Intoeing or “Pigeon Toed” Children

Is intoeing or being pigeon toed impacting your child’s activity? Or as a parent or caregiver, is the intoeing of your child a cause for concern? Consider a Gait Plate.

Recently I had two appointments in one day which involved intoeing children (commonly referred to as Pigeon Toed). This type of referral is quite normal, and is common for us to assess and treat.

What brought these parents to us? One had a child that tripped often and was experiencing knee pain (which for a 3-year-old to describe is odd). The other was congenital in nature, involving a physiological and structural reason.

Having children come through my door – and being a parent myself – I want to share with you some information on this topic that may be helpful.

Many parents ask if the gait of their children is normal; if the “flat footed, intoed” appearance will change; and if their child needs orthotics.

A couple simple questions lead me to my answer. First, I ask how old the child is. Followed by:
Do they have pain?
Do they experience tripping? And, if so, have they sustained injuries as a result?
Do they complain about their legs and feet?

If the answer to these questions is ”no,” then my answer is no; they do not need orthotics at this time.

If they answer “yes,” then I recommend an assessment to determine what intervention is necessary.

Interventions can vary; not all patients are given an orthotic. An assessment will help us determine where to go from there. Maybe it’s as simple as a change in footwear or footwear size, maybe it’s a referral to a physiotherapy, osteopathy, RMT, or chiropractor. The list goes on and on.

Treatment of children can be a very heated debate among professionals; however, in my professional opinion and from my experience, when a child:
1) can describe pain,
2) is not physically active due to discomfort, or
3) sustains injuries due to their mechanics,

I am an advocate for investigation and intervention.

More about intoeing

Generally, there are two different reasons for the presentation:

1) Hip/femur position is altered due to soft tissue restriction (muscle/tendon/ligament), or
2) Structural, due to anteversion of the femur, tibial torsion or congenital deformities.

Once the cause is determined, then we can iron out a treatment plan. Growth and physical development are primary considerations when choosing treatment, with the goal ensuring milestones are met, and range of motion and functional movement are all promoted and maintained.

For the two patients I mentioned above, both exhibited functional restriction within the hip (although one presented with a congenital deformity, anatomical cause was ruled out while soft tissue restriction was at the forefront). What does that mean? It suggests that the soft tissues of the hip/pelvis are contributing to their intoeing pattern.

But the children are growing – isn’t that normal? Yes it is, but, there is a fine line when functional restrictions create:
1) pain,
2) avoidance of activity
3) tripping, with probable injury

The goals with both of these young patients included:
1) Promotion of efficient and “normal” gait patterns/mechanics.
2) Creating muscle memory that establishes uncompensated patterns and less injury.
3) Reduced discomfort.

Use of a Gait Plate

When passive hip range of motion occurs (when I move the patient’s hip while they are laying down and relaxed), but is blocked actively while they are upright walking/running (as with a soft tissue restriction and/or muscle imbalance), the utilization of a gait plate with soft tissue restriction can have profound effects.

A gait plate can generate positive outcomes for the patient, such as:
a) less tripping
b) confidence with activity
c) motor control and patterning for walking and running

What does it look like? And, how does it work?

A gait plate’s design includes a small extension or flange to the shell of the orthosis (applied to both feet) from the 2nd metatarsal joint to the 5th metatarsal joint. This extension reduces the ability of the foot to curve inward during walking, thus promoting and encouraging the hip to “work” by turning the leg out. This action allows the foot to bend and push off from the first MTP joint (“normal gait”).

How long is this therapy necessary?

The answer all depends on the child and their observed progress. Often children outgrow their orthoses (2 shoe size growth), and another pair is created, often with a less angled flange or extension as the strength and muscle memory improves.

Additional therapy is also recommended, such as chiropractic, physiotherapy, RMT, and/or osteopath for optimal outcomes.

Good quality footwear should also be considered with this therapy, as flexible footwear functions greater when retraining the gait patterns.

Have more questions? We’d be happy to chat!

Book your appointment now.

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Call: 519-390-0327

post ankle injury

Weak Ankles Got You Down?

Do you have “weak” ankles? Suffered multiple ankle sprains in your life? Even the ones you ignored?

unstable ankle

Chronic ankle instability is a common condition that can develop after suffering multiple ankle injuries and are often a result of “minor sprains” left untreated or not properly rehabilitated. Many of us “walk off” one or two of these while playing sports in our youth. No big deal, we thought. Unfortunately, these minor tweaks can sneak back up on us years later. 

