Management of in-toe gait pattern

NewsBot · Feb 14, 2012

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Non-surgical management of a pediatric "intoed" gait pattern - a systematic review of the current best evidence.
Uden H, Kumar S.
J Multidiscip Healthc. 2012;5:27-35

BACKGROUND:
An intoed gait pattern is one of the most common referrals for children to an orthopedic consultation. Parental concern as to the aesthetics of the child's gait pattern and/or its symptomatic nature will primarily drive these referrals during a child's early developmental years. Whilst some of these referrals prove to be the result of a normal growth variant, some children will present with a symptomatic intoed gait pattern. Various treatments, both conservative and surgical, have been proposed including: braces, wedges, stretches and exercises, shoe modifications, and surgical procedures. However, which treatments are effective and justified in the management of this condition is not clear within the literature. The aim of this systematic review was to therefore identify and critique the best available evidence for the non-surgical management of an intoed gait pattern in a pediatric population.

METHOD:
A systematic review was conducted of which only experimental studies investigating a management option for an intoeing gait pattern were included. Studies needed to be written in English, pertaining to a human pediatric population, and published within a peer reviewed journal. Electronic databases were searched: Ovid (Medline), EMBASE, AMED, PubMed, SportDiscus, CINAHL, and Cochrane Library. The National Health and Medical Research Council's designation of levels of hierarchy and the Critical Appraisal Skills Programme cohort studies critical appraisal tool were used.

RESULTS:
Five level IV studies were found. The studies were of varied quality and with mixed results. Gait plates, physiologic/standardized shoes, and orthotic devices (with gate plate extension) were shown to produce a statistically significant improvement to an intoed gait pattern. Shoe wedges, torqheels, and a leather counter splint were not able to reduce an intoed gait pattern.

CONCLUSION:
There is limited evidence to inform the non-surgical management of a pediatric intoed gait pattern. The body of evidence that does exist is small (n = 5) and of varied quality, which means recommendations arising from this evidence base should be interpreted with caution. There is generally weak evidence that suggests that gait plates and orthotic devices with a gait plate extension may assist in the management of a pediatric intoed gait pattern.
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Admin2 · Feb 14, 2012

Related threads:
Other threads tagged with in-toe gait

Simon Spooner · Feb 14, 2012

NewsBot said: ↑

[/URL]Gait plates, physiologic/standardized shoes, and orthotic devices (with gate plate extension) were shown to produce a statistically significant improvement to an intoed gait pattern.
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Can't spell "gait" consistently, but never mind. That'll be garden "gate plate extensions" they're talking about- right? And this passed through the reviewers eyes... Yet, clearly not their brains.

Bug · Feb 18, 2012

Oh dear, the brain is an amazing thing.

Good to see it out there though.

NewsBot · May 20, 2014

The Therapeutic Effect of Tibia Counter Rotator With Toe-Out Gait Plate in the Treatment of Tibial Internal Torsion in Children
Su Min Son, et al
Ann Rehabil Med. 2014 Apr;38(2):218-225. English.

Objective
To evaluate the therapeutic effect of a Tibia Counter Rotator (TCR) with toe-out gait plate (GP) upon tibial internal torsion by a comparative analysis of transmalleolar angle (TMA) and gait analysis with GP alone.
Methods
Twenty participants with tibial internal torsion were recruited for this study. Each 10 participants were included in group A with TCR and GP application and in group B with GP application only. The TMA and the kinematic results were used for the evaluation of the therapeutic effects of orthoses.
Results
Within each group, TMA showed a significant increase after treatment. Group A showed a continuous improvement up to six months, however, group B showed an improvement up to five months only. Group A showed a significantly higher correction effect than group B after treatment. Regarding kinematic data, both groups showed a significantly decreased mean ankle adduction angle after treatment. However, group A showed a significantly lower mean ankle adduction angle than group B after six months.
Conclusion
The group with TCR and GP showed a significantly better outcome and continued correction force compared to the group with GP only. Our results suggest that TCR with GP may be useful therapeutic orthoses for children with tibial internal torsion.
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NewsBot · Oct 7, 2014

Gait deviations and compensations in pediatric patients with increased femoral torsion.
Bruderer-Hofstetter M1, Fenner V, Payne E, Zdenek K, Klima H, Wegener R.
J Orthop Res. 2014 Oct 4.

Coxa antetorta describes an abnormal torsion of the femur. It is commonly considered a cosmetic problem and is treated surgically only in severe cases and the presence of physical complaints. The purpose of this study was to identify deviations in gait kinematics and kinetics in pediatric patients caused by coxa antetorta and to categorize these deviations into primary and secondary deviations. We conducted a retrospective, cross-sectional three-dimensional (3D) gait analysis study to detect gait deviations in adolescents (n = 18; age range 10.5-17.5 years) with coxa antetorta compared to age-matched healthy control subjects (n = 17). Principal component (PC) analysis was used for data reduction. Linear mixed models applied to PC-scores were used to estimate the main effects within retained PCs followed by a post-hoc subgroup analysis. Patients walked with smaller external foot progression angle, greater knee adduction, more internally rotated and flexed hips and greater anterior pelvic tilt. Subgroup analysis revealed that-depending on knee alignment-patients had higher knee and hip adduction moments. These deviations in joint kinematics and kinetics may be associated with physical complaints and accelerated development of osteoarthritis. Assessment of gait deviations related to coxa antetorta using 3D gait analysis may be an additional tool in individual clinical decision-making.
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NewsBot · Jun 28, 2017

