first, as muscle stretching and strengthening can improve symptoms (although not the deformity itself) in some children. Correction is achieved by an osteotomy, which involves cutting the bone, rotating it into an appropriate position, and then holding it in position generally with a nail, plate or pins.

What can I expect in the future in my child with intoeing and outtoeing?

As mentioned, most children do not require treatment. Studies have not found any clear evidence of arthritis or other issues in most children with these conditions. In fact, one study studied high school sprinters and found an unexpectedly high percentage of adolescents with femoral anteversion, suggesting that in these children the intoeing was helpful for sprinting.

For adolescents with persistent pain or functional difficulties, there is concern that these issues can persist in adulthood if they are not treated. In particular, children with a combination of femoral anteversion and external tibial torsion can often have difficulties with their kneecap.