Gait Course Flipbook by CCAcademicAffairs

Connecticut Children’s Center for Motion Analysis

Clinical Gait Analysis A Focus on Interpretation

June 2-4, 2025 Simsbury, Connecticut

Dear 2025 Gait Course Participant: Welcome to Connecticut and the 2025 Gait Course! We are thrilled that you have chosen to participate in the 2025 Clinical Gait Analysis: A Focus on Interpretation course. Over the next few days, you will gain valuable insights into comprehensive clinical gait analysis and learn how to incorporate this useful tool into your clinical practice. We hope that you are as excited to be at the course as we are to host you. We at Connecticut Children’s are proud to collaborate with esteemed faculty from Gillette Children’s Hospital in Saint Paul, Minnesota, Shriner’s Hospital for Children/ UC Davis School of Medicine in California, and Catholic University Hospital in Leuven, Belgium. Together, we bring a wealth of knowledge and experience to enhance your learning. To get the most out of this course, we encourage you to engage fully—listen actively, ask questions, and share your insights. We look forward to working with you over the coming days and hope you leave feeling inspired, informed, and equipped with valuable new perspectives. Enjoy the course and we hope you take home valuable tools for your practice!

Sincerely,

Kristan Pierz, MD Medical Director Center for Motion Analysis

Sylvia Õunpuu, MSc Kinesiologist Center for Motion Analysis

399 Farmington Avenue, 3rd Floor, Farmington, CT 06032 ￭ 860.837.9201 ￭ 860.837.9213 fax ￭ www.connecticutchildrens.org

Registration Registration & Information Desk The Registration and Information Desk is located on the 2nd floor adjacent to the Laurel conference rooms. On Monday morning between 7:30 and 8:00 AM, please stop by the desk to pick up your name badge and additional materials. Your name badge serves as your entry pass to the course venue and to all sessions, coffee breaks, and meals. We kindly ask that you wear your badge visibly at all times while on site. The Registration and Information Desk will remain open throughout the duration of the course. If you have any questions or need assistance at any point, please don’t hesitate to visit us—we’re here to help!

Luggage Storage If you have checked out of the hotel, but are still attending the meeting, you may store your luggage at the hotel’s front desk until your departure.

Course Hours: Monday: June 2, 8:00-5:15 Tuesday: June 3, 8:00-5:25 Wednesday: June 4, 8:00-4:45

Presentations: All presentations can be found using the QR Code provided by CME.

WiFi Information Network: blueStreak *Not password protected for easy connectivity.

There will be several power stations available throughout the conference room; however, please note that they will not be located at every table. We kindly ask that you arrive with your laptop fully charged to ensure you have adequate power during sessions.

Pre-Function Space

Floor Plan

Use staircase to go to registration desk and meeting rooms.

Meeting/Breakout Rooms

Registration Desk

Lunch

SIGHTS, BITES, & DELIGHTS We’re delighted that you’ve chosen to attend this year’s Gait Course in the beautiful town of Simsbury, Connecticut. To help make your stay even more enjoyable, we’ve included a list of local favorites—dining spots, attractions, and activities we think you’ll love. Thank you for joining us. We look forward to a productive and inspiring event!

Fine Dining

Casual Dining

Metro Bis 690 Hopmeadow Street Simsbury, CT 860-651-1908

Abigail's Grille & Wine Bar 4 Hartford Road Simsbury, CT 860-264-1580

Millwright's 77 West Street Simsbury, CT 860-651-5500

Plan B Simsbury 4 Railroad Street Simsbury, CT 860-658-4477

Present Company 2 Tunxis Road Tariffville 860-658-7890

La Joya Fresh Mexican 834 Hopmeadow Street Simsbury, CT 860-217-0229

Fast Food National chain restaurants can be found on Route 44 in Canton, Simsbury, and Avon

Little City Pizza 152 Simsbury Road Avon, CT 860-658-4001 Max A Mia 70 East Main Street Avon, CT 860-677-6299

Dessert

Things to See

Tulmeadow Farm Ice Cream 255 Farms Village Road West Simsbury, CT 860-658-1430

-Pinchot Sycamore Tree -Old Drake Flower Bridge -Hublein Tower -Numerous walking paths/trails and hikes in Simsbury!

