In-toeing & Out-toeing in Children

In-toeing (“pigeon toes”) and out-toeing (“duck feet”) describe common walking patterns in children where the feet turn inward or outward, respectively. These gait variations are frequently observed during early childhood development and, in the vast majority of cases, are normal parts of growth that resolve naturally over time without causing pain or long-term problems. Understanding the typical causes can provide reassurance, but knowing when to seek advice from a paediatric podiatrist in Singapore is also helpful for parents.

These conditions are typically identified by observing a child’s walking or running pattern. Key signs include:

• Feet Turning Inward (In-toeing): The toes point towards each other when walking or standing.
• Feet Turning Outward (Out-toeing): The toes point away from each other, sometimes excessively.
• Awkward Gait: The child’s walk might appear slightly clumsy or unusual.
• Tripping: Children who in-toe may trip over their own feet more frequently, especially when tired.
• Sitting Positions: Some children who in-toe prefer sitting in a “W” position (knees bent, feet out to the sides).
• Shoe Wear Pattern: Sometimes, unusual wear patterns on shoes might be noticed.

Importantly, typical developmental in-toeing and out-toeing do not usually cause pain.

These walking patterns are generally due to normal variations in the alignment of the leg bones during growth, which tend to correct themselves over time. The common causes originate from three main areas:

• Foot (Metatarsus Adductus): A common condition where the foot itself curves inward from the middle part to the toes. Often present from birth (possibly due to positioning in the womb) and usually resolves in the first few years. This typically causes in-toeing.
• Lower Leg (Tibial Torsion): An inward (internal) or outward (external) twisting of the shin bone (tibia). Internal tibial torsion is a common cause of in-toeing in toddlers, while external tibial torsion can cause out-toeing. Both usually improve naturally as the child grows.
• Upper Leg (Femoral Version): Twisting of the thigh bone (femur). Increased inward twist (femoral anteversion) is common in children aged 3-6 and causes both knees and feet to point inward. Increased outward twist (femoral retroversion) causes the knees and feet to point outward. These rotational variations typically decrease with age.
• Underlying Conditions: While most cases are developmental, in some instances, in-toeing or out-toeing can be a sign of other underlying medical conditions. These might include:
  • Neurological Conditions: Such as cerebral palsy, which affects muscle control and coordination.
  • Bone Conditions: Certain bone diseases or skeletal dysplasias that affect bone shape and growth.
  • Hip Conditions: Problems like developmental dysplasia of the hip (DDH) or slipped capital femoral epiphysis (SCFE, usually in older children/adolescents).

It’s important to note that these underlying conditions usually present with other signs and symptoms. A thorough assessment by a podiatrist or doctor can help rule these out.

• Frequent Tripping: Can sometimes impact confidence or participation in activities.
• Cosmetic Concerns: Older children or adolescents may become self-conscious about their gait pattern.
• Pain (Uncommon): Persistent pain is unusual for developmental variations and warrants investigation for other causes.

Most cases are diagnosed through observation by parents or paediatricians during routine check-ups. If concerns persist or specific symptoms arise, a consultation with a podiatrist at Fine Podiatry Clinic involves:

• Detailed History: Discussing pregnancy, birth, developmental milestones, family history, and specific parental concerns (e.g., tripping, pain, other symptoms).
• Observational Gait Analysis: Watching the child walk and run to assess the pattern.
• Physical Examination:
  • Assessing the rotational profile of the hips, knees, and ankles (measuring the degree of rotation in the femur and tibia).
  • Examining the shape of the foot (checking for metatarsus adductus).
  • Checking range of motion in joints.
  • Performing a basic neurological screening to rule out underlying conditions.
• Ruling Out Other Conditions: Ensuring the gait pattern isn’t due to more serious orthopaedic or neurological issues, especially if atypical signs are present.
• Imaging (Rarely Needed): X-rays are typically not required for diagnosing common developmental in-toeing or out-toeing unless other conditions are suspected based on the clinical examination.

For the vast majority of children with in-toeing or out-toeing, the best approach is reassurance and observation.

• Non-Surgical Treatments:
  • Observation: Monitoring the child’s growth and gait pattern over time, as most cases resolve spontaneously. This is the standard approach.
  • Parental Reassurance & Education: Explaining the natural history of these conditions is often the most important “treatment.”
  • Orthotic Supports: While observation is primary, if deemed necessary after a thorough assessment, our podiatrists may recommend special custom orthotics. These devices are designed to help manage foot position, improve stability, or address compensatory issues related to the gait pattern in specific situations. Their use depends on the underlying cause and the individual child’s needs.
  • Stretching/Exercises (Specific Cases): Gentle stretching might be recommended for associated tight muscles in some specific, less common scenarios, guided by the podiatrist.
  • Bracing/Special Shoes: These are generally not required or effective for correcting typical developmental rotational variations (tibial torsion, femoral version). Their use is reserved for very specific, persistent, or atypical cases under specialist guidance.
• Surgical Options: Surgery is extremely rare for developmental in-toeing or out-toeing. It is only considered in older children (typically over 8-10 years old) with severe, persistent, functionally limiting deformities that haven’t resolved naturally, and usually performed by paediatric orthopaedic surgeons.

Note: Our podiatrists focus on accurate diagnosis, providing reassurance, monitoring development, and determining if any intervention, such as orthotics, is appropriate for your child’s specific situation, while also identifying the rare cases potentially linked to underlying conditions that may require further investigation or referral.

Since these are usually normal developmental variations, prevention isn’t applicable. However, parents can support healthy foot development:

• Allow Natural Development: Avoid trying to force foot positions. Let children walk and play freely.
• Appropriate Footwear: Ensure shoes fit well (length and width), are flexible at the ball of the foot, and provide adequate support for activities. Avoid overly rigid or corrective shoes unless specifically prescribed by a specialist for a diagnosed condition.
• Discourage “W” Sitting (If Excessive): While common, persistently sitting in the “W” position may be associated with increased femoral anteversion in some children. Gently encouraging other sitting positions like cross-legged or side-sitting can be helpful if “W” sitting is the child’s only preferred position.

Encourage Varied Play: Activities that promote balance and coordination are beneficial for overall motor development.