Responses OUT TOE GAIT
Patricia Rogel
Description
Collection
Title:
Responses OUT TOE GAIT
Creator:
Patricia Rogel
Date:
6/14/2020
Text:
This is a great forum to invite and encourage scholarly discussions based on evidence and experience. PTs are a huge referral source for pediatric practices, so it’s best we are allies and not adversaries. Here are the responses I received from our O & P list serve. There were one or two that were not consistent with what I’ve done for out-toeing – but certainly worth exploring.
“I would suggest you speak with Cascade DAFO. I do some ed work for them and can share with you that they have great outcome studies associated with their orthoses.
“Have you used the Surestep AFO? I’ve had great luck with this brace as long as the patient/ parent can tighten them enough. I mark the straps or they never get them tight enough. They work great when done right.
“I would contact Surestep. (BTW - Surestep reached out and offered to review the case with me with video/images.)
“One thing I know is that either you or another orthotist is going to end up making the exact device that the PT is imagining, and it will do nothing for the rotation at the hip.
You already know that you can tuck in the calcaneus, support the arches, and help reduce planovalgus... but without access to the magical skyhooks that the PTs seem to have, you have no leverage for major rotational control.
“EDS can be challenging and considering you say external hip rotation is the primary issue, that will need to be addressed more than the AFO. At 5'2 and 140 lbs, you could fit with a SWASH orthosis. For the AFOs, plastic standard trimlines with molded inner boots made from 12A Aliplast with lateral containment. Other options if the laxity is severe; Fuzion AFO from Orthomerica or Arizona style. Side note on EDS, I had a teen who was falling a lot from her knees buckling. I put her in the FreeWalk stance control KAFOs. I told her she would hate them at first, which was correct. I started by leaving them both unlocked for her to get used to them. Then transitioned to the stance control. After a learning curve, she loved them and continues to wear them today, several years later. I don't have any studies to cite, just experience.
“I'm probably stating the obvious to you, but my off the top ideas are lateral forefoot extension (encompass little toe), medial external shoe/brace wedging, medial tibial Sabolich, lateral forefoot flange, internal ankle strap originating inside AFO above the medial malleolus, casting in subtalar neutral if possible (if it is an adult, not being too aggressive), snug encompassing of heel, and of course plastic choices depending on skin condition and tolerance.
“From my experience, this problem can't be influenced by either an AFO or SMAFO, it requires a shoe modification. lateral wedge, flare and/or buttress. If using a medial wedge to make it less energy efficient for him to walk over the wedge, it might work depending on the flexibility at the hip. I don't know if I would try the lateral unless it also included an outflare and squared heel ( in a sagittal view the heel would be rounded medially and come to a point laterally so that the floor reaction from initial contact forces [or coaxes] the leg to internally rotate.)
“I’ve had a reasonable amount of success in the past cutting them footplate into a gait plate. (A gait plate orthosis is a rigid device to alter function of the leg in a child with an in-toe or out-toe gait. Schuster originally described the device as a flat, rigid plate cut to the outline of the shoe. The distal edge was angulated to alter the break in the shoe. Under normal conditions, a shoe breaks at a right angle to the line of progression of the foot. The rigid extension, crossing the MPJs, alters this break, forcing a change in the walking direction.
“You fix the CAUSE of rotation. Nothing you can do with anything below the knee, if rotation is at the hip. Neither ankle or knee have significant transverse plane rotation in them.
“Have you checked for gastroc contractures? (if tight, increase heel rise of afo)
If the patient has EDS or similar, then excessive genurecurvatum will be painful.
If they are sedentary (or have a crouch gait), then they will quickly develop gastroc contractures.
The gastroc contracture will increase the magnitude and duration of the toe lever from mid to late stance… all of this getting sent to the knee in an extensor moment.
And the external rotation coming from the hip is a compensatory motion. By externally rotating, you both allow the patient to advance at an oblique angle rather than directly over the toe, plus you effectively reduce the toe lever.
Research shows that when using a CAM boot, external rotation magnitudes triple over control groups.
Before anything else, see what happens if you put half inch heel lifts in both shoes.
“I did try those mods (Cusick) with little to no effect in the 90s. I truly wanted them to work. Alas, it failed on multiple occasions.
“I thought you might find this helpful. Even though they are not modifications the dynamics are applicable to any orthosis.
<URL Redacted>
“Unfortunate, I have found nothing below the hip controls rotation. When PTs come to ask what can be done, I tell them PT and surgery. That is just the way it is. I would enjoy being wrong.
