Biomechanical characterization and clinical implications of artificially induced toe-walking: differences between pure soleus, pure gastrocnemius and combination of soleus and gastrocnemius contractures

The purpose of this study was to characterize biomechanically three different toe-walking gait patterns, artificially induced in six neurologically intact subjects and to compare them to selected cases of pathological toe-walking. The subjects, equipped with lightweight mechanical exoskeleton with elastic ropes attached to the left leg's heel on one end and on shank and thigh on the other end in a similar anatomical locations where soleus and gastrocnemius muscles attach to skeleton, walked at speed of approximately 1m/s along the walkway under four experimental conditions: normal walking (NW), soleus contracture emulation (SOL), gastrocnemius contracture emulation (GAS) and emulation of both soleus and gastrocnemius contractures (SOLGAS). Reflective markers and force platform data were collected and ankle, knee and hip joint angles, moments and powers were calculated using inverse dynamic model for both legs. Characteristic peaks of averaged kinematic and kinetic patterns were compared among all four experimental conditions in one-way ANOVA. In the left leg SOL contracture mainly influenced the ankle angle trajectory, while GAS and SOLGAS contractures influenced the ankle and knee angle trajectories. GAS and SOLGAS contractures significantly increased ankle moment during midstance as compared to SOL contracture and NW. All three toe-walking experimental conditions exhibited significant power absorption in the ankle during loading response, which was absent in the NW condition, while during preswing significant decrease in power absorption as compared to NW was seen. In the knee joint SOL contracture diminished, GAS contracture increased while SOLGAS contracture approximately halved knee extensor moment during midstance as compared to NW. All three toe-walking experimental conditions decreased hip range of motion, hip flexor moment and power requirements during stance phase. Main difference in the right leg kinematic and kinetic patterns was seen in the knee moment trajectory, where significant increase in the knee extensor moment took place in terminal stance for GAS and SOLGAS experimental conditions as compared to SOL and NW. The kinetic trajectories under SOL and GAS experimental conditions were qualitatively compared to two selected clinical cases showing considerable similarity. This implies that distinct differences in kinetics between SOL, GAS and SOLGAS experimental conditions, as described in this paper, may be clinically relevant in determining the relative contribution of soleus and gastrocnemius muscles contractures to toe-walking in particular pathological gait.