In-toeing & Out-toeing in Toddlers

Whether your baby rises from a crawl with a shaky first step or a full-on sprint across the living room, chances are you'll be on the edge of your seat. But remember — a child's first steps usually aren't picture perfect.

Learning to walk takes time and practice, and it's common for kids to start walking with their toes and feet turned at an angle. When feet turn inward — a tendency referred to as walking "pigeon-toed" — doctors call it in-toeing. When feet point outward, it's called out-toeing.

It can be upsetting to see your child develop an abnormal gait, but for most toddlers with in-toeing or out-toeing, it's usually nothing to worry about. The conditions do not cause pain and usually improve as kids grow older.

Almost all healthy kids who toe-in or -out as toddlers learn to run, jump, and play sports as they grow up, just the same as kids without gait problems.

In-toeing and Out-toeing

Most toddlers toe-in or -out because of a slight rotation, or twist, of the upper or lower leg bones.

Tibial torsion, the most common cause of in-toeing, occurs when the lower leg bone (tibia) tilts inward. If the tibia tilts outward, a child will toe-out. When the thighbone, or femur, is tilted, the tibia will also turn and give the appearance of in-toeing or out-toeing. The medical term for this is femoral anteversion. In-toeing can also be caused by metatarsus adductus, a curvature of the foot that causes toes to point inward.

Why some kids develop gait abnormalities and others don't is unclear, but many experts think that a family history of in-toeing or out-toeing plays a role. So, if you toed-in or -out as a child, there's a chance that your child could develop the same tendency.

Also, being cramped in the womb during pregnancy can contribute to a child in-toeing or out-toeing. As a fetus grows, some of the bones have to rotate slightly to fit into the small space of the uterus. In many cases, these bones are still rotated to some degree for the first few years of life. Often this is most noticeable when a child learns to walk because if the tibia or femur tilt at an angle, the feet will too.

Does Walking Improve?

As most kids get older, their bones very gradually rotate to a normal angle. Walking, like other skills, improves with experience, so kids will become better able to control their muscles and foot position.

In-toeing and out-toeing gets better over time, but this happens very gradually and is hard to notice. So doctors often recommend using video clips to help parents track improvement. Parents can record their child walking, and then wait about a year to take another video. This usually makes it easy to see if the gait abnormality has improved over time. In most cases, it has. If not, parents should speak with their child's doctor to discuss whether treatment is necessary.

In the past, special shoes and braces were used to treat gait abnormalities. But doctors found that these didn't make in-toeing or out-toeing disappear any faster, so they're rarely used now.

If Walking Does Not Improve

Speak with your doctor if you're concerned about the way your child walks. For a small number of kids, gait abnormalities can be associated with other problems. For example, out-toeing could signal a neuromuscular condition in rare cases.

Have your child evaluated by a doctor if you notice:

• in-toeing or out-toeing that doesn't improve by age 3
• limping or complaints of pain
• one foot that turns out more than the other
• developmental delays, such as not learning to talk as expected
• gait abnormalities that worsen instead of improve

The doctor can then decide if more specialized exams or testing should be done to make sure that your child gets the proper care.