Gait plates are a specialised orthotic modification used to influence the angle of gait and can be a useful tool in managing in‑toe gait in children when applied to the right patient and integrated into a broader treatment plan. This essay will outline the biomechanics and causes of in‑toe gait, the design and mechanism of gait plates, the evidence for their effectiveness, clinical indications and limitations, and practical considerations for their use in paediatric practice.
In‑toe gait in children
In‑toe gait (or pigeon‑toeing) describes a walking pattern in which the feet point medially relative to the line of progression. It is common in early childhood and is most frequently associated with three main anatomical contributors: metatarsus adductus, internal tibial torsion, and increased femoral anteversion.
In many toddlers, mild in‑toeing is considered a normal variant of development and often improves spontaneously as rotational alignment normalises with growth. However, persistent or severe in‑toe gait can be associated with frequent tripping, reduced participation in play or sport, pain, and cosmetic or psychosocial concerns for the child and family. For these children, intervention may be warranted, beginning with careful assessment to determine the primary level of rotational deformity (foot, tibia, or femur) and to exclude neuromuscular or structural pathology.
Gait plate design and mechanism
A gait plate is an orthotic design feature that modifies the distal contour and line of flexion of the device to alter the child’s angle of gait. Unlike traditional functional orthoses that typically terminate just proximal to the metatarsal heads, gait plates extend distally beyond the metatarsophalangeal joints asymmetrically to influence how the shoe flexes and how the foot operates within the shoe.
For in‑toe gait, the gait plate is commonly extended laterally so that the distal edge finishes under or past the lateral toes, shifting the effective flexion line and making it easier and more comfortable for the foot to externally rotate during propulsion. The device is thought to act via a combination of mechanical constraint and proprioceptive feedback: as the child attempts to toe‑in, contact with the orthosis and shoe encourages a subtle out‑toe position that gradually becomes the preferred pattern while the device is worn.
Gait plates can be fabricated as modifications to custom orthoses or as stand‑alone flat plates sourced from rigid materials such as polypropylene or carbon fibre, then posted or contoured as required. They are typically used inside everyday footwear, including school shoes and runners, provided there is sufficient depth and width to accommodate the extended forefoot section.
Evidence for effectiveness
The literature on gait plates is relatively limited but suggests that they can produce a measurable improvement in the angle of gait and reduce functional problems such as tripping in children with in‑toe gait. Early work by Schuster in the 1960s reported improvements of around 15° in angle of gait with gait plate use in children with rotational gait abnormalities. Subsequent studies have shown more modest but statistically significant reductions in in‑toeing, along with decreased tripping and high levels of parental satisfaction.
A more recent study of children with in‑toe gait due to increased femoral anteversion found that a gait plate insole worn in ordinary shoes increased the angle of gait by approximately 11.1° compared with barefoot walking and by around 7° compared with shoes alone. The same study reported changes in centre of pressure displacement in the anterior–posterior direction, indicating a subtle alteration in gait mechanics rather than a purely cosmetic change. Importantly, these improvements occurred immediately when the device was worn, which supports the view that gait plates primarily modify gait while in situ rather than permanently correcting underlying torsional deformities.
Clinical reports from podiatry practices indicate that gait plates can noticeably reduce tripping and improve the appearance of gait in children with more severe in‑toeing, with many parents reporting that children adapt quickly and find the devices comfortable. However, there is limited high‑quality long‑term data on whether these devices influence structural rotational alignment over time, so they should be viewed as functional aids rather than definitive corrective tools.
Indications, limitations, and clinical decision‑making
Gait plates are most appropriately indicated in children who have persistent in‑toe gait beyond the expected age of spontaneous resolution, particularly when it is associated with frequent tripping, pain, or psychosocial distress. They can be especially useful when the in‑toe gait is functionally significant but surgery would be disproportionate or inappropriate given the child’s age and overall function.
Before prescribing a gait plate, practitioners should identify the primary source of in‑toeing, as some causes are less responsive to conservative approaches. For example, tibial torsion is often reported not to respond meaningfully to splints, footwear modifications, or physical therapy alone; surgical derotation may be considered only in older children with severe functional limitations. In contrast, in‑toe gait related to increased femoral anteversion has shown measurable improvement in angle of gait when a gait plate insole is used, suggesting that in these cases the device can be an effective adjunct to monitoring and exercise.
A key limitation is that gait plates are generally effective only while worn; they do not necessarily resolve the underlying torsional deformity. Clinicians should therefore avoid over‑promising structural correction and instead frame the goal as improving function, reducing tripping, and enhancing the cosmetic appearance of gait during use. Additionally, the extended distal profile may limit footwear options, and careful shoe selection is essential to avoid pressure on the toes or poor fit.
Practical application in a paediatric treatment plan
In practice, gait plates should be prescribed as part of a comprehensive management plan for the child with in‑toe gait rather than as a stand‑alone cure. This plan typically begins with a detailed history and physical examination, including assessment of rotational profiles (foot progression angle, thigh–foot angle, hip rotation range), neuromuscular status, and any associated pain or functional limitations.
When gait plates are selected, custom devices are often designed from a cast or scan to incorporate both standard orthotic features (such as rearfoot posting or arch support) and the specific gait plate extension tailored to the child’s pattern of in‑toeing. The child and family are counselled on a gradual wear‑in schedule to allow adaptation and to monitor for pressure areas or discomfort, with follow‑up reviews to assess changes in gait and function over time.
Adjunctive therapies frequently include stretching and strengthening programs targeted at identified deficits, such as hip external rotator strengthening or calf and hamstring stretching, as well as postural and balance work. Many clinicians also incorporate gait retraining strategies, using verbal cues, visual feedback, and sometimes video to help the child internalise a straighter foot progression pattern. In this context, the gait plate can be seen as a facilitative device that reinforces the desired movement pattern with each step, complementing active rehabilitation efforts.
Ultimately, gait plates represent a useful tool in the paediatric podiatrist’s repertoire for managing symptomatic or functionally significant in‑toe gait, offering a non‑invasive means to improve gait appearance and reduce tripping while a child continues to grow and develop. Used judiciously and with clear expectations, they can play an important role in supporting both physical function and the child’s confidence during everyday activities.