Out-toeing

Out-toeing is a common, normal variance of gait and usually does not require intervention or onward referral. It usually improves as a child grows. Out-toeing often runs in families, and can persist into adult life but rarely causes problems. It is commonly seen in later walkers and may be associated with knock knees (genu valgus) and flat feet.

Common causes:

• External femoral torsion
• External tibial torsion
• Marked flat feet/ calcaneo-valgus foot posture

Less Common causes:

• Legg-Calve Perthes Disease /Slipped Capital Femoral Epiphysis, especially when unilateral – due to decreased hip rotation and abduction

Action: Key assessment points

• Observe gait pattern and ensure symmetrical
• Check for full range of movement in the lower limb joints, especially the hips
• Check for abnormal neurology in both the upper and lower limbs

Action: Referral not indicated

• Symmetrical asymptomatic out-toeing
• Please do not refer patients on parental concern alone. Reassure the parent/guardian
• If indicated give APCP advice leaflet tilted choosing footwear for children

Action: Refer to Paediatric Physiotherapy

• Out-toeing associated with hip/knee/ankle pain
• There is associated muscle tightness and/or weakness

Action: Refer to Paediatric Orthopaedics

• Asymmetrical hip range of motion (you may wish to request AP/frog lateral pelvis first)
• Child is over 8/9 years of age with pain and/or significant deformity causing psychological distress
• Persistent pain associated with out-toeing that has not improved with physiotherapy/orthotics

Action: Refer to ED/CAU

• Sudden onset of out-toeing following trauma, particularly if asymmetrical and associated with a limp - may suggest Perthes/SCFE

Action: Refer to Podiatry or Orthotics

• Flat feet/calcaneo-valgus foot is causing pain, rubbing or uneven shoe wear