Paediatric Lower Limbs: Intoeing Vs. Out-toeing
Do your child's toes point in or out?
In-toeing and out-toeing are common concerns Splash families ask us about. These foot positions are often considered part of normal development in a growing child. We help identify when there may be another underlying factor that needs to be addressed.
Seek support from your physio or paediatrician if:
you see the change only on one side
the foot is stiff and not flexible
you notice your child may be in pain
it is affecting child's ability to participate in activities
the posture is not improving over time
IN-TOEING
You might have observed your child is prone to tripping, and that their feet turn inwards while they are walking.
Intoeing is common in children from infancy to childhood and usually resolves by 10 years of age without the need of treatment. The Royal Children's Hospital identifies three main causes of in-toeing that are related to a child's development age.
Metatarsus Adductus
What?
"Kidney Shaped Foot", is the best way to explain how the foot is positioned, where the foot curves inwards.
Why?
This is thought to occur due to the positioning of the baby during pregnancy and therefore commonly seen from birth to the first few years of life.
Where?
It usually occurs in both feet but sometimes not to the same degree.
How?
The foot is usually flexible and resolves without the need for treatment by 2-3 years old. But as always if you are concerned please ask for support.
Internal Tibial Torsion
This is the most common cause of intoeing in children.
What?
The child's knees point forwards but the lower leg turns inwards.
When?
This is usually seen in children between 3- 10 years of age and "unwinds" on it own by around the age of 8 years old.
Where?
It generally is seen in both legs when the child is standing.
Image description: TOP: Metatarsus adductus: normal, mild, moderate and severe
BOTTOM: line drawing of a child with
(left) tibial torsion, feet turned inwards, arrows pointing inwards to show rotation through lower leg
(right) femoral torsion), feet turned inwards, arrows pointing inwards to show rotation through upper leg.
Femoral Anteversion/ Internal Femoral Torsion
What?
This is where the upper leg (thigh bone) turns inwards causing "squinting" knees.
When?
It is more common in children aged 4-7, girls more than boys.
Most children improve by 8 without the need for treatment.
Where?
Both legs are affected, and this is seen is standing.
Children often use w- sitting.
(See our article "Do we worry about w- sitting?")
OUT-TOEING
Out-toeing is when foot is rotated outwards. It is commonly seen in the early stages of walking, but is less common than in-toeing.
There are three main causes for out-toeing:
Tight muscles that control the turning of the hip
External Tibial Torsion: where the child's knees point forwards but the lower leg turns outwards
Femoral Retroversion: upper leg (thigh bone) turns outwards
Image description: Photo of infant lower limbs standing on floor with feet pointing outwards. Infant wears a nappy, and two small toys are on ground near its feet.
While these postures can be typical in stages of development, please seek support from your physio or paediatrician if:
you see the change only on one side
the foot is stiff and not flexible
you notice your child may be in pain
it is affecting child's ability to participate in activities
the posture is not improving over time
At Splash Physiotherapy: We regularly assess and monitor the lower limbs of all the children we work with, educate and discuss findings with our families.
We observe how you child walks, runs and moves, assess their position in standing and laying and measure range of movement of each joint of the lower limbs. These measurements are then compared against "normative" values and checked if they fall within expected age range. We provide referrals to GP's and other health care professionals if required and work together with your team to deliver the best possible outcome for your child.
References:
Jones, Stanley & Knadehar, Sumukh. (2013). Normal Variants of the Lower Limbs in Paediatric Orthopaedics. International Journal of Clinical Medicine
Graham HK. In Broughton Ed's. Paediatric Orthopaedics 1997 Chapter 14 Normal Variants
Image reference:
This advice is general in nature. Please consider if it is right for you, and speak to your physiotherapist or paediatrician if you have any concerns.
Rebecca Bacusmo is a Splash physiotherapist working with children and young adults in aquatic, land and telehealth physiotherapy. She is passionate about helping children learn and develop functional skills to assist them in participating in meaningful activities in everyday daily life at home, school and their communities. Rebecca has daily aquatic sessions available at two private swimming schools in Moonee Ponds and Greensborough, Melbourne, combined with daily home, school and Telehealth sessions and sports and recreation intensives over the school holidays.
