Toe-out Gait Research Articles

Effects of foot progression angle adjustment on external knee adduction moment and knee adduction angular impulse during stair ascent and descent

Foot progression angle adjustment was shown to reduce external knee adduction moment (EKAM) and knee adduction angular impulse (KAAI) during level ground walking. However, evidence on effects of foot progression angle adjustment on the above surrogate measures of medial knee loading during stair climbing is limited. Hence, this study examined the effects of toe-in and toe-out gait on EKAM and KAAI during stair ascent and descent. Kinematic and kinetic data were collected from thirty-two healthy adults during stair ascent and descent with toe-in, toe-out and natural gait. A repeated measures ANOVA indicated that toe-in gait significantly reduced the first EKAM peak (P < 0.001) and KAAI (P = 0.002), while toe-out gait significantly increased the first (P < 0.001) and second (P = 0.04) EKAM peaks and KAAI (P < 0.001) when compared with natural gait during stair ascent. During stair descent, toe-in gait significantly reduced the first (P < 0.001) and second (P = 0.032) EKAM peaks and KAAI (P < 0.001), whilst toe-out gait significantly increased the first EKAM peak (P = 0.022) and KAAI (P = 0.028) when compared with natural gait. In conclusion, toe-in gait was found to be a viable strategy in reducing medial knee loading during stair climbing.

Toe-in and toe-out walking require different lower limb neuromuscular patterns in people with knee osteoarthritis

Toe-in and toe-out gait modification has received attention lately as a promising treatment for knee osteoarthritis due to its potential to improve knee joint loading and pain. However, the neuromuscular patterns associated with these walking styles are not well known, a factor that may influence knee joint load itself. Our aim was to conduct a thorough examination of the neuromuscular patterns associated with toe-in and toe-out walking in people with knee osteoarthritis. Fifteen participants were instructed to walk in four different foot rotations: 10° toe-in, 0°, as well as 10° and 20° toe-out. Nine surface electrodes were placed over lower extremity muscles and a variety of muscle activation parameters were examined. Peak and average medial hamstrings muscle activation was increased (p = 0.001, p < 0.001) during toe-in walking compared to toe-out walking. As well, average lateral gastrocnemius muscle activation was higher (p = 0.001) during toe-in walking compared to 20° toe-out. Medial thigh muscle co-contraction was higher (p = 0.003) during toe-in walking compared to all other conditions, and medial to lateral gastrocnemius activation ratio was lower (p = 0.032) during toe-in walking. These findings suggest potential overall increased joint loading with toe-in walking as a result of muscle co-contraction. Long-term assessment of these strategies is warranted.

The effects of toe-out and toe-in postures on static & dynamic balance, risk of fall and TUG score in healthy adults

BackgroundToe-in and toe-out foot positions have not yet been tested for dynamic balance and risk of fall. The aim of this study was to investigate the effects of these two modifications on static and dynamic postural stability and risk of fall through instrumental (Biodex Balance System®) and functional (timed up and go-TUG test) tools. MethodologyTwenty healthy adults (8 males, 12 females, age: 29±4.10years, BMI: 21.56±2.36kg/m2) participated in this study. Static and dynamic (levels 8 and 2) balance with single stance and double stance and dynamic (level 8 and levels 6–2) for risk of fall with double stance were tested with the Biodex Balance System with three self-selected feet positions: straight (13.8°), toe-out (35.6°) and toe-in (−11.9°) for each test condition. Additionally, TUG test was performed with toe-out and toe-in gait. ResultsThe results of repeated measures ANOVA showed significant differences (p<0.05) between straight and modified toe angles in balance at dynamic level 2 with both double and single stance conditions. Significant differences (p<0.001) were also found in TUG scores for the test conditions. ConclusionToe-in and toe-out gait modifications have significant effects on balance at higher levels of platform tilt and functional balance. Further investigations with knee osteoarthritis patients and electromyography may provide insight in balancing strategies adopted by the body in toe-out and toe-in gait.

