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All About Out-Toeing

toddler's feet on the sofa

What is Out-toeing

From Olympic winners to all-star athletes and A-list celebrities, many of us suffer from foot conditions and abnormalities. One of the most common, out-toeing, is a term used to describe the appearance of a child’s walking pattern when one or both feet point outwards instead of pointing straight ahead. Many times, the condition is first noticed when children are learning to walk or the bottoms of the child’s shoes don’t wear evenly. However, in most young children, in-toeing or out-toeing is caused by a torsional deformity that appears for a short period and then disappears during the normal stages of leg development. There are several common causes of out-toeing and, fortunately, many of these causes do not require intervention. 

Parents rightfully worry that in-toeing or out-toeing will permanently interfere with their child’s ability to walk and run normally. Out-toeing is not painful, but it can cause a child to trip or fall more easily.  It usually gets better as kids grow older, however. Almost all toddlers who out-toe learn to run, jump, and play as they grow up, the same as other kids.

Common Causes of Out-toeing

  • Flat Feet – Flat feet can contribute towards the appearance of out-toeing as low or normal arches can cause the feet to splay outwards.
  • External Tibial Torsion – Tibial torsion is the twisting of a child’s shinbone, also known as the tibia. In some cases, tibial torsion causes a toddler’s legs and feet to turn inward (internal tibial torsion), giving them a pigeon-toed appearance. Other times, the legs turn outward (external tibial torsion) causing the feet to turn out. The condition is often related to tight ligaments and tendons in the upper leg that cause the lower leg to twist as a child grows. 

Symptoms of external tibial torsion usually appear when children are slightly older, between the ages of four and seven. One or both feet rotate outward and may cause the child to trip or stumble. A pediatric orthopedic specialist may inquire about the child’s family history and can perform a physical exam by measuring the rotation of your child’s legs and feet. 

In many cases, treatment is focused on exercises designed to reduce strain on the joints and tissue around the tibia. However, correction of a severe tibial torsion in children can require a surgical procedure called an osteotomy, which requires cutting the tibia bone to correct the rotation.

  • Womb Placement – Some cases of out-toeing are caused by a baby’s position in the uterus even before they are born. If your baby’s hips were pressed with the tibia rotating outwards in the uterus, they may have out-toeing as a toddler. As a baby grows in the womb, some of the bones have to twist a little to fit into the small space. Those bones become untwisted over the first few years of life as kids grow. But sometimes the child’s hips can be rotated externally outwards because of the position in the womb, taking longer to align properly.
  • Self-Limitation – Another common cause of out-toeing is self-limitation. Often, self-limiting beliefs are rooted in past experiences like pushing your child to walk too early, causing stress that results in an improper gait.

Less Common Causes of Out-toeing

  • Femoral Retroversion – Femoral Retroversion is a rotational or torsional deformity in which the femur or thigh bone twists outward in relation to the knee, causing the knee to twist outward relative to the hip. This condition is diagnosed during childhood and is characterized by the unusual “duck feet” posture and walking that the child develops. Symptoms may include difficulty running, flat feet, poor balance, and hip or knee pain.

Many children born with femoral retroversion will outgrow the condition. For those who do not, a mild case may not cause significant health problems. In severe cases, however, surgery may be needed to correct the rotation.

  • Slipped Capital Femoral Epiphysis (SCFE) – This is one of the most common developmental conditions of the hip joint in adolescents. SCFE occurs when the top or head of the femur bone slips off the neck of the thigh bone through the growth plate, causing trauma to the hip. The decreased rotation of the hip joint allows the feet to appear out-toed. Symptoms of SCFE include problems walking, limping, pain in the hips, groin, or around the knees, stiffness, or less than usual hip movement. 

SCFE is always treated with surgery to stabilize the growth plate that slipped. Before surgery, the doctor will try to prevent any further slipping by encouraging rest and the use of crutches to avoid putting weight on the affected leg.

  • Cerebral Palsy – The most common motor disability in childhood is caused by abnormal brain development or damage to the developing brain and affects the ability to control muscles. Cerebral palsy can result in rotational abnormalities and functional limitations of the femur, tibia, and/or foot, which can ultimately affect the alignment of the limbs and cause out-toeing. As a result, children may have difficulty with walking and running. Delays in reaching developmental milestones, stiff, floppy, or clumsy movements, weak arms or legs, random uncontrolled movements, muscle spasms, and tremors are all common symptoms.

Cerebral palsy is generally diagnosed a few months to a year after birth using CT scans or MRIs. An EEG, genetic testing, or metabolic testing might also be recommended by your child’s physician. 

There is no cure for cerebral palsy; however, there are many treatment options that may help improve your child’s daily functioning. Physical, occupational, and speech therapy are an integral part of the treatment plan. Medicines that can reduce muscle tightness might be used to improve functional abilities. In certain cases, surgery can lessen muscle tightness or correct bone changes caused by spasticity. 

If Your Child is Exhibiting Any Rotational and Gait Abnormalities, Call Us to Ease Your Concerns

While out-toeing may present some early challenges for children and be worrisome for parents, the truth is that most children live a normal, active and healthy life. Children with out-toeing generally go on to have no limitations in their activities and will join their friends playing outdoors or participating in competitive sports. If a functional problem exists and the child is exhibiting developmental delays or unusual patterns in walking, consult with a member of our team and we’ll get to the root of the problem. Our compassionate team of specialists understands that any developmental issues affecting your child are concerning. When it comes to childhood orthopedic issues, it’s important to begin treatment early. We will examine your child, carefully explain any issues, and guide you step-by-step through treatment. Learn more about our pediatric orthopedic practice at or book an appointment at (973) 538-7700. Through procedures that lessen pain and improve mobility, your child will be walking, running, and jumping for joy.

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Regular Hours: 9am-5pm
Walk-in Hours* (Cedar Knolls): 5pm-8pm


Regular Hours: 9am-5pm
Walk-in Hours* (Cedar Knolls): 5pm-8pm


Regular Hours: 9am-5pm
Walk-in Hours* (Cedar Knolls): 5pm-8pm


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