PROGRAM AT A GLANCE Monday June 2 (Course Day 1) Time 7:30 8:00 8:10 10:10 10:35 12:00 1:00 1:20 3:30 3:55 4:15

Agenda Registration/Material Pick-Up Welcome and Introductions & Orientation Lecture Break Lecture & Breakout Session Lunch Review of AM Breakout Session Lecture & Breakout Session Break Review of PM Breakout Session Case Study 1 – Guided

Location Pre-function Area Laurel A Laurel A Laurel B & C Laurel A Evergreens Laurel A Laurel A Laurel B & C Laurel A Laurel A

Tuesday June 3 (Course Day 2) Time 8:00 9:15 9:40 10:55 12:15 1:15 3:00 4:00 4:25

Agenda Lecture Break Case Study 2 Lecture Lunch Lecture Case Study 3 Break Case Study 4

Location Laurel A Laurel B & C Laurel A, Talcott, Penwood, Atrium & Pre-function Laurel A Evergreens Laurel A Laurel A, Talcott, Penwood, Atrium & Pre-function Laurel B & C Laurel A, Talcott, Penwood, Atrium & Pre-function Wednesday June 4 (Course Day 3)

Time 8:00 9:50 10:15 10:55 11:55 12:55 1:55 2:20 3:15 4:25

Agenda Lecture Break Lecture Case Study 5 Lunch Lecture Break Elective 1 Elective 2 Final Remarks

Location Laurel A Laurel B & C Laurel A Laurel A, Talcott, Penwood, Atrium & Pre-function Evergreens Laurel A Laurel B & C Laurel A, Talcott, Penwood, Atrium & Pre-function Laurel A, Talcott, Penwood, Atrium & Pre-function Laurel A

PROGRAM Day 1 Monday June 2 (Course Day 1) Start Time

Lecture Name

Faculty

Location

7:30 AM

Registration

8:00 AM

Welcome and Introductions and Orientation

Kristan Pierz, MD

Laurel A

8:10 AM

Qualitative Description of Typical Gait Terminology

Tom Novacheck, MD

Laurel A

8:40 AM

Intro to Clinical Gait Model (with marker placement-demo, including pelfix)

Zahra Bassiri, PhD Jennifer RodriguezMacClintic, DPT

Laurel A

9:25 AM

Kinematics Concepts and Typical Patterns

Kristan Pierz, MD

Laurel A

10:10 AM 10:35 AM 11:10 AM 11:20 AM

Break - snacks and coffee provided Clinical Exam - A Focus on Relationship with Gait Model in Terms of Angle Definitions

Laurel B & C Jean Stout, PT, MS

Laurel A

All Faculty/Small Groups

Laurel A

Transit Time Kinematic and Clinical Exam Break Out Session

12:00 PM Lunch

Evergreens

1:00 PM

Review of Break Out Sessions: Questions and Concerns

Tom Novacheck, MD All Faculty

Laurel A

1:20 PM

Kinetics Concepts and Typical Patterns

Sylvia Õunpuu, MSc

Laurel A

2:05 PM

Intro to EMG Data: Typical Patterns

Kaat DesLoovere, PhD

Laurel A

All Faculty/Small Groups

Laurel A

2:40 PM Transit Time 2:50 PM Kinetics and EMG Break Out Session 3:30 PM 3:55 PM 4:15 PM 5:15 PM

Break - snacks and coffee provided Review of Break Out Sessions: Questions and Concerns Case Study 1 - Methods explanation - guided with audience participation End first day

