Gait plates

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i have a interest in paed biomechanics and i have treated a few patients in the past with intoeing gait,one of the standard approaches to intoeing gait is the use of gait plates,A.Redmond wrote an article on the use of gait plates and how 14 out of 17 patients he had treated had reduced episodes of tripping ,what i want to know is,how the gait plate actually works what mechanical function is it based on this may sound like a daft question but then again if you dont ask you dont get i wait for your answers with great interest
thanks

 

thanks for the two articles posted is there anything else out there on the use of gait plates

 

I have used quite a lot of gait plates in paediatrics over the years. If my primary concern is a transverse plane problem I will use a flat gait plate which I have the lab make for me from a template. I take a template from the shoe and mark the met heads and the apex of the 5th digit (for intoe). I will then draw on the template where i want the gait to finish - I usually finish just proximal to the 1st met head and at the apex of the 5th digit. I have the plate made from a subortholen material (usually multicolour so the child accepts it more readily). It is left uncovered and the only adjustment I may need to do is a minor grind to ensure it sits flat in the shoe. It is bevelled at the distal edge for comfort. the shoe must be very flexible as the aim is to change the break line of the shoe in gait. (Tax has a small section in his old text Podopaediatrics - if you haven't read that one). The shoe also needs to be very lightweight - this often means they are the inexpensive shoes!!! I have used them very successfully in the "jelly sandals" for girls that come in bright colours and have a heel counter but are very flexible!
if you are having frontal plane problems them I may combine them with a casted device in an attempt to obtain some frontal plane control but beware - if you are trying to effectively control moderate to severe pronation problems you are likely to increase the intoe and parents need to be aware of this. i will discuss of course the aim of my therapy and what is most important to address first!!
of course at the same time as a gait plate is used the underlying factors ( muscle tightness at hips etc ) also need to be addressed.
By the way i find that the cost of a flat gait plate is quite low and very effective.
All the best
cpcpod

 

gait plate

thanks for the reply ,i myself use gait plates quite often ,but still find it difficult to locate research articles about the subject
wayne

 

Not a huge fan of gait plates as I am still havn't seen a enough research to show that changing the gait forces through little growing bones is appropriate and all too often I have seen them issued with disregard to the cause of the intoeing.

If you look at some of the main causes:

Intoe gait from the hip: Interal hip position due to "w" sitting and poor core strength, how will a gait plate change this? You need to re-educate the sitting position, improve core strength, stretch out the adductors and strengthen the abductors.

Intoe from the tibia: Osseous rotation, is this familial or is there a posture such as sitting or ball sleep that is inhibiting the bodies natural inclination to derotate the tibia during natural growth, how would a gait plate change this? Wouldn't a CRS/dennis browne bar and investigation into sitting and sleeping posture have more effect?

Intoe from metadductus: How would gait plate change this? If it is that bad then a surgical opinion should be sought, if not then should first port of call be protecting the foot from becoming a skew foot. If a flat gait plate was used wouldn't this hasten the process of the foot becoming skew by forcing the change in foot posture and placement.

I guess we really need to be clear in our diagnosis of what is causing and then logically think through what we arae treating and why, otherwise our gait plate becomes a bandaid solution, changing the appearance and not the cause.

Cheers
Cylie

 

Hi Wayneb,

I think that once you have eliminated the causes of intoeing outlined by Bug, there are a few left that are a result of compensating by avoidence for a "weak foot", one that would otherwise be grossly pronated. Another avoidence strategy can be the toe walker.

In this case a gait plate, which incorporates frontal plane axial momments may be helpful. Nevertheless, it needs to be well managed, and as mentioned by cpcpod shoes need to be very flexible. I only use these in pre schoolers as I think they are only a walking device and not suitable for running sports.

For the others not within my narrow category, I tend to use 2-5 extensions(reverse Morton's) on their devices, which do seem to improve angles also.