The ankle is a complex joint with a very unique structure. When standing and walking the ankle assists the leg with movement over the foot, and assists the foot with shock absorption for the entire body. To work properly, the ankle depends very heavily on the surrounding muscles and joints.

ankle anatomy

An injury to your foot or ankle often “alters” your walking for a bit. It may disrupt your balance, or can have profound effects on other parts of your body due to compensations (sore hip anyone?).

When you sprain your ankle, the ligaments (whose job is to hold bone to bone) are stretched or torn. Ligaments do not regenerate or repair themselves, so each additional sprain leads to further stretching and weakening. This is why it is so easy to sprain your ankle over and over again.

After an injury, rehabilitation is so important. The ankle requires stability; and since the ligaments are stretched or torn, the only way to regain joint stability is for muscles to double their duty – function/strength and stability.

Typically, the “giving way” that occurs during a sprain, happens while you’re walking or doing other activities. It is typical for it to happen more frequently on uneven terrain, but can just as easily happen while walking on a smooth surface. In severe cases, it can also happen when you’re just standing.

post ankle injury

Common Complaints:
1) A repeated turning of the ankle, especially on uneven surfaces or when participating in sports
2) Ongoing discomfort within the joint with pain and swelling.
3) The ankle feels wobbly or unstable.

How can we help?

Custom foot orthotics incorporate your anatomical structure, and promote the function of the joint effectively. Proprioception and balance are essential, and when ankle instability is high, assistance from an external source can help the foot and ankle remember the desired motor pattern of the muscles.
Custom orthotics can also reduce the lateral spill and turning over of the ankle by ensuring the lateral forefoot balance is even to promote forward motion through the 1st and 2nd toe, and not off the outside of the foot.

Higher cut footwear (shoes that allow you to sit deeper) can improve your proprioception and increase the sensory stability of the ankle. Confidence with each step maintains activity and reduces symptoms related to immobility.

foot ankle compression

Compression socks that end just below the knee can promote healthy fluid movement and reduce stagnant swelling present from repeated trauma. Fluid build-up can restrict joint movement and cause stiffness, impact muscle function and performance. (How can those muscles do their job if they are over run by swelling?)
Compression socks will help move the fluid from the foot/ankle and up the leg to the pump in the calf. From there, each step or muscle contraction pumps the fluid back up the body to be recycled.

Bracing is another option that allows for the ankle to be functional and protected during activity. There are different types of braces, sleeves, wraps and boots that can be effective in reducing injury. One of our favourites is the ASO Ankle Brace. The option to have more or less support is available. The boot design with lacing accommodates different foot shapes and sizes. The ankle cuff caps off the support by stabilizing the tibia and fibula and the long flexors and extensors contributing to ankle function.

Let us help your ankles! Give us a call today to book an appointment.

The Right Fit – A Guide To Proper Fitting Footwear

Image 1

When searching for a new pair of shoes, finding the right pair that fits you the best can be a difficult and daunting task. Understanding shoe anatomy can assist you when we dive deeper into fit. Take a look at image 1 to help guide you through the different parts that make up a shoe.

Important Things To Consider When Making Your Footwear Choice

Consider the shape of your foot

Are your feet wide or narrow?
Do you have high arches or low arches?
Do you have any abnormalities or bony prominence’s that affect fit of footwear?

Not all shoe widths, sizes and shapes are the same. Individuals can vary in size from brand to brand, so don’t get hung up on the size number when choosing a shoe. Consider the last shape, fit of the toe box, and features such as seamless uppers, or the type of closure (laces, velcro, slip on) as it relates to your foot.

Every shoe is made on a last which can vary between each individual shoe manufacturing company. Additionally, different last shapes can vary between shoe models within the same brand. In general there are three different categories of lasts. These are the straight last, semi-curved last and curved last.

Typically the wider and flatter your foot, you should gravitate towards a shoe that is made on a straight last. Low arched (Pes Planus) feet generally need a sole unit that mimics the shape of your foot, broad and more rectangle in shape. If you are not sure what the last of the shoe looks like, a trick is to look at the bottom of the shoe and check the shape of the sole unit. If the sole is narrow and cuts into the arch this shoe is not for you. Your foot will overhang the base of the shoe and be squished into a position that is not natural to your shape, this can create balance and stability problems.  With a low arch or flat foot, check to see if the shoe you desire comes in different widths and try them on. You may be surprised how simply increasing your width can improve your comfort!

