Initial pre-referral workup

Clinical history

Commonly seen in early walkers due to restricted internal rotation of the hip.

May be associated with knock knees (genu valgum) and flatfoot.

Be aware of serious causes such as slipped upper femoral epiphysis.

Physical examination

Observe the child’s gait.

Place in prone and check for internal and external hip range of motion, thigh-foot angle, and foot posture.

GP management

Reassure the parents that the majority of out-toeing will resolve as the child grows and that no treatment is required.

Exclude other causes such as slipped upper femoral epiphysis.

Refer parents to Out-toeing in children (fact sheet) (TBD).

Indications for specialist referral

Routine

• if progressive out-toeing
• functional difficulties
• asymmetrical deformity
• thigh-foot angle exceeds 30 to 40 degrees