Laurel B & C Jon Davids, MD /All Faculty Sylvia Õunpuu, MSc Kristan Pierz, MD

Laurel A Laurel A

PROGRAM Day 2 Tuesday June 3 (Course Day 2) Start Time 8:00 AM 8:45 AM 9:15 AM 9:40 AM 10:55 AM 11:35 AM

Lecture Name Sagittal Plane: Typical Deviations & Possible Causes Transverse/Coronal Plane: Typical Deviations & Possible Causes

Faculty

Location

Kristan Pierz, MD

Laurel A

Jean Stout, PT, MS

Laurel A

Break - snacks and coffee provided

Laurel B & C

Case Study 2

All Faculty/Orthopedics

Laurel A, Talcott, Penwood, Atrium & Pre-function

Lever Arm Dysfunction in Pathological Gait

Tom Novacheck, MD

Laurel A

Interactions Across Planes

Sylvia Õunpuu, MSc

Laurel A

12:15 PM Lunch 1:15 PM 2:05 PM

Kinematic and Kinetic Relationships in Pathological Gait & The Influence of Trunk Motion on Gait Overview of Pathological Gait in Cerebral Palsy & Definition of Crouch Gait

2:50 PM

Transit time to case study rooms

3:00 PM

Case Study 3

4:00 PM

Break - snacks and coffee provided

4:25 PM

Case Study 4

5:25 PM End second day

Evergreens Sylvia Õunpuu, MSc

Laurel A

Andrew Georgiadis, MD

Laurel A

All Faculty/Orthopedics

Laurel A, Talcott, Penwood, Atrium & Pre-function Laurel B & C

All Faculty/Orthopedics

Laurel A, Talcott, Penwood, Atrium & Pre-function

PROGRAM Day 3 Wednesday June 4 (Course Day 3) Start Time 8:00 AM 8:45 AM 9:20 AM

Lecture Name Indications for Soft Tissue Surgery in Cerebral Palsy Indications for Skeletal Surgery in Cerebral Palsy Understanding Orthotic Function using Gait Analysis

9:50 AM

Break - snacks and coffee provided

10:15 AM 10:45 AM

Pathophysiology, Assessment and Treatment of Spasticity

Faculty

Location

Jon Davids, MD

Laurel A

Andrew Georgiadis, MD

Laurel A

Kaat DesLoovere, PhD

Laurel A Laurel B & C

Kaat DesLoovere, PhD

Laurel A

Transit time

10:55 AM

Case Study 5

11:55 AM

Lunch

Avoidable Iatrogenic Complications in 12:55 PM Cerebral Palsy - What Have We Learned? The Importance of Motion Analysis Gait Analysis and Tx Decision-making in 1:25 PM Charcot-Marie-Tooth 1:55 PM

Break - snacks and coffee provided

2:20 PM

1st Electives

3:05 PM

Transit time

3:15 PM 2nd Electives

All Faculty

Laurel A, Talcott, Penwood, Atrium & Pre-function Evergreens

Tom Novacheck, MD

Laurel A

Kristan Pierz, MD

Laurel A Laurel B & C

All Faculty/Orthopedics

Laurel A, Talcott, Penwood, Atrium & Pre-function

All Faculty/Orthopedics

Laurel A, Talcott, Penwood, Atrium & Pre-function

4:15 PM Transit time 4:25 PM

Audience Questions/Comments - complete course reviews

4:40 PM

Final Closing Comments

Laurel A Kristan Pierz, MD

Laurel A

ELECTIVE 1 ASSIGNMENTS Elective 1 Sessions June 4 – 2:20pm

Myelo Gait Biomechanics Presenter: Jean Stout, PT, MS Location: Laurel A

Unraveling the Gait Decline in Duchenne Muscular Dystrophy: Insights from 3D Motion Analysis Presenter: Kaat DesLoovere, PhD Location: Pre-Function Area Surgical Procedures: Q&A Presenter: Kristan Pierz, MD; Jon Davids, MD; Tom Novacheck, MD; Andrew Georgiadis, MD; Emily Andrisevic, MD Location: Penwood Modeling: Q&A Presenter: Zahra Bassiri, PhD Location: Atrium