3 Lasts

Individuals with high arched (Pes Cavus) feet will typically fit better in a shoe that is made on a semi-curved or curved last. The semi-curved and curved last tends to contour to the foot structure, offering a glove like feel and hug into the arch. High arched feet generally require more depth and adjustability through the instep. This foot structure takes up more space height wise through the instep as the bony structure and arch is raised significantly.  Shoes with less volume such as slip on shoes can be a struggle for the high arched foot structure. Less space and a lack of adjustability can lead to uncomfortable pressure, toe clawing, and numbness. In conjunction with the curve of the last, you need to consider the toe shape of each last. This can range from narrow tapered toe boxes, a circular toe box, square toe box, and an anatomical toe box. High arched feet can be deceiving, and can often be wider at the ball of the foot, have elongated toes and dropped metatarsal arches. Similar to the low arched foot, if the shoe you desire comes in different widths, try them on!

** Tip – when trying on the shoe, remove the factory liner and stand on it. Does your foot fit within the shape and space of this liner? This is a good indicator of fit.

Upper construction and design can assist with fit and comfort as well. Many shoe companies now design their uppers with less stitching and printed designs. Less stitching improves flexibility of the upper material, thereby reducing irritation to the top of the foot and providing a better overall fit. Feet that have characteristics such as clawing of toes, bunions and any other bony prominence’s appreciate the flex and stretch of material that make up the upper as well.

Lacing For Common Fit Issues

Heel slipping because of a narrow heel and wide forefoot?
Do your toes go numb when your shoes are laced?
Do you need more space for the big toe because of bunions, arthritis or gout?

Changing your lacing technique can go a long way with comfort and fit, allowing for more space in the shoe for areas of high pressure or friction. In clinic we often see patients who loosen their shoes to accommodate for any of the above issues. Although a loose shoe relieves pressure, it also reduces foot security and the overall function of the shoe.  Loose footwear can lead to tripping, toe clawing as toes work harder by gripping to hold the shoe on, calf and arch discomfort from the improper/overuse of the long toe flexors, it can also increase inversion ankle sprains as the foot slides more easily within the unsecured and unstable shoe. If lacing techniques do not seem to make a difference, then re-consideration of the width, depth, last, style and size of the shoe is necessary.

What About Off-Set or Shoe Drop?

Off-set of this shoe is 16 mm-10 mm = 6 mm.

The off-set or shoe-drop is the difference between the amount of material under the heel and the amount of material under the forefoot (front) of a shoe. The material in-between is classified as the midsole of a shoe. Commonly shoes incorporate more material under the heel in order to help absorb the impact of landing as we heel strike. This absorption helps our bodies with the distribution of force as we make contact with the ground. In other words, it eases the initial impact on the joints and tissues of the feet and lower legs.

The recommended off-set for footwear will vary between different activities. For instance, running shoes may range from 8 mm to 12 mm off-set, while fitness and training shoes, court shoes and cleats will range from 0 mm to 4 mm off-set. Protection from injury and optimal performance are considered when shoes are designed with or without an off-set.

Clinically, the off-set is also important to consider when making recommendations for our patients who are dealing with specific injuries, present with an anatomical or structural need and for assisting/complementing neurological conditions. If you have a goal to reduce your off-set, this can be done strategically and via the assistance/guidance of a gait and lower limb specialist.

Foot and Lower Limb Mechanics

Do you supinate (foot rolls out) or overpronate (foot rolls in) upon landing?
Do you have an abnormal alignment of the lower leg, knees and feet? Bowlegged, knock-kneed, or leg length difference?
Do you notice that the wear pattern on the bottom of your shoes are different left to right? Maybe there is excessive wear on the sole of each shoe?
Do you have any chronic injuries that do not seem to resolve with replacing footwear?

If you answer yes to any of the above questions, consider getting a second opinion from a Pedorthist before committing to a shoe. Biomechanical anomalies and functional restrictions can impact how a shoe will interact and respond to your specific mechanics. During your assessment bring older footwear for us to evaluate the wear patterns, ask any questions you may have, and tell us your goals! We are here to help find a shoe that will  work best for you, your mechanics and activities.

Stay tuned for our analysis of walking vs. running shoes; and a list of some of our favourites!