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Out Toeing During Gait

8/14/2015

4 Comments

 
Picture
In last week's post, I discussed how functional impairments should lead to local bio mechanical testing. For example, femoral adduction/internal rotation noted during a squat should lead the practitioner to check gluteus medius strength. Another great example commonly seen in foot and ankle patients is out toeing during gait assessment. I often think about out toeing as the "too many toes" sign seen when examining a patient in standing from the posterior view. What does it mean when someone is out toeing during gait or static standing?

First, out toeing can originate from several different areas. The patient may be resting in hip external rotation, tibial external rotation, or calcaneal eversion. Finding the cause of the dysfunction will allow you to better diagnose and treat the problem. Specifically, when assessing the foot and ankle, it is important to think about why the patient is moving in that manner & what muscles are not being engaged due to this compensation. Due to the out toeing pattern, many times these patients will be lacking ankle dorsiflexion (Remember dorsiflexion [DF] primarily occurs at the talocrural joint. When assessing DF in clinic, be sure to keep the motion in the sagittal plane. I often see people measuring a combined DF and eversion movement. This is not accurate.) In addition to lacking dorsiflexion, they will also have hypomobile talocrural joint mobility. Finally, if a patient is out toeing, they are not engaging their plantarflexors appropriately. These patients will out toe to avoid normal heel to toe progression. They will avoid toe off due to increased stress across the foot. To compensate for the lack of toe off, the body will out toe to complete the gait cycle 


This person has a mild out toe during gait. They also are avoiding toe off and not engaging their plantarflexors.
Good technique for a patient lacking TCJ mobility

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4 Comments
Glenn
8/14/2015 04:31:55 am

Why is it so common to see patients with a lack of DF?

An anatomical predisposition to favour PF > DF?
Is it muscle strength imbalance of PF > DF?
Sleeping with bed sheets tucked to promote PF all night?
An inactive lifestyle that doesn't stress the talocrural joint?

Thanks for the post!

Reply
Jim
9/19/2015 02:44:34 pm

Glenn,

Thank you for the comment. I think you got it right with all of those examples. Similar to how we round our shoulders in sitting, the muscles on the front of the body become asymmetrical with the posterior chain. I definitely believe the last example you gave is what limits us so often. Rarely to individuals explore the full range of their TCJ which causes TCJ hypomobility and PF muscle tightness.

Thanks for following the post!

Jim

Reply
Kendall
7/10/2018 07:47:42 am

This information was helpful in determining why my patient demonstrates increased ER and toeing out. In my pt they wear B AFOs as they do not have any active DF, they have Spina Bifida and it is unlikely they will regain active DF. Do you have any treatment ideas that can decrease the toeing out? I have been focusing on strengthening the hip musculature.

Reply
TSPT
7/19/2018 10:21:31 am

Hi Kendall,

The question probably needs to look at why there is out-toeing occurring. Typically with AFO's, there is a lack of DF that can occur so the hips will ER as a result. If that is not the case, definitely look at improving hip IR mobility and strength both in OKC and CKC to improve the function with gait. Hope this helps!

Reply



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  • Home
  • About Us
  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
    • Physical Therapist Consultant Course
    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test