Gait Abnormalities

Presentation

• Femurs (thighs) internally rotated
• Knee caps face toward each other when walking
• +/- inward turning of tibia and feet
• Excessive rotation of pelvis in stance and swing phase of gait
• Knock-knees / in-turned legs in conjunction with pigeon toes
• Inturned position is often more pronounced at the end of the day when child is fatigued
• Child often sits in a "W" position
• +/- Hip or patello-femoral pain with weight-bearing sports
• +/- Complain of lower leg/shin pain at end of day or at bed time
• May occur on its own or in combination with pigeon toe feet

Possible Causes

• Femoral anteversion (hip internal rotation > 70 degrees)
• Ligamentous laxity of hips causing excessive internal rotation of hips and thighs with associated weakness of pelvic and hip muscles
• Genu valgus

Non-Surgical Management Options

• Core and pelvic stability exercises
• Strengthening of pelvic and hip musculature
• Proprioceptive exercises
• Spiral Thigh Brace   for biofeedback and gait re-education worn for 4-5 hours a day for a period of 3-6 months or as indicated by health professional
• Customised orthotics to avoid overuse of feet and encourage control of movement from the pelvis and lower trunk

Tip Toe walking can be a feature of a number of type of childhood disorders including:

(i) Cerebral Palsy (CP)

Increased neurological tone and/or spasticity in the lower limbs is a cause of toe waking. The spasticity in the legs can cause the calves to tighten and reduce in length, forcing the feet into a plantar flexed (pointed position). The tightness in the calves reduce child’s ability to rest heels on the ground. In addition children with CP often have very weak muscles in the lower limbs making walking with the correct muscles very difficult. Tip toe walking is an adaptive walking pattern to allow the child to locomote despite weak pelvis muscles and tonal changes.

(ii) Hypermobility Disorders

Children with hypermobility often have ligamentous laxity in the hip/knee/ankle joints. In association with this it is quite common for the proximal muscles (core/pelvis/hip) to be weak and the longer distal muscles (hamstrings /calves ) to be strong. Hypermobile children are often unable to stabilise or control movement efficiently due to weakness around the pelvis and thus overuse the calf muscles as an adaptive mechanism to facilitate walking.

(iii) Autism Spectrum Disorders (ASD)

There is a higher incidence of hypermobility and ligamentous laxity in the ASD population in comparison to the normal population. Like the hypermobile group, weakness in the trunk and and pelvis predispose these children to overuse of the calves and hamstrings and thus tip toe walking.

Signs and Symptoms in Tip Toe Walkers

• Child walks on tip toes with heels raised off floor
• Gastroc-soleus (calf muscles) muscles often look well developed
• Decreased length of gastroc-soleus and hamstrings
• Changes in foot shape due to abnormal weight bearing (fan shaped forefoot/ flat foot/ pronated foot or pes cavus)
• Weakness in hip and pelvic muscles
• Often have weakness in core muscles
• May complain of lower leg/calf or shin pain
• +/- increased tone in lower limbs (in cases of cerebral palsy)

Non-Surgical Management Options

• Stretching of tight muscles groups (gastroc-soleus and hamstrings)
• Strengthening of pelvis muscles (especially gluteus medius and quadriceps) and core stability muscles
• Botox ( in cases where increase tone is a cause)
• +/-   Spiral Th igh Brace or Spiral Power Shorts   for gait retraining
• +/- Orthotics from a podiatrist to reduce overuse of ankle foot and stabilise foot so that child is encouraged to use hip muscles to control movement and balance as opposed to using tip toes

A child who has tip toed since they started to walk and has maintained the pattern for years, often has no memory or concept of what it feels like to walk in a different or more normalised pattern . The Spiral Thigh Brace   is a biofeedback tool to facilitate motor learning and development of new motor memories to help the body and brain to learn to walk in a more normalised pattern. Like an exoskeleton, the Spiral Thigh Brace is body hugging and allows freedom of movement while controlling the direction of movement.