The condition known as pigeon-toed describes an inward rotation of the lower limbs, formally called in-toeing. The opposite condition, where the feet point outward instead of straight ahead, is medically termed out-toeing. Out-toeing is a common presentation in children and is typically a variation of normal development, though it can persist into adulthood.
Defining Out-Toeing and Its Common Names
Out-toeing is a rotational gait abnormality where the feet turn away from the body’s midline during walking or standing. This outward orientation contrasts sharply with in-toeing. While out-toeing is less common than its inward-pointing counterpart, it is frequently noticed when a child begins to walk.
The most widely used informal name for out-toeing is “duck-footed”. This description comes from the visual similarity of the gait to that of a duck or penguin, where the feet are angled laterally. Another informal term is splay-footed.
The degree of out-toeing is measured by the foot progression angle, which is the angle formed between the line of forward progression and the long axis of the foot. A positive angle indicates out-toeing, while a negative angle signifies in-toeing. Parents may first notice the condition because a child appears to waddle or because the outer edges of their shoes show uneven wear patterns.
Anatomical Sources of Outward Rotation
The outward turn of the feet can originate from structural twists at three main levels of the leg: the hip, the shin bone, or the foot itself. The most frequent causes are rotational variations in the femur (thigh bone) or the tibia (shin bone). Determining the precise anatomical source is necessary for accurate diagnosis and management.
Femoral Retroversion
One possible origin is femoral retroversion, which involves an outward rotation of the femur relative to the hip joint. This twisting causes the entire leg, from the hip down, to turn externally. Femoral retroversion is considered the least common of the major causes of out-toeing in children.
External Tibial Torsion
A major source is external tibial torsion, which is an outward twist in the shin bone (tibia). The tibia naturally rotates externally as a child grows, but an excessive amount of this rotation causes the foot to be angled outward from the knee down. This condition tends to become more pronounced in later childhood years.
Pes Planus (Flat Feet)
The appearance of out-toeing can sometimes be caused or worsened by foot-level issues, such as pes planus or flat feet. When the arch of the foot collapses, the foot pronates, or rolls inward, the forefoot can appear to turn outward relative to the rest of the leg. However, flat feet are generally considered a less common cause of significant out-toeing compared to bony rotations higher up the leg.
Typical Prognosis and Management
In the majority of cases, out-toeing is a benign, self-correcting condition that resolves naturally as a child grows. The outward rotation is often a result of the position a baby held in the womb, and the bones gradually rotate to a more typical alignment as they develop. Most children outgrow the condition without intervention, often by the age of six to eight years.
For mild to moderate cases, medical professionals typically recommend simple monitoring, often suggesting that parents periodically take videos of the child walking to track progress. This approach avoids unnecessary intervention, as older treatments like special shoes or bracing do not speed up the natural resolution process. Intervention is usually reserved for instances where the condition is progressive, asymmetrical, or causes functional difficulties.
Management for persistent or severe out-toeing focuses on the underlying cause. If muscle imbalances or tightness are contributing, physical therapy involving stretching and strengthening exercises may be recommended. For foot-related issues like flat feet, custom orthotic devices may be prescribed to improve foot alignment and provide support. In rare and severe cases, such as those causing significant functional impairment, surgical correction may be considered.