“I’ve done gait plate cut outs on AFO/SMO and it has worked in some cases where the rotation coming from the hip is not caused by excessive tightness. The cut out can be done only at the AFO foot plate and then leave the SMO intact. Another approach is with posting, sometimes it works but I find the cut out works best. If this doesn’t work or the outtoeing is too much, you know what’s next, de rotation straps or twister cables.
“I know it seems too simple, but I’ve had a reasonable amount of success in the past cutting them footplate you a gait plate. I don’t do a tremendous amount of peds and nearly none now.
“You might consider elastic twister straps as they will provide a lot more control than mods to an AFO.
“Common Rotational Variations in Children
Todd L Lincoln 1, Patrick W Suen; J Am Acad Orthop Surg. Sep-Oct 2003;11(5):312-20.
doi: 10.5435/00124635-200309000-00004.
Affiliations expand PMID: 14565753 DOI: 10.5435/00124635-200309000-00004
Abstract: Most rotational variations in young children, such as in-toeing, out-toeing, and torticollis, are benign and resolve spontaneously. Understanding the normal variations in otherwise healthy children is vital to identifying true structural abnormalities that require intervention. A deliberate assessment of the rotational profile is necessary when evaluating children who in-toe or out-toe. In-toeing is usually attributable to metatarsus adductus in the infant, internal tibial torsion in the toddler, and femoral anteversion in children younger than 10 years. Out-toeing patterns largely result from external rotation hip contracture, external tibial torsion, and external femoral torsion. Although congenital muscular torticollis is the most common explanation for the atypical head posture in children, more serious disorders, including osseous malformations, inflammation, and neurogenic disorders, should be excluded.
“Orthoses for rotational disorders benefit from flanges and extensions such as gait plates. Orthoses for angular disorders benefit from high posting and out-flared or wide posts to stabilize the post plate in the frontal plane.
Patricia Rogel, CO, LO, OTR/L
Chicago Pediatric Orthotics
Concourse Office Plaza, Tower 1
4711 Golf Road, Suite 1055
Skokie, IL 60076
224-470-8550 (ph)
224-470-8553 (fax)
<URL Redacted>
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OANDP-L is a forum for the discussion of topics
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should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
“I would suggest you speak with Cascade DAFO. I do some ed work for them and can share with you that they have great outcome studies associated with their orthoses.
“Have you used the Surestep AFO? I’ve had great luck with this brace as long as the patient/ parent can tighten them enough. I mark the straps or they never get them tight enough. They work great when done right.
“I would contact Surestep. (BTW - Surestep reached out and offered to review the case with me with video/images.)
“One thing I know is that either you or another orthotist is going to end up making the exact device that the PT is imagining, and it will do nothing for the rotation at the hip.
You already know that you can tuck in the calcaneus, support the arches, and help reduce planovalgus... but without access to the magical skyhooks that the PTs seem to have, you have no leverage for major rotational control.
“EDS can be challenging and considering you say external hip rotation is the primary issue, that will need to be addressed more than the AFO. At 5'2 and 140 lbs, you could fit with a SWASH orthosis. For the AFOs, plastic standard trimlines with molded inner boots made from 12A Aliplast with lateral containment. Other options if the laxity is severe; Fuzion AFO from Orthomerica or Arizona style. Side note on EDS, I had a teen who was falling a lot from her knees buckling. I put her in the FreeWalk stance control KAFOs. I told her she would hate them at first, which was correct. I started by leaving them both unlocked for her to get used to them. Then transitioned to the stance control. After a learning curve, she loved them and continues to wear them today, several years later. I don't have any studies to cite, just experience.
“I'm probably stating the obvious to you, but my off the top ideas are lateral forefoot extension (encompass little toe), medial external shoe/brace wedging, medial tibial Sabolich, lateral forefoot flange, internal ankle strap originating inside AFO above the medial malleolus, casting in subtalar neutral if possible (if it is an adult, not being too aggressive), snug encompassing of heel, and of course plastic choices depending on skin condition and tolerance.
“From my experience, this problem can't be influenced by either an AFO or SMAFO, it requires a shoe modification. lateral wedge, flare and/or buttress. If using a medial wedge to make it less energy efficient for him to walk over the wedge, it might work depending on the flexibility at the hip. I don't know if I would try the lateral unless it also included an outflare and squared heel ( in a sagittal view the heel would be rounded medially and come to a point laterally so that the floor reaction from initial contact forces [or coaxes] the leg to internally rotate.)