Clinical and biomechanical changes following a 4-month toe-out gait modification program for people with medial knee osteoarthritis: a randomized controlled trial

To compare changes in knee pain, function, and loading following a 4-month progressive walking program with or without toe-out gait modification in people with medial tibiofemoral knee osteoarthritis. Individuals with medial knee osteoarthritis were randomized to a 4-month program to increase walking activity with (toe-out) or without (progressive walking) concomitant toe-out gait modification. The walking program was similar between the two groups, except that the gait modification group was trained to walk with 15° more toe-out. Primary outcomes included: knee joint pain (WOMAC), foot progression angles and knee joint loading during gait (knee adduction moment (KAM)). Secondary outcomes included WOMAC function, timed stair climb, and knee flexion moments during gait. Seventy-nine participants (40 in toe-out group, 39 in progressive walking group) were recruited. Intention-to-treat analysis showed no between-group differences in knee pain, function, or timed stair climb. However, the toe-out group exhibited significantly greater changes in foot progression angle (mean difference=-9.04° (indicating more toe-out), 95% CI:-11.22°,-6.86°; P<0.001), late stance KAM (mean difference=-0.26%BW*ht, 95% CI:-0.39%BW*ht,-0.12%BW*ht, P<0.001) and KAM impulse (-0.06%BW*ht*s, 95% CI:-0.11%BW*ht*s,-0.01%BW*ht*s; P=0.031) compared to the progressive walking group at follow-up. The only between-group difference that remained at a 1-month retention assessment was foot progression angle, with greater changes in the toe-out group (mean difference=-6.78°, 95% CI:-8.82°,-4.75°; P<0.001). Though both groups experienced improvements in self-reported pain and function, only the toe-out group experienced biomechanical improvements. NCT02019108.

Lower limb muscle activation patterns during foot rotation gait modification in people with knee osteoarthritis

Lower limb muscle activation patterns during foot rotation gait modification in people with knee osteoarthritis

A randomized controlled trial investigating clinical and biomechanical changes following toe-out gait modification for knee osteoarthritis

A randomized controlled trial investigating clinical and biomechanical changes following toe-out gait modification for knee osteoarthritis

Subject-specific toe-in or toe-out gait modifications reduce the larger knee adduction moment peak more than a non-personalized approach

The knee adduction moment (KAM) is a surrogate measure for medial compartment knee loading and is related to the progression of knee osteoarthritis. Toe-in and toe-out gait modifications typically reduce the first and second KAM peaks, respectively. We investigated whether assigning a subject-specific foot progression angle (FPA) modification reduces the peak KAM by more than assigning the same modification to everyone. To explore the effects of motor learning on muscle coordination and kinetics, we also evaluated the peak knee flexion moment and quadriceps-hamstring co-contraction during normal walking, when subjects first learned their subject-specific FPA, and following 20 min of training. Using vibrotactile feedback, we trained 20 healthy adults to toe-in and toe-out by 5° and 10° relative to their natural FPA, then identified the subject-specific FPA as the angle where each subject maximally reduced their larger KAM peak. When walking at their subject-specific FPA, 18 subjects significantly reduced their larger KAM peak; 8 by toeing-in and 10 by toeing-out. On average, subjects reduced their larger KAM peak by 18.6 ± 16.2% when walking at their subject-specific FPA, which was more than the reductions achieved when all subjects toed-in by 10° (10.0 ± 17.1%, p = .013) or toed-out by 10° (11.0 ± 18.3%, p = .002). Quadriceps-hamstring co-contraction and the peak knee flexion moment increased when subjects first learned their subject-specific FPA, but only co-contraction returned to baseline levels following training. These findings demonstrate that subject-specific gait modifications reduce the peak KAM more than uniformly assigned modifications and have the potential to slow the progression of medial compartment knee osteoarthritis.

A novel mutation in the hepatocyte nuclear factor-1β gene in maturity onset diabetes of the young 5 with multiple renal cysts and pancreas hypogenesis: A case report.

