Is in-toing gait physiological in children? : Results of a large cohort study in 5910 healthy (pre-) school children

Background

In-toeing is a major concern of many parents presenting their children to pediatric orthopedists. Foot progression angle (FPA) quantifies the rotation of the foot’s longitudinal axis during gait, with negative values describing in-toeing and positive values describing out-toeing. Although it has been shown that the FPA changes over the course of a child’s development, reference values for the normal FPA-range are lacking.

Research question

This study aimed to establish reference values in 1–14 year old healthy children and to implement FPA-percentile curves for daily clinical use.

Methods

5910 healthy children performed at least 3 repetitions of barefoot walking over an instrumented walkway using a pressure measurement platform. The FPA [°] was extracted and analyzed by age and gender (mean ± standard deviation; median with percentiles, MANOVA (age, gender) and Wilcoxon-Signed-Rank test for intra-individual side differences (α = 0.05).

Results

FPA maximum was observed in 2-year-old children and diminished significant until the age of 4 to moderate out-toeing. For ages 5–14, no statistically significant differences in FPA values were present (p > 0.05). MANOVA confirmed age (p < 0.001) and gender (p < 0.001) as significant FPA influencing factors, without combined effect (p > 0.05). In every age group, right feet showed significantly greater out-toeing (p < 0.05).

Significance

Percentile values indicate a wide FPA range in children. FPA development in young children shows a spontaneous shift towards moderate external rotation (age 2–4), whereby in-toeing ≤ 1–5° can be present, but can return to normal. Bilateral in-toeing after the age of four and unilateral in-toeing after the age of seven should be monitored.

Keywords

Foot progression angle ; Children ; In-toeing ; Out-toeing ; Gait