“I’ve had a reasonable amount of success in the past cutting them footplate into a gait plate. (A gait plate orthosis is a rigid device to alter function of the leg in a child with an in-toe or out-toe gait. Schuster originally described the device as a flat, rigid plate cut to the outline of the shoe. The distal edge was angulated to alter the break in the shoe. Under normal conditions, a shoe breaks at a right angle to the line of progression of the foot. The rigid extension, crossing the MPJs, alters this break, forcing a change in the walking direction.
“You fix the CAUSE of rotation. Nothing you can do with anything below the knee, if rotation is at the hip. Neither ankle or knee have significant transverse plane rotation in them.
“Have you checked for gastroc contractures? (if tight, increase heel rise of afo)
If the patient has EDS or similar, then excessive genurecurvatum will be painful.
If they are sedentary (or have a crouch gait), then they will quickly develop gastroc contractures.
The gastroc contracture will increase the magnitude and duration of the toe lever from mid to late stance… all of this getting sent to the knee in an extensor moment.
And the external rotation coming from the hip is a compensatory motion. By externally rotating, you both allow the patient to advance at an oblique angle rather than directly over the toe, plus you effectively reduce the toe lever.
Research shows that when using a CAM boot, external rotation magnitudes triple over control groups.
Before anything else, see what happens if you put half inch heel lifts in both shoes.
“I did try those mods (Cusick) with little to no effect in the 90s. I truly wanted them to work. Alas, it failed on multiple occasions.
“I thought you might find this helpful. Even though they are not modifications the dynamics are applicable to any orthosis.
<URL Redacted>
“Unfortunate, I have found nothing below the hip controls rotation. When PTs come to ask what can be done, I tell them PT and surgery. That is just the way it is. I would enjoy being wrong.
“I’ve done gait plate cut outs on AFO/SMO and it has worked in some cases where the rotation coming from the hip is not caused by excessive tightness. The cut out can be done only at the AFO foot plate and then leave the SMO intact. Another approach is with posting, sometimes it works but I find the cut out works best. If this doesn’t work or the outtoeing is too much, you know what’s next, de rotation straps or twister cables.
“I know it seems too simple, but I’ve had a reasonable amount of success in the past cutting them footplate you a gait plate. I don’t do a tremendous amount of peds and nearly none now.
“You might consider elastic twister straps as they will provide a lot more control than mods to an AFO.
“Common Rotational Variations in Children
Todd L Lincoln 1, Patrick W Suen; J Am Acad Orthop Surg. Sep-Oct 2003;11(5):312-20.
doi: 10.5435/00124635-200309000-00004.
Affiliations expand PMID: 14565753 DOI: 10.5435/00124635-200309000-00004
Abstract: Most rotational variations in young children, such as in-toeing, out-toeing, and torticollis, are benign and resolve spontaneously. Understanding the normal variations in otherwise healthy children is vital to identifying true structural abnormalities that require intervention. A deliberate assessment of the rotational profile is necessary when evaluating children who in-toe or out-toe. In-toeing is usually attributable to metatarsus adductus in the infant, internal tibial torsion in the toddler, and femoral anteversion in children younger than 10 years. Out-toeing patterns largely result from external rotation hip contracture, external tibial torsion, and external femoral torsion. Although congenital muscular torticollis is the most common explanation for the atypical head posture in children, more serious disorders, including osseous malformations, inflammation, and neurogenic disorders, should be excluded.
“Orthoses for rotational disorders benefit from flanges and extensions such as gait plates. Orthoses for angular disorders benefit from high posting and out-flared or wide posts to stabilize the post plate in the frontal plane.
Patricia Rogel, CO, LO, OTR/L
Chicago Pediatric Orthotics
Concourse Office Plaza, Tower 1
4711 Golf Road, Suite 1055
Skokie, IL 60076
224-470-8550 (ph)
224-470-8553 (fax)
<URL Redacted>
CONFIDENTIALITY NOTICE: This e-mail message and any attachments are for the sole use of the intended recipient(s) and may contain proprietary, confidential, trade secret or privileged information. Any unauthorized review, use, disclosure or distribution is prohibited and may be a violation of law. If you are not the intended recipient or a person responsible for delivering this message to an intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Patricia Rogel, “Responses OUT TOE GAIT,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/255014.
