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In-toeing Gait Management: A Student Trial of Methods


The most common treatment options today for in-toeing gait are de-rotation straps, twister cables and HKAFOs. There have been simpler and less invasive options in past treatments modalities such as Gait Plates documented by Schuster in 1967. Unfortunately, there are only 5 research studies available and only 3 of them quantify the results. Due to the poor amount of any published quantitative data regarding their efficacy, they are rarely used in mainstream pediatrics and orthopedics. Also, "In the absence of established best evidence based practice, the provision of both safe and quality health care cannot be assured" (Uden 2012). Therefore, research is needed in this area which prompted a student trial of methods involving Gait Plates for studying the effects on in-toeing.

Gait plates

A gait plate (Figure 1 ) is a dynamic in-shoe correction made of carbon fiber, polypropylene and other materials. It is situated under the heel and mid foot within a shoe, and it is used to treat toe-in and toe-out. In order to treat in-toeing, the gait plate should be cut proximal to the first metatarsal head and reach to the distal end of the fifth phalange. To treat toe-out, do the opposite.

The goal of the gait plate is not to correct, but to provide a combination of neuromuscular reeducation, encouraging realignment of the hip in gait and improving coordination, balance, pain, posture and strength.

This trial of methods project proceeded to understand how this little known method works. The purpose of this project is to prove if in fact the gait plates are able to increase the toe-out angle during gait and to quantify the results. For this project, I used 5 of my cousins whose parents gave me their consent to allow them to participate of this trial of methods. There were 2 boys and 3 girls; the ages range from 8 to 14. Bilateral foot impressions in neutral position were taken using the Foamart Foot impression system. None of the participants knew about the goal of the project, it was only explained to the parents. The gait plates were fabricated using 1/8" polypropylene, Pe-lite Polyethylene foam and leather (Figure 2 ). It is noteworthy that no evaluation was performed in any of the participants, therefore we continued with the project believing that none of them had in-toeing gait.

The only variable studied was the toe in/out angle of the foot during 6 laps at a comfortable speed of 3 different walks: Original (no gait plates), Gait plate (right after fitting), and with the gait plate after walking with it for 15 minutes. The data was recorded with a 16 foot GaitRite Carpet and was evaluated with the ProtoKinetics Movement Analysis Software. Of the 5 participants, only 4 collections were used due to one of the participants having overheard the goal of the project and tried to help manipulate the results, hence the results were disqualified.

In the final results of the participants, there was a consistent finding of approximately 1.5 to 2.5 degrees of increased toe out in both feet in an average number of 28 steps per participant. Figure 3 shows a comparison of the average results of the original walk and the walk after 15 minutes of wearing the gait plates for the 4 participants. It is noted that 3 of them did not present with in-toeing gait and that their toe out angle was increased with the gait plates.

To focus on participant 4 (Figure 4 and Figure 5 ), it is observed that the original walk started with a negative number, which means that the steps are in-toed. During this walk, the participant gave a total of 20 intoed steps out of 26. Immediately after fitting, the toe out angle averages changed to positive, increasing a total of 2.273 degrees and 4.245 degrees on the right and left respectively. In this participant's case, a repeated walk was requested using a longer stride. The longer stride allowed the gait plate to use a longer lever arm, hence providing a better performance. During this walk, the toe out angle averages increased 3.862 degrees on the right foot and 3.976 degrees on the left when compared to the original walk. The participant reduced the amount of in-toed steps significantly to 7, thirteen in-toed steps less than in the original walk.

An interesting part of this project was the unexpected participant presenting with in-toeing gait. Taking advantage of this opportunity, it was decided to analyze one more walk without the gait plates. Only 3 in-toed steps were present and the averages were 2.984 degrees and 2.716 degrees for the right and left foot respectively. If it was possible to improve an in-toed gait in only 15 minutes with a gait plate, then what would be the potential outcome in 1 week, 1 month, or as long as the treatment needs to be. These results opens the door to a possible new treatment approach for managing in-toeing gait.

To close with a quote from Walt Disney, "We keep moving forward, opening new doors, and doing new things, because we're curious and curiosity keeps leading us down new paths." That is exactly what I was, curious. I was curious enough to go out of my way, fabricate gait plates with no instruction manual, and try to understand how the device works. This is just the beginning of something that can become our first choice of treatment for managing in-toeing gait. I encourage you to do research, to ask questions, to find answers and share the information, as I did. Do it for all the patients that are possibly over treated when they could be using something as simple as a shoe insert.

*I have a full presentation with videos and more information about the gait plates and this project. If interested, please do not hesitate to contact me at . Thank you*

Bibliography:

  1. Hayley Uden and Saravana Kumar. Non-surgical management of pediatric "intoed" gait pattern a systematic review of the current best evidence. Journal of Multidisciplinary Healthcare 2012:5 27-35
  2. Schuster RO. A device to influence the angle of gait. J Am Podiatry Assoc. 57(6):269-270, 1967
  3. Redmond AC. An evaluation of the use of gait plate inlays in the short-term management of the in-toeing child. Foot Ankle Int. 1998;19(3):144-148
  4. Redmond AC. The effectiveness of gait plates in controlling in-toeing symptoms in young children. Journal of the American Podiatric Medical Association 2000;90(2):70-76
  5. Valmassy RL. The use of gait plates for in-toed and out-toed deformities. Clinics in Podiatric Medicine and Surgery 1994;11:211-217

Orializ M Gonzalez, B.A.S OP, St Petersburg College, is a Graduate Student MSIEOP, Florida State University