Cheers
Shane

 

thanks for your input much appreciated.I agree with you (bug) there is very little evidence out there the reason for me posting the question in the first place.However i am not saying that gait plates are the answer but what i am trying to achieve is to affect the biomechanical function of the legs at propulsion stage of gait by reversing the breakline of the shoe,whatever worth you put on anecdotal evidence it seems to work in about 50% of the patients i treat.I will only say this is a short term approach to the management of symptomatic intoeing gait as we are all aware the condition improves with time,if not aesthetically it will funtionally.Is there anybody out there who uses gait plates on a regular basis? would like to here your opinion

yhanks
wayne

 

the youngest age at which gait plates can be used for femoral antiversion? gina. When is the Denis Browne bars strongly indicated and age at which it is mostly affective and duration of use?

 

Is anyone able to answer these questions?

 

Hey all.

Have used gait plates for a few years with mixed success, some successes and some spectacular failiures.

The earliest i have ever used them was on a 6YO diplegic who had just come out of hip twisters. As a general rule however i find they work better in slightly older children .

I find the footwear is important, it needs to hold the foot down onto the orthotic firmly. As such i often use them in conjunction with piedros or other specialist footware.

I have also used them effectivly as a hybrid with a UCBL with a dorsal foldover.

As with all such things, you have to pick your patients.


Regards
Robert

 

Orthotic Devices with Out-toeing Wedge as Treatment for In-toed Gait in ChildrenPedro V. Munuera, Jose M. Castillo, Gabriel Dominguez, and Guillermo Lafuente
Journal of the American Podiatric Medical Association
Volume 100 Number 6 472-478 2010

 

No age, it is the femur and no plate or foot plate will change it. Don't forget this paper:
Lower-extremity rotational problems in children. Normal values to guide management LT Staheli, M Corbett, C Wyss and H King J Bone Joint Surg Am. 1985;67:39-47.

Intoeing is a generally a normal variant. Out of 3 SD from the norm or unilateral intoe walking and it's off to the specialist you go.

Gait plates are a cosmetic fix only, we don't know the long term impact on young and developing feet. When the child comes out of them with straight gait and we "Tah Da!" We are are kidding oursleves that we have done something, the body has naturally fixed itself.

Sitting and sleeping positions should be discussed otherwise reassuring parents, regular monitoring (including video/photographic)is all the treatment that healthy intoe walkers need.

Treating this with unnecessary and costly orthotics are one of the things that continues to create the great podiatry/orthopaedic divide in the paediatric world. Understanding the child's natural development is imperative.

Rant over....

 

Agreed. Cylie ive liked all your posts ive read on PA =D

 

Gday Cylie, what's "ball sleep"?

 

Gait plates seem to be rather controversial. I have not used many over the years but the times I have I felt they were the right option. The children I used them on were all 8 or 9 and although they may have self corrected without the plates I think the importance of the psychology and placebo should not be underestimated. If it makes them feel more confident and they start participating in sport isn't this an important part of their treatment also?

 

Thanks Jon

Mark, it is when the baby/toddler/child maintains the in utero position for sleeping. They sleep on their tummies with knees to the chest and feet curled under their bottoms with the weight of the bottom on the internally rotated lower limb and feet. I tried to find a good photo out there but couldn't. I know the textbook by Tax has a good one in it if you have a copy. I'll try and scan it at work next week and post for you.

Some little ones maintain this as the preferred sleeping position up to 2-3 year old. I every ball sleeping client I have seen has increased tib torsion for their age. Not every internal tib torsion child though ball sleeps. I personally think it is just one of those factors that slows the natural body's de-rotational process a little.

 

Hmmm.

No.

It depends. Sometimes, perhaps even most of the time, I think what you say above is true. But I think you go a little far when you talk in absolutes. To dismiss the change caused by gait plates as "cosmetic" is, I feel, inaccurate. Can any functional (much less kinematic) change be merely "cosmetic"?

Whether the change is for the better, of no moment, or for the worse we might debate. But certainly not merely cosmetic.