THE EFFECT OF TOE-IN/TOE-OUT VARIATION ON LOCOMOTION:
A COMPREHENSIVE REVIEW
Sarah Ann Irsik
Honors Thesis Appalachian State University May, 2017

Gait modifications can alter energy demands and cost of transport. Specifically,
alterations in toe-in and toe-out alignment have been found to affect force production
abilities during gait. However, the terminology used when describing alterations in toein/toe-out
alignment is somewhat differential. The aims of this thesis were to conduct a
literature review to define terminology associated with toe-in/toe-out gait as well as
determine implications on force production, injury, disability, trainability, performance,
and analyze possibilities for further investigations. Reference articles were collected
from journal databases such as PubMed, Web of Science, Google Scholar, and
SPORTDiscuss, by searching for studies related to intoeing gait, foot progression angle,
and metatarsophalangeal joint during running. After reviewing the literature it was
concluded that toe-in/toe-out modification could alter the gear ratio of the foot and
result in a more mechanically advantageous gait pattern. Further inquiries are
necessary to determine the exact parameters for degrees of intoeing and outtoeing that
are beneficial, as well as its impact on performance during different phases of gait or
movement patterns.
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NewsBot · Jan 11, 2018

Spectrum of Diagnosis and Disposition of Patients Referred to a Pediatric Orthopaedic Center for a Diagnosis of Intoeing.
Faulks S, Brown K, Birch JG.
J Pediatr Orthop. 2017 Oct/Nov;37(7):e432-e435. doi: 10.1097/BPO.0000000000001007.

BACKGROUND:
Orthopaedic surgeons frequently evaluate otherwise healthy children for concern of intoed gait. Intoeing in otherwise healthy young children due to metatarsus adductus, internal tibial torsion, and increased femoral anteversion do not typically require orthopaedic treatment. This study reviewed the actual diagnosis, management, and disposition of patients referred to a pediatric orthopaedic specialty hospital for a diagnosis of intoeing; the efficacy of an Advanced Practice Provider (APP) assessment program to screen and triage patients with a primary complaint of intoeing; and parental satisfaction with that program.

METHODS:
We established an "Intoeing Clinic" conducted by APPs to conduct initial evaluations of patients referred for a diagnosis of intoeing meeting-specific criteria, including (1) a referring provider's diagnosis of "intoeing"; (2) the patient was under the age of 9 years; and (3) there was no suggestion of comorbidity in the information provided by the referring provider to imply a diagnosis other than "benign" intoeing. Under pediatric orthopaedic surgeon "on-call" supervision, APPs were authorized to perform clinical assessments supplemented by radiographs and laboratory investigations as deemed necessary. We performed an Institutional Review Board-approved, retrospective medical record review of all patients appointed to our Intoeing Clinic over a 30-month period (March 2010 to September 2013).

RESULTS:
About 95% of 926 patients appointed to APP Intoeing Clinic were confirmed to have a diagnosis of "benign" intoeing or a similar "benign" diagnosis; 5% of these patients requested a reevaluation for the same concern. Approximately 5% were determined to have a nonbenign diagnosis, either known to the family/provider, but not conveyed at the time of referral (4%), or identified at our institution (1%). Two patients (0.2%) were determined at follow-up examination to have a neurological abnormality at the subsequent examination.

CONCLUSIONS:
An "Intoeing Clinic" staffed by experienced Advanced Pediatric Practitioners or equivalent, with appropriate orthopaedic surgeon availability for consultation can be an effective and efficient method of evaluating patients referred for a diagnosis of "intoeing."
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NewsBot · Sep 7, 2018

Reverse-Shoe Wearing Method for Treating Toe-In Gait in Children Can Lead to Hallux Valgus.
Li Y et al
Med Sci Monit. 2018 Sep 4;24:6157-6164. doi: 10.12659/MSM.909072.

BACKGROUND The aim of this study was to compare the effect of 2 methods for treating toe-in gait in children (reverse-shoe wearing and orthopedic insoles) and to determine whether reverse-shoe wearing results in hallux valgus. MATERIAL AND METHODS Between July 2012 and July 2014, 337 children diagnosed with toe-in gait over 2 years were recruited. For 139 children, parents selected use of reverse-shoe wearing treatment (RS group) and for 198 children, parents selected orthopedic insoles treatment (OI group). There were 98 children in the RS group and 167 in the OI group who completed the 12-month therapy and follow-up. We excluded 28 children who failed to complete the study, and 44 children who ceased treatment within the first month were selected as controls. Patients were assessed for up to 24 months after the cessation of treatment. Foot progression angle (FPA) and presence and degree of hallux valgus angle (HVA) were recorded. RESULTS FPA was significantly reduced after 6 months in both RS and OI groups (P<0.05). FPA returned to almost normal after 12 months of treatment, with no significant difference between the 2 groups. There were 29 cases (51 feet) of hallux valgus in the RS group after 12-month treatment; the HVA had significantly declined by 2 years after treatment with normal shoe wearing but did not return to normal. CONCLUSIONS Corrective treatment should be used with children diagnosed with toe-in gait over 2 years showing no remission. Both reverse-shoe wearing and orthopedic insoles show similar levels of treatment success, but reverse-shoe wearing has a significant adverse effect of hallux valgus.
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