In-toeing and out-toeing is one of the common causes for referrals to the paediatric orthopaedic surgeon. In-toeing is more common than out-toeing, with most cases being benign afflictions with no functional consequences.

When a child presents with toeing in/out problems, evaluation focuses on ruling out any underlying cause before labelling it as benign. Most children however have what is called physiological (normal) flatfeet due to looseness (laxity) of ligaments or excess chubby fat underneath the skin, which is normal. Unilateral or asymmetrical deformities are more likely to be secondary to underlying diseases/ defects. Diseases affecting bones, ligaments, muscles, joints or nerves may all cause flatfeet. Problems in knee/hip or rarely back also may masquerade as toeing problems

Age at presentation gives a rough idea of the most probable site of affection. For example, in-toeing presenting before 3 years of age is most likely to be due to the shin bone turning in (tibial intorsion), whereas, beyond 3 years, excessive thigh bone rotation (femoral anteversion) is a more common cause.


Investigations are not required for diagnosing toeing in/out. They are required only when other problems are suspected to be causing them.


Management depends on the age at presentation, the level at which the deformity occurs and the underlying cause, if any, braces and special shoes are universally ineffective. Reassurance explaining the natural course of resolution of the problem, is enough most of the times, besides regular (usually yearly) reviews. The need for surgery is mainly dictated by the functional impairment caused by these deformities, rarely ever for cosmetic concerns.