Out Toeing During Gait

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 

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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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