A 17-year-old Chinese male was hospitalized exhibiting hyperglycemia and increased serum urea nitrogen and creatinine levels in addition to weight loss. The patient was treated with gliclazide. The patient was 150 cm tall, weighed 35 kg and had no family history of diabetes or kidney disease. Physical examination revealed cephalus quadratus, rachitic rosary and a visible toe-out gait. Laboratory examinations revealed that the patient's fasting plasma glucose and glycosylated hemoglobin levels were markedly increased, fasting plasma C-peptide level was slightly increased and no peak 2 h postprandial was observed. Diabetic autoimmune antibodies [islet cell cytoplasmic autoantibodies (ICA), glutamic acid decarboxylase autoantibodies (GADA), isulinoma-2-associated autoantibodies (IA2A) and insulin autoantibodies (IAA)] were negative. Levels of serum electrolytes decreased, uric acid and parathyroid hormone increased, mild albuminuria was detected and there was a low proportion of urine. The patient also presented with low bone mass and cataracts. Abdominal computed tomography (CT) revealed a bilateral atrophic kidney with multiple renal cysts, primarily located at the junction of renal cortex and medulla, with a diameter of 0.3-0.7 cm. CT also revealed hypogenesis of the body and tail of the pancreas. In an oral glucose tolerance test, the mother and paternal uncle of the patient were diagnosed with type II diabetes and the patient's sister, maternal uncle and paternal grandpa were diagnosed with glucose tolerance impairment. Genetic testing revealed an unreported amino acid mutation in exon 2 of hepatocyte nuclear factor 1β (c.391C>T), a nonsense mutation of CAA to TAA at codon 131. This mutation was identified in the proband but not in any other family members.

Analysis of Tibialis Anterior and Gastrocnemius Muscle Activity According to Toe Angle during Gait

Background/Objectives: The purpose of this study was to determine the effects of changing the foot progression angle (FPA) on muscular activity of the lower extremity in 21 healthy male and female subjects in their 20s. Methods/Statistical analysis: After electromyographic (EMG) electrodes were positioned over the tibialis anterior (TA) and gastrocnemius (GCM) muscles, subjects underwent gait evaluation under three PFA magnitudes ( -10°, 10°, 30°) to measure the root mean square (RMS). Multivariate Analysis of Variance was used for statistical analysis along with Tukey's post-hoc test. An alpha of 0.5 is considered to be statistically significant. Findings: Comparison of changes in muscle activity of the TA and GCM during walking under different FPA magnitudes revealed no significant difference during –10° toe-in and 30° toe-out gaits. However, during 10° normal gait, the total activity of the two muscles was significantly lower on both sides in comparison with those found during –10° toe-in and 30° toe-out gaits. Improvements/Applications: It will be necessary to conduct further study with subjects who actually walk with either toe-in gait pattern or toe-out gait pattern to ensure the impact of their gait patterns.

Effect of Foot Progression Angle and Lateral Wedge Insole on a Reduction in Knee Adduction Moment.

This study evaluated the effect of foot progression angle on the reduction in knee adduction moment caused by a lateral wedged insole during walking. Twenty healthy, young volunteers walked 10 m at their comfortable velocity wearing a lateral wedged insole or control flat insole in 3 foot progression angle conditions: natural, toe-out, and toe-in. A 3-dimensional rigid link model was used to calculate the external knee adduction moment, the moment arm of ground reaction force to knee joint center, and the reduction ratio of knee adduction moment and moment arm. The result indicated that the toe-out condition and lateral wedged insole decreased the knee adduction moment in the whole stance phase. The reduction ratio of the knee adduction moment and the moment arm exhibited a close relationship. Lateral wedged insoles decreased the knee adduction moment in various foot progression angle conditions due to decrease of the moment arm of the ground reaction force. Moreover, the knee adduction moment during the toe-out gait with lateral wedged insole was the smallest due to the synergistic effect of the lateral wedged insole and foot progression angle. Lateral wedged insoles may be a valid intervention for patients with knee osteoarthritis regardless of the foot progression angle.

Toe-Out Gait Decreases the Second Peak of the Medial Knee Contact Force.

Toe-out angle alternation is a potential tactic for decreasing the knee adduction moment during walking. Published reports have not examined the medial knee contact force during the toe-out gait, although it is a factor affecting knee articular cartilage damage. This study investigated the effects of increased toe-out angle on the medial knee contact force, using musculoskeletal simulation analysis. For normal and toe-out gaits in 18 healthy subjects, the muscle tension forces were simulated based on the joint moments and ground reaction forces with optimization process. The medial knee contact force during stance phase was determined using the sum of the muscle force and joint reaction force components. The first and second peaks of the medial knee contact force were compared between the gaits. The toe-out gait showed a significant decrease in the medial knee contact force at the second peak, compared with the normal gait. In contrast, the medial knee contact forces at the first peak were not significantly different between the gaits. These results suggest that the toe-out gait is beneficial for decreasing the second peak of the medial knee contact force.

