Children who have an inward turn of their toes draw the anxiously look of concerned parents all over the school playgrounds, pediatric clinics and suburbs. This original gait pattern – often referred to as intoe gait or “pigeon-toeing” – is one of the more common explanations put forth in pediatric podiatry. Gait plates for intoe gait have also been used, having been designed to counter this pattern in the growing child.

This article discusses specifically what intoe gait entails, how the design of gait plates function, the reality of what literature provides us about their effectiveness, who are candidates, and how this could and should be used in life.

Understanding Gait Plates for Intoe Gait

This is a gait pattern where one or both feet turn internally in stance and swing phase. It is very common in young children, and in many cases will return to normal spontaneously as the growth and development of the musculoskeletal system takes place. However, others may have persistent intoeing well into later childhood that has negatively impacted their confidence, ability to be active and wear patterns at footwear use.

Three common structural problems most frequently result in intoe gait.

Femoral anteversion- a mild inward twist of the thigh bone.

Tibial torsion is a medial twist of the lower leg, which causes the foot’s natural direction of pointing to change.

Metatarsus adductus is a condition affecting the foot. It is one of the specific foot conditions and is known to cause an inward curving of the anterior part of the foot from the midfoot and is responsible for the foot having a banana-shaped configuration.

All of these causes occurs at a different level in the limb and this is important when deciding if gait plates or other interventions are indicated.

Signs, symptoms, and everyday effects Parents generally start to notice intoeing once a toddler begins to walk independently (years one to three). The most common complaints are recurrent trips and falls on level surfaces and an unsteady running gait. Some children implement a compensatory gait- swinging the leg outward during each step- to prevent the feet from colliding with each other.

Wear pattern on shoes may be indicative as well, if the outside of the heel and the inside of the forefoot are wearing more than normal. Others become self-aware about the way they move, potentially deterring them from sport and physical activity.

—What is a Gait Plate and how does it function? A gait plate is actually one specific type of foot orthotic and has one simple function:to change foot progression angle. Gait plates are different from orthopaedic shoes or orthotics, as they do not provide pressure redistribution or arch support, but by working on modifying where the foot prefers to flex at toe-off, when the heel lifts.

This image demonstrates how by adding an extension to the lateral, (outer) part of the forefoot the plate would be cambering the foot outwards each step.

Design features of gait plates The primary characteristic of the gait plate is the long lateral flange. This is a stiff or semi-stiff extension that hangs over the toes. I added this to form a Mechanical lever. With walking, as the heel hits the ground the outside of the plate hits first, forcing everting movement during initial contact.

A majority of other gait plates will fit within ordinary shoes (typically what are known as “trainers,” or even dress shoes) and will be made of polypropylene or some other rigid material. Most are flat rather than contoured, indicating they are not functional orthotic devices (arch control).

Gait plates versus other intoeing solutions Prior to the use of gait plates it was common practice to use clinician visual assessment alone to establish the presence of intoeing (acceptable for mild cases) or Denis Browne bars (now defunct in most nations).

Standard arch-supported orthotics actually don’t provide any correction for rotational gait problems. Shoe modifications such as medial wedging may be helpful in some cases of metatarsus adductus. Gait plates position themselves in between these extremes: more specific than series production orthotics, less invasive than surgery and more evidence based than outdated devices.

They’re not a cure, but they are able to force motor patterns in to what is a highly active period of bone growth.

Effectiveness of Gait Plates for Intoe Gait

The clinical evidence in support of the use of gait plates is in certain respects quite promising, but it is not definitive in most instances. Much of the literature supporting the various interventions centers on short-term outcomes in children with tibial torsion or metatarsus adductus where mechanical redirection of the foot is perhaps most sensibly applied biomechanically.

What the Studies Demonstrate in terms of Effectiveness Several prospective clinical studies and small randomized controlled trials have indicated significant benefits in foot progression angle by continuing gait plate wear. One of the commonest quoted result is a reduction of around 5′-10′ of the intoeing angle after several months of use, however this is a meaningful difference for moderate presentations.

Parents also found reduced trips, falls and near misses (1,3,4)and video gait analysis shows more neutral foot placement (2). Results are, generally speaking, perhaps most reliable in children from three to eight years old, when the bone interfaces are undergoing active remodeling.

Limitations, dangers and what is still unknown Yep – the evidence base remains somewhat sparse. Are mostly small in size, not longer-term (two years); do not always control for actual natural resolution that was going to happen irrespective of treatment. Some children seem to complain of initial discomfort; there are also reports of changes in balance.

Long term results—Do gait plates provide permanent results or are they just a delay to natural correction—is still very uncertain. Gait plates, in particular, may not be effective for everyone and clinicians ought to acknowledge their limitation.

Who can benefit from Gait Plates? All called for.1 Not every child with intoeing can do. Gait plates should be used when the persistent intoeing beyond age 4 is functionally limiting or causing secondary problems such as frequent falls or pain.

Age, severity and underlying cause factors Children aged approximately three to ten years would probably show the best response as the skeleton retains sufficient plasticity during that period. For the mild cases in children less than three years old, they are usually followed rather than treated.

The reason for it is hugely significant. Gait plates are most justifiable in cases of tibial torsion and metatarsus adductus, where the deformity is at or just above foot level. The origin of femoral anteversion at the hip makes it inappropriate for foot-based interaction because the mechanical difference between both locations is too great.

When are gait plates not a good idea? Significant structural deformities, stiff metatarsus adductus (not reducible passively), or intoeing with underlying neurological pathology such as cerebral palsy means alternative measures need consideration. The above conditions should always be excluded prior to the use of any orthotic device by a podiatrist or orthopedic professional.

— ## How to obtain and use gait plates safely Gait plates must only be recommended and fitted by an appropriately trained health professional such as a podiatrist experienced in assessing children. Buying generic versions online for oneself is fraught with risk, such as unsuitable-fitting and wrong-treatment.

Assessment, Fit and Shoes selection. A comprehensive assessment would involve observational gait analysis, testing of rotational profile and may involve video recording. Typically, the gait plate is either made to fit or selected from a prefabricated series depending on the size of the foot and the amount of deformity.

Choosing you child’s footwear is more important than most would think – a boot with a secure heel counter, flat insole and sufficient depth to take the appliance without putting pressure on the toe area is essential.

Daily use/exercises,f/up reviews During most daily waking hours, children are off gait plates starting with full-time use over 1 st week as tolerated. Using plates together with workout equipment that is designed to strengthen the hip, or using it together with gait retraining activities can enhance the results.

Follow-up visits at three to six month intervals enable the clinician to evaluate the patient’s progress, modify the device as the foot develops, and establish when treatment can be terminated.