Toeing Out
Toeing out, or out-toeing, is not as common as intoeing. Excessive out-toeing is considered a normal variant. Observation and parental reassurance are the mainstays of therapy.
Differential Diagnosis
- Femoral retroverson
–Usually bilateral with excessive external and limited internal range of motion of both hips
- External tibial torsion
–More common than femoral retroversion
–May be related to in utero positioning and is sometimes associated with calcaneovalgus foot
- Slipped capital femoral epiphysis (SCFE)
–Most common in obese adolescent boys
–Unilateral out-toeing with painful hip
–Pain and limited range of motion or antalgic externally rotated gait pattern
- Talipes calcaneovalgus
–Positional deformity in which the foot is extremely dorseflexed and everted
- Everted flat feet
–Children stand in a toe out position but toe in when walking
- Triceps surae muscle contracture
–Can be seen with cerebral palsy
- Vertical talus (rocker-bottom foot)
- Congenital absence of the fibula
–Shortening of the peroneal and triceps surae muscles result in bowing of the tibia and equinovalgus
- Maldirection of the acetabulum
–If the acetabulum faces posteriorly, leg position is everted
Workup and Diagnosis
- History is generally limited
–Development and milestones are generally normal
–Hip pain and limp are red flags for SCFE
- Physical examination consists of a rotational profile using four elements to help with diagnosis and monitoring
- First element: Hip rotation
–Measurement is performed in prone position, hips extended and knees flexed to 90°
–Lateral rotation; external rotation with >70° indicates femoral retroversion
–Medial rotation; internal rotation with <20° also indicates femoral retroversion
- Second element: Thigh-foot angle
–Measurement is performed in prone position, hips extended, and knee flexed at 90°, evaluating long axis of foot relative to axis of thigh
–Neutral or foot pointed outward >40° (normal 0–30°) indicates external tibial torsion
- Third element: Foot evaluation
–Foot alignment is assessed in prone and standing position; heel bisector line should line up with second metatarsal
- Fourth element: Foot progression angle (gait evaluation)
–When the child walks, estimate the angle of the foot relative to the line of progression
–If patella is outward, then the femur may be retroverted
–If patella points straight, then the tibia or foot is causing the deviation
Treatment
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Natural history of rotational variations is gradual normalization and is not altered by nonsurgical methods
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Out-toeing is generally self-limited and improves at 2–3 years old until 8 years old; reassurance that the condition will improve is the most important component of treatment
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The use of orthotics, shoe modifications, or exercises is ineffective
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Surgical correction is reserved for severe gait deformity or when related to SCFE
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Even after surgical intervention for SCFE, external rotational abnormality into adolescence may persist, and derotational osteotomy may be beneficial
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Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Toe pain
Read excerpts from these other book chapters related to Toe pain:
Medical Books Excerpts
- Toeing In
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Toe pain
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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» Next page: Toeing In (In A Page: Pediatric Signs and Symptoms)
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