Comparison of Mirror, Raw Video, and Real-Time Visual Biofeedback for Training Toe-Out Gait in Individuals With Knee Osteoarthritis

ObjectiveTo compare performance error and perceived difficulty during toe-out gait modification in people with knee osteoarthritis (OA) across 3 different types of visual feedback: mirror, raw video, and real-time biofeedback of toe-out angle. DesignRepeated-measures, within-subject trial. SettingUniversity motion analysis laboratory. ParticipantsIndividuals with knee OA (N=20; 11 women; mean age, 65.4±9.8y) participated in this study. Seven participants had mild knee OA, 9 had moderate knee OA, and 4 had severe knee OA. InterventionsParticipants were trained to walk on a treadmill while matching a target indicating a 10° increase in stance phase toe-out compared with toe-out angle measured during self-selected walking. The target was provided visually via the 3 types of feedback listed above and were presented in a random order. Main Outcome MeasuresKinematic data were collected and used to calculate the difference between the target angle and the actual performed angle for each condition (toe-out performance error). Difficulty was assessed using a numerical rating scale (0–10) provided verbally by participants. ResultsToe-out performance error was significantly less when using the real-time biofeedback method than when using the other 2 methods (P=.025; mean difference vs mirror=2.05°; mean difference vs raw video=1.51°). Perceived difficulty was not statistically different between the groups (P=.51). ConclusionsAlthough statistically significant, the 2° difference in toe-out gait performance error may not necessitate the large economic and personnel costs of real-time biofeedback as a means to modify movement in clinical or research settings.

Effects of a 10-week toe-out gait modification intervention in people with medial knee osteoarthritis: a pilot, feasibility study

To examine the feasibility of a 10-week gait modification program in people with medial tibiofemoral knee osteoarthritis (OA), and to assess changes in clinical and biomechanical outcomes. Fifteen people with medial knee OA completed 10 weeks of gait modification focusing on increasing toe-out angle during stance 10° compared to their self-selected angle measured at baseline. In addition to adherence and performance difficulty outcomes, knee joint symptoms (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale and total score, numerical rating scale (NRS) of pain), and knee joint loading during gait (late stance peak knee adduction moment (KAM)) were assessed. Participants were able to perform the toe-out gait modification program with minimal to moderate difficulty, and exhibited significant increases in self-selected toe-out angle during walking (P < 0.001). Joint discomfort was reported by five participants (33%) in the hip or knee joints, though none lasted longer than 2 weeks. Participants reported statistically significant reductions in WOMAC pain (P = 0.02), NRS pain (P < 0.001), WOMAC total score (P = 0.02), and late stance KAM (P = 0.04). These preliminary findings suggest that toe-out gait modification is feasible in people with medial compartment knee OA. Preliminary changes in clinical and biomechanical outcomes provide the impetus for conducting larger scale studies of gait modification in people with knee OA to confirm these findings.

Foot orthoses induce immediate changes in lower limb neuromotor control of gait in people with patellofemoral joint osteoarthritis: a pilot study

Foot orthoses induce immediate changes in lower limb neuromotor control of gait in people with patellofemoral joint osteoarthritis: a pilot study

Joint contact force at medial compartment of tibio-femoral joint decreases in toe-out gait

Joint contact force at medial compartment of tibio-femoral joint decreases in toe-out gait

Toe-out gait modification improves pain and reduces joint loading in people with medial compartment knee osteoarthritis

Toe-out gait modification improves pain and reduces joint loading in people with medial compartment knee osteoarthritis

The therapeutic effect of tibia counter rotator with toe-out gait plate in the treatment of tibial internal torsion in children.

ObjectiveTo 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.MethodsTwenty 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.ResultsWithin 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.ConclusionThe 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.