 

Isn't a gait plate for in toed gait just an early Sagittal plane device? Lateral ff post with a first ray cut away?

Me thinks!

 

Graham, I see gait plates as the end of the lateral end of the device being extended to the 5th, the medial stopping behind the first. There is no forefoot posting.

Robert, I did put in there, anything more than 3SD from the normal, in the thigh foot angle or tibial torsion then there should be consideration for treatment. I still do not think a gait plate is the appropriate treatment though.

I mean cosmetic in the way that the a plate/orthotic causes an immediate and obvious gait change by means of a forcing the foot to act in a certain way to change the appearance of gait only when worn. It is not something that will permanently correct the gait, this is what the body naturally does.

Plus, in the past when I have used them, they hurt the child, they are also an aversion device. When we start using them in adults with internal tibial torsion with success I might reconsider my stance a little, but for now I will speak in absolutes got my treatment, I see no place for them for treating the children I see with intoeing gait caused by upper or lower legs, and think they are a costly and useless device.

 

By that token almost all the devices we use are cosmetic. Do not FFO's change the appearance of gait when not worn? Do UCBLs permanently correct the gait?

Depends on the research you read and how you measure it I suppose. But I think to dismiss something which only works when its being worn as "cosmetic" is more than a bit strong!

Got your treatment?

Its a view of course. But the cost is no more than any device and the use is a highly subjective measure. Useless is, in my view, an unsupportable statement. If someone is tripping over their feet and cracking their face off the playground every 10 minutes before the device, and not doing so after it then whether or not it accelerates tibial derotation is a side issue.

Take, as an example, a Downs child with 12/12 LLAS hypermobility. Their UCBL Probably won't "correct" the feet. But it WILL enable them to function more efficiently.

Is it then useless?

 

Sorry Robert, that will teach me to post so late at night, I start typing like English is my second language. I did meant regarding my treatment. I don't use them, haven't for a very long time as I don't see them as necessary in the children that I assess and treat, which is a sole paediatric load is a few. I am happy to take the conservative approach with this one.

I do understand what you mean though but I don't see an intoe gait though as causing pain or reducing function in the children that are within the normal intoe position.

When you "cosmetically" change a pronated foot in a child with a disability or with pain you will either reduce the pain or improve the foot function to allow them participate at a more appropriate level in normal activities. Therefore it isn't a cosmetic fix, it is a functional change, sure the foot is still the same when they don't wear them, however wearing them changes things substantially.

Normal intoe walking don't cause pain, doesn't cause balance problems, doesn't cause anything other than intoe walking. If the tripping is that severe, there is the potential for a lot more going on that just intoe walking. It's just my experience but, I see very few that have that amount of tripping that you describe that have intoeing within the normal range, I could probably count them on one hand in the last 15 years. I then think these kids need a lot more investigation than just jumping to a gait plate. You just can't compare the 2 devices as they provide such different impacts.

I think we are actually agreeing on some level here, the main point of my original rant is to ensure there is consideration of the definition for normal intoe walking and understanding the normal variants of foot position.

 

My problem is when I'm posting on my phone! The predictive text throws up some very unfortunate typos sometimes. Poron and porno being the one which crops up most often.

I think you see intoeing much as I (and perhaps you) see asymptomatic hypermobile "flat feet" (hate that term). Treat it if there is a reason, but don't go gung ho and try to "correct" something which is not "incorrect" in the first place.

That I would agree with!

 

Yup, yup and yup!

I only see children in my public role. The majority are under 6 and consist pretty much a mix of intoe walking, hypermobile flat feet, toe walking and "other". I am tainted and totally agree with your last statement. I think it is hard for the generalist pod sometimes to work out normal intoe and abnormal intoe walking which is why these discussions are so importent.

As for the pesky typo's, for future reference, don't let it correct evaluation to ejaculation - just as bad as the poron/porno. Anyone that knows me knows how mortified I would have been following the responses to "that" email.

