# Foot Contact Dynamics and Fall Risk among Children Diagnosed with Idiopathic Toe Walking
## 4 Discussion  
Our major findings reveal that cITW are more prone to falls due to (i) lower toe clearance (increased trip risk), (ii) high horizontal heel velocity along with reduced transitional acceleration of COM (slip initiation risk), and (iii) reduced stability when stiffening during stance. We also found cITW typical walking to be inherently inefficient due to several reasons, such as (i) significantly higher push-off impulses, (ii) more knee flexion angles during stance, (iii) high vertical heel velocity, and (iv) already plantar flexed ankle fail to produce force generation capacity during push-off. These results have several broader impacts, for example, (i) foot segment angles and peak-push of impulses could possibly reveal critical insights into severity of ITW, (ii) since no previous study has established norms for foot contact dynamics among cITW population this study will serve as background work, (iii) new interventions, such as providing haptic feedback during toe walking [32] and identifying toe walking utilizing artificial intelligence [33], will help to develop novel interventions. Toe walking may be associated with several other disorders and diagnoses, such as cerebral palsy (CP), muscular dystrophy, autism, myopathy, mental retardation, childhood schizophrenia, and muscular dystrophy [1; 34; 35]. Some researchers claim that ITW children do not have neurological signs [34], but only clinical signs of limited active dorsiflexion during gait. Others claim that ITW may be due to unknown deficits in the central nervous system or a neuropathic process as in muscle properties [36]. ITW children have been reported to have delayed the corticospinal tract [35]. Idiopathic toe walking is commonly diagnosed in pediatric orthopedic clinics as benign and it is often not informed to parents as a significant concern. If the complication gets aggravated with injuries, treatments, such as botox, casting, or ankle-foot orthotics (AFO), or even orthopedic surgery, is often \begin{table}
\begin{tabular}{c c c c c} \hline \hline  & & **Control** & **ITW** \\ \cline{2-5}  & **Toe Walking** & **Typical Walking** & **Toe Walking** & **Typical Walking** \\ \hline \hline Stride Length * [mm] & 921.4 \(\pm\) 197.5 & 1066.0 \(\pm\) 237.1 & 980.5 \(\pm\) 169.3 & 911.2 \(\pm\) 145.1 \\ Stride Time [s] & 0.8 \(\pm\) 0.1 & 0.9 \(\pm\) 0.1 & 0.8 \(\pm\) 0.07 & 0.9 \(\pm\) 0.1 \\ Single Stance Duration [s] & 0.3 \(\pm\) 0.03 & 0.3 \(\pm\) 0.01 & 0.3 \(\pm\) 0.01 & 0.3 \(\pm\) 0.03 \\ Minimum Toe Clearance [mm] & 2.7 \(\pm\) 10.5 & 2.7 \(\pm\) 11.1 & 8.9 \(\pm\) 17.1 & 0.3 \(\pm\) 13.1 \\ Step Width [mm] & 147.0 \(\pm\) 38.9 & 133.6 \(\pm\) 28.6 & 167.3 \(\pm\) 41.3 & 145.2 \(\pm\) 47.4 \\ Horizontal Foot Contact Velocity [mm/s] & \(-\)154.3 \(\pm\) 316.4 & 16.7 \(\pm\) 176.7 & \(-\)47.7 \(\pm\) 220.0 & \(-\)97.4 \(\pm\) 231.4 \\ Vertical Foot Contact Velocity * [mm/s] & 27.3 \(\pm\) 172.1 & \(-\)291.2 \(\pm\) 360.9 & \(-\)29.3 \(\pm\) 108.1 & \(-\)123.1 \(\pm\) 211.0 \\ Transitional Acceleration of COM * [mm/s\({}^{2}\)] & \(-\)288.0 \(\pm\) 4771.5 & 782.94 \(\pm\) 2631.8 & 1284.0 \(\pm\) 3636.5 & 99.964 \(\pm\) 2366.8 \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Gait parameters associated with ITW and control. Here significant differences are represented by * (_p_ < 0.05).