Impact of foot progression angle on the distribution of plantar pressure in normal children

BackgroundPlantar pressure distribution during walking is affected by several gait factors, most especially the foot progression angle which has been studied in children with neuromuscular diseases. However, this relationship in normal children has only been reported in limited studies. The purpose of this study is to clarify the correlation between foot progression angle and plantar pressure distribution in normal children, as well as the impacts of age and sex on this correlation. MethodsThis study retrospectively reviewed dynamic pedobarographic data that were included in the gait laboratory database of our institution. In total, 77 normally developed children aged 5–16years who were treated between 2004 and 2009 were included. Each child's footprint was divided into 5 segments: lateral forefoot, medial forefoot, lateral midfoot, medial midfoot, and heel. The percentages of impulse exerted at the medial foot, forefoot, midfoot, and heel were calculated. FindingsThe average foot progression angle was 5.03° toe-out. Most of the total impulse was exerted on the forefoot (52.0%). Toe-out gait was positively correlated with high medial (r=0.274; P<0.001) and forefoot impulses (r=0.158; P=0.012) but negatively correlated with midfoot impulse (r=−0.273; P<0.001). The moderating effects of age and sex on these correlations were insignificant. InterpretationFoot progression angle demonstrates significant impact on the distribution of foot pressure, regardless of age or sex. Foot progression angle should be taken into consideration when conducting pedobarographic examinations and balancing plantar pressure as part of the treatment of various foot pathologies.

Biomechanical mechanisms of toe-out gait performance in people with and without knee osteoarthritis

BackgroundToe-out gait modification (increased toe-out angle) has been proposed to decrease medial knee joint loading and slow disease progression in patients with knee osteoarthritis. However, the manner in which toe-out gait modification is performed is unknown. The purposes of this study were to assess the biomechanical strategies of achieving a toe-out gait, and to compare these strategies between older individuals with knee osteoarthritis and young, healthy individuals. MethodsLower limb biomechanics were evaluated for ten patients with knee osteoarthritis and for ten young, healthy individuals during treadmill walking. Two trials, consisting of natural gait followed by a ten degree increase in toe-out angle were performed. Transverse plane rotations of the thigh, shank and foot segments were calculated and compared between walking conditions and groups. FindingsExternal rotation changes with toe-out were significantly different between the thigh and shank, and thigh and foot (P<0.001), but not between the shank and foot (P=0.48). External rotation at each segment was not significantly different (P>0.05) between groups, with the exception of thigh rotation during natural gait (P=0.04). InterpretationCurrent findings suggest that increased toe-out gait is primarily achieved through rotation of the shank and foot, with less contribution from the thigh, and those individuals with knee osteoarthritis perform a toe-out gait biomechanically similar to young, healthy individuals. Gait modification programs should address individuals' limitations, such as joint stiffness, to ensure functional performance of toe-out gait modification.

Altering foot progression angle in people with medial knee osteoarthritis: the effects of varying toe-in and toe-out angles are mediated by pain and malalignment

To evaluate if altering the foot progression angle (FPA) by varying magnitudes during gait alters the external knee adduction moment (KAM), knee flexion moment (KFM), knee extension moment (KEM) and/or symptoms in people with medial knee osteoarthritis (OA). Potential influence of pain and knee malalignment on load-modifying effects of FPA was investigated. Participants (n=22) underwent 3-dimensional gait analysis to measure KAM peaks, KAM impulse, KFM and KEM peaks. Following natural gait, five altered FPA conditions were performed in random order (10° toe-in, 0° FPA, 10° toe-out, 20° toe-out and 30° toe-out). A projection screen displayed their real-time FPA. Pain/discomfort at knees and feet/ankles were evaluated for each condition. Linear mixed models were used for statistical analysis. Toe-in reduced the early stance peak KAM and KEM but increased the KAM impulse, late stance peak and KFM. Toe-out reduced the KAM impulse, late stance peak and KFM (P<0.001) but increased the early stance peak KAM and KEM. All effects were greater in participants with more varus knees. Pain significantly mediated the effect of altered FPA on the KAM impulse and late stance peak. In more painful individuals, toe-in was predicted to reduce the KAM impulse and late stance peak, and increase them for toe-out gait. There were no immediate symptomatic changes. Effects of altered FPA vary across all medial knee load parameters and it is difficult to determine an optimal direction of FPA change. Future studies should consider Western Ontario McMaster Universities OA Index (WOMAC) pain to judge the likely effects of altered FPA.