Out-toeing: External tibial torsion and ankle pronation

My 10 month old has demonstrated out-toeing on one side for the past 2+ months during sitting on the floor, in his high chair, while hands and knees crawling, and standing/cruising. His ped ruled out hip dysplasia when I first brought him in for it and said it looked more like tibial torsion which should resolve - this was about 1.5 months ago and I’m seeing some improvement in NWB but not in WBing. He’s meeting milestones with pulling to standing, using a push walker, and cruising however continues to stand and walk in an over pronated and our-toeing position. Should I work on his alignment and hip/glute strengthening now or let him work through it since he is meeting milestones? Would supportive shoes be helpful? I’ve attached pictures to help show his positioning!

Hi! The challenge is if it is tibial torsion that is a bony alignment problem. It never hurts to do extra hip/glut/core strengthening though! Does he pull to stand always with the same side or does he switch on and off? Does he prefer to go one direction more than the other with cruising? Sorry, I have more questions than answers right now!

No worries! I am an ortho PT so I know you need more info :). He always pulls to stand leading with the right leg and pushes through that foot turned out 90 degrees. Up stairs he goes left knee straight to right foot. He will cruise either direction but probably has a preference to go to the right. He also doesn’t squat a ton, would prefer to bend at the hips to pick up an object on the floor instead of bend his knees/ankles.

1 Like

Thanks so much for posting this question! I’m hesitant to recommend anything like a supportive shoe at this point because he’s still so young and is meeting his milestones.

Many times alignment can self correct over time with more WB activities so the fact that he’s only 10 months and is just at the beginning leaves me to think this is a bit of a “wait and see” for at least 2 more months. Especially since you’ve already seen some improvement

It certainly wouldn’t hurt to do squatting and standing during play and encourage him to cruise more in both directions through motivational toys to help build symmetrical strength. Also assisting on the stairs to encourage more symmetry can help with quad strengthening

I’m definitely open to hearing what other PTs might suggest cause it’s not black and white exactly.

1 Like

I agree with everything @tots-allison said! I had an idea you might be a PT by the language you described it in! Also if you can work on pulling to stand through the left as well. Climbing or crawling on soft surfaces can be good for all strengthening. I just created a ‘hill’ for my 9 month old to crawl up and it was a good workout for him and by the end his head was being used to help him! https://www.instagram.com/p/CCBy7WBhER1/?utm_source=ig_web_copy_link

1 Like

This is very helpful!! Thank you. I’ve got some good ideas on how to work on symmetrical strengthening. He loves to be on the move and climbing so he will probably love climbing a pillow hill!


How does he do with side sitting? Thinking if the out-toeing is coming from his hips. I love doing some hip movements after diaper changes. I totally agree with @tots-allison and @Starfishtherapies. Hip/quad/core strengthening will definitely help, and a lot of ankle alignment issues resolve once kids start walking independently. With over pronated feet, I like personally to wait before intervening with shoes and/or orthotics to allow for strengthening of the ankle/foot muscles. It may look different once he starts walking! Hope that’s helpful!

Great question. He doesn’t hang out in side sitting but he’s able to transition through side sitting into crawling (I think, if I’m thinking of side sitting correctly). However, he does prefer to transition with the R hip in ER almost always, and generally sits with R hip in ER and left in neutral which makes me think it could also be hip related! So I’ve been trying to encourage and reposition sitting in the other position. Here’s a photo to show how he prefers to sit. Open to any recommendations on motivating different types of sitting.

1 Like

@rebecolasurdo7 He is such a cutie!! Side sitting is a great position to encourage during play! If you have any tall toys (tables with two of its legs off, a taller cause and effect toy) or simply placing a toy on a stool, couch cushion or shoebox to elevate it off of the floor will help him with side sitting motivation. Simple hip movements like rotating his hips with hip/knee flexion in both directions when he’s on his back or even in a sitting position will help get familiar with IR (wiper on the bus goes swish swish is my go-to line when trying hip movements!). High sitting is another position you can try! If he likes sitting on the stool/couch cushion, try reaching for toys on the floor. If he reaches on the floor towards the right, the left leg has to internally rotate.

*These are just generic suggestions and not specific PT advice.