 

LOL

So what do you prefer cylie, hard porno or soft porno? Personally I find the 4 week ejaculations are more favourable with hard porno but thats just me.

 

Well, the time line is really a personal preference however I can tell you that upper management do not like the suggestion that a 6 monthly schedule is adequate. They tend to seek clarification (insert mortification here....all over again!).

As for soft or hard, personal preference again.

I'm now really sure this is not where I wanted this thread to go - ROFL!!!!

 

In this months JAPMA:

Orthotic Devices with Out-toeing Wedge as Treatment for In-toed Gait in Children

 

I would first of all like to thank everyone involved in this and associated threads, even although the discussions have made my head hurt!:hammer:

I have been looking through the threads on Metadductus and intoeing for inspiration in the treatment of an 11yo boy with Metadductus. He presented for Ax c/o pain in both heels and "severe" intoeing. o/e Hamstrings and Calf Muscles are very tight, hip RoM at least 45deg int/ext rotn, mild genu valgum (within normal range) Tibial torsion within normal range, medial deviation of STJ, and significant flexible Metadductus (haven't measured angle). Calves are very weak, struggling to lift heel off floor in single leg stance. He is able to consciously correct gait for some of the time but intoeing when running can be > 60deg. He is keen to play sport but heel pain restricts activity significantly. Any suggestions for treatment? I noted the lateral skive and valgus forefoot correction but the eversion of the calc is such that that lateral skive would probably not work (I think!).

PS - be kind, first post!

 

Hey pm. Welcome to the party. Might we have a name to know you by?

First things first, what is the patients presenting complaint? You mention heel pain. Plantar or posterior? He is the right age for severs....

Your treatment should focus on this. The biometrics are interesting but peripheral. The pain is what he came to you with. Don't get sidetracked by the shape of the feet.

Normal rules of assessment. So tell us about the heel pain. Because the tx will depend what we are treating.

 

Oops, the name is Alastair.

The heel pain is on the plantar, posterior aspect, too low for severs. Initial treatment was simple, added 6mm poron heel cushion and PMP to runner insole, this has help to reduce the heel pain and increase activity a bit. Basketball coach has been very understanding and puts him on for short bursts and then lets him rest. Has also been working with the physio to try improving stretch and strength. Initially heel strike was very heavy but this has noticably decreased on this assessment, however noting that foot strike is more midfoot now.

Having read the posts, I completely agree with the idea of not treating if it's not causing a problem. And I am inclined to think that the Metadductus is probably only part of the problem. There is a high amount of lateral instability when the feet adduct, especially during running, this also tends to cause the foot to catch on the back of the supporting leg during swingthrough.

If orthotic treatment is indicated, the metadductus will play a significant roll in the prescription, even if it is not what need to be treated?

 

Hello Alastair.

Don't rule out severs disease. Generally it does present as posterior but if you look at an x ray



The apophysis is plantat posterior. I see no reason why the more plantar part of the apophysis might be inflamed, particularly if the patient has a heavy heel strike on the more lateral side of the heel.

I would certainly be thinking in terms of heel cushions / raises. Otherwise (and its always tricky without the patient in front of you!), I would be thinking in terms of medial rearfoot wedging with a substantial lateral arch and forefoot valgus extension to sulcus. Strengthening exercises for the calves and stretches for the Calves and Hams. Depending on the degree of the met adductus I may also consider reverse last footwear. My objective would be to work on a less lateral and softer heel strike to reduce trauma to the lateral part of the calcaneal apophysis.

 

That's a fair point, it could be well worth investigating. I can also see how that prescription could work, would you also include a heel raise in that script? Or could you replace the medial rearfoot post with the heel raise?

 

It would depend on how much post / skive I'd need to have the desired effect. If possible, I'd put the poron raise on top of the medial post (on top of the insole). If not, I'd use the poron underneath the medial heel skive.

 

Appreciate your help, sometimes can't see the wood for the trees!

Alastair