Gait & Sports Presenter: Sylvia Õunpuu, MSc Location: Talcott

Elective Assignments Booth, Megan Coley, Catherine Doescher, Carrie Dumaine, Anne Marie Englebretson, Natalie Harrison, Cat Hassan, Yusra

Horowitz, Kevin Lawing, Cheryl Mackey, Catherine McKenzie, Courtney Parrett, Matthew Troksa, Brianna Zuccolo, Jennifer

Broehl, Jacqueline Hiller, Emily Ojelade, Aanuoluwapo

Salem, Murad Vinson, Amanda Yang, Chen

Baker, Tad Englert, Ethan Graham Gimenez, Cheryl Graves, Ashley

Ludwig, Meryl Malenfant, Emilie Seth, Shay Smith, Ann Steed, Lisa

Bunkell, Lizabeth Caminita, Mia Collins, Samantha Hill, Tessa Lapen, Rhianna

Lévesque-Jalbert, Marie Moore, Lucas Schreiber, Verena Wacker, Elizabeth

Badhyal, Subham Breneman, Mike Doll, Kym Dressler, Brittany Garrah, Sydney Hirshman, Emma

Horodyski, MaryBeth LeSueur, Joseph Miller, Mary Orban, Erin Shifflett, Tessa Webster, Andrea

ELECTIVE 2 ASSIGNMENTS Elective 2 Sessions June 4 – 3:15 pm Functional Outcomes Using the Gait Outcomes Assessment List (GOAL) Presenter: Jean Stout, PT, MS Location: Pre-Function Space

Foot Analyses - Understanding Foot Models Presenter: Tom Novacheck, MD Location: Laurel A

Enhancing Observational Gait Analysis: Current low tech (mobile device videography) and future high tech (markerless motion capture, machine learning) options Presenter: Jon Davids, MD Location: Talcott Orthopedic Imaging Presenter: Andrew Georgiadis, MD and Emily Andrisevic, MD Location: Atrium Toe Walking: How Do You Know Who to Worry About Presenter: Jennifer RodriguezMacClintic, DPT, and Kristan Pierz, MD Location: Penwood Setting up a Gait Lab – Q&A Presenter: Zahra Bassiri, PhD and Sylvia Õunpuu, MSc Location: Atrium

Elective Assignments Garrah, Sydney Horodyski, MaryBeth Lapen, Rhianna Troksa, Brianna Wacker, Elizabeth Badhyal, Subham Baker, Tad Booth, Megan Collins, Samantha Doescher, Carrie Dumaine, Anne Marie HassanN Yusra Hill, Tessa Broehl, Jacqueline Caminita, Mia Gimenez, Cheryl Graves, Ashley Hirshman, Emma LeSueur, Joseph Ludwig, Meryl Breneman, Mike Bunkell, Lizabeth Parrett, Matthew Shifflett, Tessa Coley, Catherine Doll, Kym Dressler, Brittany Englebretson, Natalie Harrison, Cat Horowitz, Kevin Moore, Lucas Seth, Shay Yang, Chen

Hiller, Emily Lawing, Cheryl Lévesque-Jalbert, Marie Salem, Murad Schreiber, Verena Vinson, Amanda Zuccolo, Jennifer Mackey, Catherine McKenzie, Courtney Miller, Mary Ojelade, Aanuoluwapo Orban, Erin Webster, Andrea

Englert, Ethan Graham Malenfant, Emilie Smith, Ann Steed, Lisa

Case Study 2 Groups Group 1 – Location: Laurel A Bassiri, Zahra Breneman, Michael Dressler, Brittany Dumaine, Anne Miller, Mary Group 3 – Location: Laurel A Englebretson, Natalie Steed, Lisa Vinson, Amanda Webster, Andrea Yang, Chen Group 5 – Location: Laurel A Baker, Tad Bargmann, Lauren Coley, Catherine Englert, Ethan Ludwig, Meryl Group 7 – Location: Pre-function Collins, Samantha Lapen, Rhianna McKenzie, Courtney Seth, Shay Shifflett, Tessa Group 9 – Location: Talcott Gimenez, Cheryl Levesque-Jalbert, Marie Schreiber, Verena Wall, Jon

