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Updated: Jan 1, 2026
Clinical-oriented Three-dimensional Gait Analysis Method for Evaluating Gait Disorder
Published on: March 4, 2018
Causes of out-toeing gait in children with cerebral palsy
Lisa A Cao1, Susan A Rethlefsen2, Tishya A L Wren3
1Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
Insights
Out-toeing in children with cerebral palsy (CP) often has multiple causes and differs between unilateral and bilateral involvement. Understanding these factors is crucial for effective treatment planning in children with CP.
Area of Science:
- Orthopedics
- Pediatric Neurology
- Biomechanical Engineering
Background:
- Out-toeing is a common gait deviation in children with cerebral palsy (CP).
- It significantly contributes to functional limitations and lever arm dysfunction.
- Accurate diagnosis of out-toeing causes is essential for successful treatment.
Purpose of the Study:
- To identify the primary contributors to out-toeing gait in children with CP.
- To investigate whether these contributors differ between children with bilateral and unilateral CP involvement.
Main Methods:
- Retrospective analysis of computerized gait data from 261 children with CP (344 affected sides).
- Prevalence of different out-toeing causes calculated separately for bilateral and unilateral CP groups.
- Statistical comparison using Fisher's Exact test to determine group differences.
Main Results:
- Pes valgus was the most frequent cause in bilateral CP (71%), while pelvic external rotation dominated in unilateral CP (64%).
- Over half of cases involved multiple causes: 62% in unilateral and 53% in bilateral CP.
- In bilateral CP with multiple causes, pes valgus was present in 91%, often with hip/pelvic rotation or tibial torsion.
- In unilateral CP with multiple causes, pelvic and hip external rotation were common (83% and 63% respectively).
Conclusions:
- Out-toeing in children with CP is frequently multifactorial, with over 50% of cases having multiple contributing factors.
- The specific causes and their combinations vary significantly between children with bilateral and unilateral CP.
- These findings underscore the need for comprehensive pre-treatment assessments to address all underlying pathologies for optimal outcomes in children with CP.
Background:
Out-toeing is common in children with cerebral palsy (CP), contributing to lever arm dysfunction and functional limitations. It is important to determine the cause(s) of out-toeing prior to treatment, whether surgical or non-surgical.
Research Questions:
What are the contributors to out-toeing in children with CP and do they differ between children with bilateral and unilateral involvement?
Methods:
The causes of out-toeing gait were determined retrospectively, with the use of computerized gait analysis, in 261 children with cerebral palsy (344 sides). The prevalence of various causes was calculated separately for children with bilateral and unilateral involvement, and compared statistically between groups using Fisher's Exact analysis.
Results:
The most common cause of out-toeing was pes valgus in bilaterally involved subjects (71%) and pelvic external rotation (64%) in unilaterally involved subjects. Over half of the cases of out-toeing were due to multiple causes: 62% of the unilateral group and 53% of the bilateral group. In limbs with multiple causes of out-toeing in the bilateral group, pes valgus was one of the causes in 91% of limbs (146/161), and was most commonly combined with hip external rotation (27%), pelvic external rotation (22%), or external tibial torsion (20%). For the unilateral group with multiple causes of out-toeing, pelvic external rotation was one of the causes in 83% of limbs (20/24) and hip external rotation in 63% (15/24). Both were present (with or without additional causes) in 46% (11/24) of such limbs.
Significance:
The causes of out-toeing are multifactorial in over half of affected limbs of children with cerebral palsy. They also differ for children with bilateral and unilateral involvement. These findings should be carefully considered prior to non-surgical or surgical treatment of out-toeing gait in these patients, to allow all sites of pathology to be addressed, and to optimize outcomes.
