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Intoeing / Outoeing in Children Care Pathway Overview

In-toeing / out-toeing in children is a normal part of a child's development and does not require referral into Orthopaedics. Please manage in Primary Care with advice, encouragement and self-management.

Practice Point

The advice in this pathway applies to patients up to musculoskeletal maturity at approximately 18 years of age.

Please click the relevant flowchart box to be taken directly to textual information

                                                        

Red Flags
  • Persistent pain, redness, heat, swelling, raised body temperature
  • History of trauma/injury/fracture
  • Inability to weight bear
  • Sudden onset of unilateral in-toeing/out-toeing
  • Multiple joint pain/swelling
If fracture suspected, follow the Fracture pathway
If infection suspected, treat accordingly
If multiple joint pain/swelling consider Rheumatology referral
For persistent foot or ankle pain, weakness, limping swelling or stiffness, encourage patient to self-refer into Childrens Physiotherapy Services (GCS)
Presentation

Much unnecessary concern is caused by the appearance of the foot and leg position when toddlers first start walking. These can include flat feet, bow legs, knock knees, toe walking and feet pointing inwards (in-toeing) or outwards (out-toeing).

As the foot and lower limb grows and develops, it undergoes various positional changes that may look like a problem to the untrained eye, but may just be a matter of developmental change.

                                                               

Differential Diagnosis
  • Fracture (follow the Fracture pathway)
  • Infection (treat accordingly)
  • Ligamentous laxity e.g.: Hypermobility, Ehlers danlos syndrome, Marfans syndrome
  • Inflammatory arthritis
  • Developmental hip dysplasia
  • Perthes disease
  • Slipped upper femoral epiphysis (SUFE)
  • Neurological disorders e.g. cerebral palsy, myelodysplasia  
Initial Primary Care Assessment
  • Observe children’s gait.
  • Confirm that gait is smooth with a heel-toe progression.
  • Does the child seem to bear weight evenly on both legs?
  • Is toe walking present?
  • Is there any evidence of pain or asymmetry?
  • Scrutinize knee position/patella direction and foot progression angle
  • On physical examination, is there any evidence of hypermobility (increased hip range of motion (arc greater than 90 degrees), elbow/ knee hyperextension, flat feet)? Hypermobility is often associated with in-toeing.
Primary Care Management

In-toeing / Out-toeing in children is a normal part of a child's development and does not require referral into Orthopaedics. Please manage in Primary Care with advice, encouragement and self-management.

Provide advice/encouragement:

  • 40% of children will in-toe at some point during their development. Four percent of adults in-toe.
  • Walking patterns continue to change until approximately eight years old.
  • Physiotherapy cannot change the shape of your child’s legs or walking pattern. This will improve naturally with time.
  • Falling is not caused by in-toeing but is a part of learning to walk
  • Encourage child to be physically active through play and sporting activities
  • Foot orthoses will not correct in-toeing or out-toeing but may help to reduce some of the associated symptoms e.g. tripping
  • Encourage child to sit with legs crossed – avoid ‘w sitting’ 

                              

 

Practice Point

The advice in this pathway applies to patients up to musculoskeletal maturity at approximately 18 years of age

When to Refer

If additional support is required to manage the problem, Gloucestershire Care Services (GCS) provides foot and ankle services in Gloucestershire.

The main entry point for foot and ankle services is via Core services, accessed via the online self-referral form, (click here for printable link), which the patient can complete themselves if able to and willing.

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