Group 2 – Location: Laurel A Bunkell, Lizabeth Hill, Tessa Caminita, Mia Lawing, Cheryl Smith, Ann Group 4 – Location: Laurel A Hassan, Yusra Moore, Lucas Ojelade, Aanuoluwapo Parrett, Matthew Zuccolo, Jennifer Group 6 – Location: Penwood Doll, Kimberly Garrah, Sydney Mackey, Catherine Schilberg, Lindsey

Group 8 – Location: Talcott Booth, Megan Doescher, Carrie Orban, Erin LaSueur, Joseph Salem, Murad Group 10 – Location: Atrium Graves, Ashley Harrison, Catherine Horodyski, MaryBeth Horowitz, Kevin Badhyal, Subham Group 11 – Location: Atrium Broehl, Jacqueline Hiller, Emily Hirshman, Emma Malenfant, Emilie Wacker, Elizabeth

Case Study 3 Groups Group 1 – Location: Laurel A Bassiri, Zahra Breneman, Michael Dressler, Brittany Dumaine, Anne

Group 2 – Location: Laurel A Hill, Tessa Caminita, Mia Lawing, Cheryl Smith, Ann

Group 3 – Location: Laurel A Englestretson, Natalie Steed, Lisa Vinson, Amanda Webster, Andrea

Group 4 – Location: Laurel A Bunkell, Lizabeth Moore, Lucas Ojelade, Aanuoluwap Zuccolo, Jennifer

Group 5 – Location: Laurel A Hassan, Yursa Miller, Mary Parrett, Matthew Yang, Chen

Group 6 – Location: Laurel A Baker, Tad Bargmann, Lauren Coley, Catherine Englert, Ethan Lugwig, Meryl

Group 7 – Location: Penwood Doll, Kimberly Garrah, Sydney Mackey, Catherine Schilberg, Lindsey

Group 8 – Location: Pre-function Collins, Samantha Lapen, Rihanna McKenzie, Courtney Seth, Shay Shifflet, Tessa Group 10 – Location: Talcott Gimenez, Cheryl Levesque-Jalbert, Marie Schreiber, Verena Wall, Jon

Group 9 – Location: Talcott Booth, Megan Doescher, Carrie LeSueur, Joseph Orban, Erin Salem, Murad Group 11 – Location: Atrium Graves, Ashley Harrison, Catherine Horodyski, MaryBeth Horowitz, Kevin Badhyal, Subham

Group 12 – Location: Atrium Broehl, Jacqueline Hiller, Emily Hirshman, Emma Malenfant, Emilie Wacker, Elizabeth

Case Study 4 Groups Group 1 – Location: Laurel A Bassiri, Zahra Breneman, Michael Dressler, Brittany Dumaine, Anne

Group 2 – Location: Laurel A Hill, Tessa Caminita, Mia Lawing, Cheryl Smith, Ann

Group 3 – Location: Laurel A Englestretson, Natalie Steed, Lisa Vinson, Amanda Webster, Andrea

Group 4 – Location: Laurel A Bunkell, Lizabeth Moore, Lucas Ojelade, Aanuoluwap Zuccolo, Jennifer

Group 5 – Location: Laurel A Hassan, Yursa Miller, Mary Parrett, Matthew Yang, Chen

Group 6 – Location: Laurel A Baker, Tad Bargmann, Lauren Coley, Catherine Englert, Ethan Lugwig, Meryl Group 8 – Location: Talcott Collins, Samantha Lapen, Rihanna McKenzie, Courtney Seth, Shay Shifflet, Tessa Group 10 – Location: Pre-function Wall, Jon Gimenez, Cheryl Levesque-Jalbert, Marie Schreiber, Verena

