In-toeing and out-toeing gait conservative treatment; hip anteversion and retroversion: 10-year follow-up.

BACKGROUND: In-toeing and out-toeing rotational deformities are among the most common referrals for consultation with orthopedic specialists. Although a few number of patients need surgical interventions, most of them get better spontaneously without major complications in adult life. In this study, we investigated the prevalence of permanent gait deformities due to hip rotational disorders in a group of patients who underwent conservative treatments. MATERIALS AND METHODS: This retrospective cohort study was conducted in the orthopedic department on patients with rotational deformities of the lower extremities (hip anteversion and hip retroversion). From 2,983 patients, 611 were included in this study and followed up for 10 years. Medial rotation of the hip, lateral rotation of the hip, and tibia fibula angle (TFA) of each patient were measured independently. RESULTS: In this study, 611 patients were assessed and 323 (143 male and 180 female) were followed up in our study. Two hundred and seventy patients had in-toeing gait disorders due to hip anteversion, which 178 of them were corrected conservatively (%). Furthermore, among 53 patients with out-toed gait due to hip retroversion, 44 patients (%) were corrected in the same conditions (P = 0.001). It was determined that gait disorders were corrected conservatively in 102 of 143 males and 120 of 180 females (P = 0.37). CONCLUSION: Our findings showed that rotational deformities are expected to be corrected by conservative management. It is better to consider surgical procedures as the last therapeutic option.

Does pathologically increased or decreased tibial torsion affect muscle activations during walking in typically developing adolescents?

A reduced capacity of plantar flexors and other muscles to extend the hip and knee during gait was shown in modelling studies when the tibial torsion angle is > 30° than normal. The aim of the current study was to determine if patients with increased or decreased tibial torsion show deviating muscle activations in knee and hip extensors in surface electromyography (EMG). Patients with CT confirmed increased tibial torsion (n = 19, ITT), decreased tibial torsion (n = 21, DTT) and age-matched healthy controls (n = 20) were included in this retrospective study. Additionally, kinematic and kinetic data were recorded during three-dimensional gait analysis. Surface EMG was recorded for vastus medialis and medial hamstrings. Statistical parametric mapping with a one-way ANOVA and post-hoc Bonferroni corrected two-sample t-tests were used to obtain differences in joint angles and moments. ITT and DTT showed an increased and decreased external foot progression angle, respectively. No additional muscle activations in vastus medialis and medial hamstrings were found in both patient groups compared to controls. DTT showed an increased hip flexion through parts of the gait cycle and both patient groups had a decreased knee extension moment in terminal stance. Our hypothesis of deviating muscle activation had to be rejected. It could be that in most orthopaedic patients the amount of exceeding tibial torsion is too low to cause substantial deviations in gait and muscle activation patterns.

Causes of out-toeing gait in children with cerebral palsy.

BACKGROUND: Out-toeing is common in children with cerebral palsy (CP), contributing to lever arm dysfunction and functional limitations. It is important to determine the cause(s) of out-toeing prior to treatment, whether surgical or non-surgical. RESEARCH QUESTIONS: What are the contributors to out-toeing in children with CP and do they differ between children with bilateral and unilateral involvement? METHODS: The causes of out-toeing gait were determined retrospectively, with the use of computerized gait analysis, in 261 children with cerebral palsy (344 sides). The prevalence of various causes was calculated separately for children with bilateral and unilateral involvement, and compared statistically between groups using Fisher's Exact analysis. RESULTS: The most common cause of out-toeing was pes valgus in bilaterally involved subjects (71%) and pelvic external rotation (64%) in unilaterally involved subjects. Over half of the cases of out-toeing were due to multiple causes: 62% of the unilateral group and 53% of the bilateral group. In limbs with multiple causes of out-toeing in the bilateral group, pes valgus was one of the causes in 91% of limbs (146/161), and was most commonly combined with hip external rotation (27%), pelvic external rotation (22%), or external tibial torsion (20%). For the unilateral group with multiple causes of out-toeing, pelvic external rotation was one of the causes in 83% of limbs (20/24) and hip external rotation in 63% (15/24). Both were present (with or without additional causes) in 46% (11/24) of such limbs. SIGNIFICANCE: The causes of out-toeing are multifactorial in over half of affected limbs of children with cerebral palsy. They also differ for children with bilateral and unilateral involvement. These findings should be carefully considered prior to non-surgical or surgical treatment of out-toeing gait in these patients, to allow all sites of pathology to be addressed, and to optimize outcomes.

Prevalence and diagnostic accuracy of in-toeing and out-toeing of the foot for patients with abnormal femoral torsion and femoroacetabular impingement: implications for hip arthroscopy and femoral derotation osteotomy.

AIMS: Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT. PATIENTS AND METHODS: A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed. RESULTS: We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified. CONCLUSION: In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218-1229.

Is in-toing gait physiological in children? - Results of a large cohort study in 5910 healthy (pre-) school children.

BACKGROUND: In-toeing is a major concern of many parents presenting their children to pediatric orthopedists. Foot progression angle (FPA) quantifies the rotation of the foot's longitudinal axis during gait, with negative values describing in-toeing and positive values describing out-toeing. Although it has been shown that the FPA changes over the course of a child's development, reference values for the normal FPA-range are lacking. RESEARCH QUESTION: This study aimed to establish reference values in 1-14 year old healthy children and to implement FPA-percentile curves for daily clinical use. METHODS: 5910 healthy children performed at least 3 repetitions of barefoot walking over an instrumented walkway using a pressure measurement platform. The FPA [°] was extracted and analyzed by age and gender (mean ± standard deviation; median with percentiles, MANOVA (age, gender) and Wilcoxon-Signed-Rank test for intra-individual side differences (α = 0.05). RESULTS: FPA maximum was observed in 2-year-old children and diminished significant until the age of 4 to moderate out-toeing. For ages 5-14, no statistically significant differences in FPA values were present (p > 0.05). MANOVA confirmed age (p < 0.001) and gender (p < 0.001) as significant FPA influencing factors, without combined effect (p > 0.05). In every age group, right feet showed significantly greater out-toeing (p < 0.05). SIGNIFICANCE: Percentile values indicate a wide FPA range in children. FPA development in young children shows a spontaneous shift towards moderate external rotation (age 2-4), whereby in-toeing ≤ 1-5° can be present, but can return to normal. Bilateral in-toeing after the age of four and unilateral in-toeing after the age of seven should be monitored.

Foot loading patterns can be changed by deliberately walking with in-toeing or out-toeing gait modifications.

The present study shows how foot loading patterns may be deliberately altered by either in-toeing or out-toeing gait during barefoot walking. The results indicate that in-toeing increasingly loads the lateral aspects of the midfoot and forefoot by as much as 61% and 49%, respectively, whereas out-toeing intensifies the load on the medial aspect, i.e. predominantly the medial midfoot and medial forefoot by as much as 72% and 52%. These findings are being discussed with respect to the potential benefits of consciously altering the gait pattern in order to off-load certain plantar regions.