• Written by Cylie Williams, Adjunct Post Doctoral Research Fellow, Monash University
imageThere are many treatments recommended for rotational deformities, but do they work and are they necessary? from

Babies regularly have their feet, legs and hips checked by their doctor in hospital, or at maternal and child-health nurse visits.

As children grow, parents are often concerned about their feet pointing inwards when they walk (also called in-toe or pigeon-toed walking) or outwards (also called out-toe walking or duck-footed).

These walking positions, commonly called “rotational deformities”, often cause parents to seek the opinion of an orthopaedic surgeon, physiotherapist or podiatrist for more specialised assessment.

Rotational deformities

When the leg or foot faces inwards or outwards during walking, it may be from a number of typical changes in the leg or foot.

When a baby is born they often have bowed or curved legs. This is thought to be because of the position of the baby in the womb.

This position can remain and seem more obvious when the child begins to walk. It may appear as if the feet face inwards. Sometimes children may appear to trip or fall over their own feet.

In-toe walking may come from a curved foot (metatarsus adductus) or an inwards twist in the leg bones (tibial or femoral torsion).

Similarly, out-toe walking may appear from the foot or leg. A foot that is very rolled in or “pronated” may appear as if it is pointing outwards. A leg may also turn outwards from the leg bones or the hip.

The flexibility of a child’s joints or the way they use their muscles could also cause in-toeing or out-toeing. A twist in their bones is one possible contributing factor to in-toe or out-toe walking.

Curved feet

Metatarsus adductus is the most common foot deformity in infants. In metatarsus adductus, the foot has a curved or banana-shaped appearance. In 95% of cases, the foot corrects itself with no treatment.

In the past, it was recommended to put shoes on the wrong feet. This is no longer recommended as it may cause further foot deformity.

Sometimes treatment is needed. Plaster casting or splinting may be required to help the foot straighten if it doesn’t on its own.

Parents should see a health professional if their child’s foot is curved, stiff and unable to be straightened, or isn’t straightening as their child gets older.

Twisted shin bones

Tibial torsion is where the lower leg or tibia turns in or outwards. An inward-turned tibia is common in children under the age of three. It usually straightens after this age and sometimes even slightly turns outward with no treatment. These changes occur in children up to the age of eight.

Health professionals will sometimes recommend children with in-toe walking wear a type of orthotic called gait plates. While gait plates may provide some cosmetic effect when worn, there is no evidence they will result in long-term change.

Parents should be cautious about claims these devices will fix in-toe walking. They need to consider if the expense is worth it for something that will naturally get better on its own. There is no good evidence stretches or footwear will change this type of walking.

Turning inwards or outwards at the hip

Femoral torsion is where the upper leg bone (femur) or hip is turned in or outwards. Children may appear to walk with their feet inwards or outward. It also looks like their knees point inwards or outwards.

The femur goes through many changes up to the age of 12 and an inward turn at the hip is more commonly seen in girls. Rotational changes at the top of the leg are also a very normal part of growth.

Walking changes from the top of the leg and hip sometimes appear more common in children who frequently W-sit. This sitting position is with their bottom on the ground and legs folded outwards.

imageW-sitting isn’t necessarily harmful, but can affect a child’s walking.Author Provided

There is no research proving sitting like this is harmful, but therapists often observe hip muscle tightness in children who sit this way and it may affect the child’s walking. As harm is unknown, it might be best to get children to sit or play in other positions.

There are no shoes, orthotics, garments, taping or stretches that have evidence supporting them being used to change walking associated with these rotational changes. Parents should seek medical attention quickly if there is pain at the hip or pain extends into the groin while walking at any age.

Children walk in-toe and out-toe for many reasons. Parents should see a health professional if their child is tripping from their leg position when their child is school-aged, if one leg turns substantially more inwards or outwards than the other, seems longer or looks very different compared to the other.

For the majority of children, in-toe or out-toe walking is just part of growth.

Cylie Williams consults in private practice and for an education company providing paediatric podiatry education. In the past, Cylie has received funding from the Australian Podiatry Education and Research Foundation for research into children's gait.

Verity Pacey receives funding from The Menzies Foundation, Arthritis Australia, Osteogenesis Imperfecta Society of Australia, Rheumatology Health Professionals Association and The Ian Potter Foundation.

Authors: Cylie Williams, Adjunct Post Doctoral Research Fellow, Monash University

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