Group 7 – Location: Penwood Doll, Kimberly Garrah, Sydney Mackey, Catherine Schilberg, Lindsey Group 9 – Location: Talcott Booth, Megan Doescher, Carrie LeSueur, Joseph Orban, Erin Salem, Murad Group 11 – Location: Atrium Graves, Ashley Harrison, Catherine Horodyski, MaryBeth Horowitz, Kevin Badhyal, Subham

Group 12 – Location: Atrium Broehl, Jacqueline Hiller, Emily Hirshman, Emma Malenfant, Emilie Wacker, Elizabeth

Case Study 5 Groups Group 1 – Location: Laurel A Bassiri, Zahra Breneman, Michael Dressler, Brittany Dumaine, Anne Miller, Mary Group 3 – Location: Laurel A Englestretson, Natalie Steed, Lisa Vinson, Amanda Webster, Andrea Yang, Chen Group 5 – Location: Laurel A Baker, Tad Bargmann, Lauren Coley, Catherine Englert, Ethan Levesque-Jalbert, Marie Ludwig, Meryl Group 7 – Location: Pre-function Collins, Samantha Lapen, Rhianna McKenzie, Courtney Seth, Shay Shifflett, Tessa Group 9 – Location: Atrium Graves, Ashley Harrison, Catherine Horodyski, MaryBeth Horowitz, Kevin Badhyal, Subham

Group 2 – Location: Laurel A Bunkell, Lizabeth Hill, Tessa Caminita, Mia Lawing, Cheryl Smith, Ann Group 4 – Location: Laurel A Hassan, Yusra Moore, Lucas Ojelade, Aanuoluwap Parrett, Matthew Zuccolo, Jennifer Group 6 – Location: Penwood Wall, Jon Doll, Kimberly Garrah, Sydney Mackey, Catherine Schilberg, Lindsey Schreiber, Verena Group 8 – Location: Talcott Booth, Megan Doescher, Carrie Orban, Erin LaSueur, Joseph Salem, Murad Group 10 – Location: Atrium Broehl, Jacqueline Hiller, Emily Hirshman, Emma Malenfant, Emilie Wacker, Elizabeth

Division of Orthopedics Center for Motion Analysis Connecticut Children’s

Clinical Gait Analysis: A Focus on Interpretation Tuesday, June 3rd Claim CME Credit Here!

Monday, June 2 Claim CME Credit Here!

AMA PRA Category 1 Credit™ - 6.75 Credit(s)

AMA PRA Category 1 Credit™ - 7.25 Credit(s)

Eeds sign-in code: 87dive https://www.eeds.com/sign_in.aspx?Sign_in_Code=87dive

Eeds sign-in code: 65feet https://www.eeds.com/sign_in.aspx?Sign_in_Code=65feet

Evaluation expiration date Saturday, July 5, 2025

Wednesday, June 4th Claim CME Credit Here!

AMA PRA Category 1 Credit™ - 6.25 Credit(s) Eeds sign-in code: 89lone https://www.eeds.com/sign_in.aspx?Sign_in_Code=89lone Evaluation expiration date Saturday, July 5, 2025

Please contact the Office of CME with questions:

CME@connecticutchildrens.org Accreditation: Connecticut Children's is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Connecticut Children's awards this live activity for a maximum of 20.25 AMA PRA Category 1 Credit™ Conflict of Interest Policy: All faculty participating in Continuing Medical Education activities sponsored by Connecticut Children’s are required to disclose to the program audience any actual or perceived conflict of interest related to the content of their presentation. Program planners have an obligation to resolve any actual conflicts of interest and share with the audience any safeguards put in place to prevent commercial bias from influencing the content. The planners, activity director and speaker(s) do not have a financial interest/arrangement or affiliation with any organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. The speaker(s) will not be discussing the use of any off-label product. Commercial Support Statement: OPED Medical, Tekscan, Noraxon USA, Advanced Mechanical Technology, INC (AMTI), and Qualysis are exhibitors for the event.

Clinical Gait Analysis: A Focus on Interpretation HOSTED BY:

Division of Orthopedics Center for Motion Analysis Connecticut Children’s

June 2 – 4, 2025 20.25 AMA PRA Category 1 Credit™ Accreditation: Connecticut Children's is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Connecticut Children's awards this live activity for a maximum of 20.25 AMA PRA Category 1 Credit™ Conflict of Interest Policy: All faculty participating in Continuing Medical Education activities sponsored by Connecticut Children’s are required to disclose to the program audience any actual or perceived conflict of interest related to the content of their presentation. Program planners have an obligation to resolve any actual conflicts of interest and share with the audience any safeguards put in place to prevent commercial bias from influencing the content. The planners, activity director and speaker(s) do not have a financial interest/arrangement or affiliation with any organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. The speaker(s) will not be discussing the use of any off‐label product. Commercial Support Statement: OPED Medical, Tekscan, Noraxon USA, Advanced Mechanical Technology, INC (AMTI), and Qualysis are exhibitors for the event.

Qualitative Description of Normal Gait Tom F. Novacheck, M.D. Professor of Orthopaedics, University of Minnesota Chair Cerebral Palsy Institute, Gillette Children’s Specialty Healthcare St. Paul, MN, USA

Objectives -- Understand 

Terminology



Prerequisites of normal gait



Subdivisions of the gait cycle



Methods of energy conservation



Relationship between potential and kinetic energy (walking and running)

What is normal walking gait? 

The usual method by which we get our hands and head from one place to another



Reciprocal



Symmetric



Reproducible



Efficient

It’s dynamic!

Requirements for Gait: 

Control System



Energy Source



Skeletal Levers



Motors (Muscles)

The Control System is Responsible for:



Initiation and control of movement Balance and stability

Energy Source 

Typical gait  has developed to maintain efficiency  energy availability (respiratory)  transport to muscles (cardiac)

Skeletal Levers Muscles forces (internal) and ground reaction forces (external) provide the power for movement  Skeletal levers (bones) provide the means by which these forces produce movement  Result in joint moments 

What is a Moment? 



The product of a force times the distance of the force from the center of an axis of rotation. An unbalanced moment produces an angular acceleration.

M Mxd=mxD

Muscle function determines form and fiber type Muscle form and fiber type determine function 

Power = force x velocity  ≈30 N / cm2

(cross sectional area)  Fiber types:

I - slow twitch, aerobic  IIa - fast twitch, aerobic  IIb - fast twitch, anaerobic 

Modes of Muscle Action 

Concentric

 shortening under tension  accelerators



Eccentric

 lengthening under tension  decelerators

 shock absorbers  stabilizers



Isometric

 tension, without change in length  stabilizers

Divisions of the Gait Cycle Stride

(Gait Cycle)

Periods

Stance Tasks

Weight Acceptance

Swing

Single Limb Support

Limb Advancement

Phases Initial Contact

Loading Response

Mid Stance

Terminal Stance

Pre Swing

Initial Swing

Mid Swing

Terminal Swing

The Gait Cycle

DS LR

Stance (60%) MST

Swing (40%)

DS TST

ISW

Toe-Off

Stride (100%)

MSW

TSW

Prerequisites of Normal Gait In order of priority: 1. Stability in stance 2. Clearance in swing 3. Pre-positioning of the foot for initial contact 4. Adequate step length 5. Energy conservation

Stability in Stance Requires: 

The stance foot to be stable on the floor



The major lower extremity joints function to:  Allow advancement of the limb in swing  Maintain balance  Provide propulsion  Insure appropriate position of the structures above 

Center of mass (COM) remains within the base of support while standing, and moves forward from one base of support to the next while walking



Trunk stability



Adequate body balance

Clearance in Swing Requires:  



Stability of the stance foot Appropriate position and power of the ankle, knee and hip on the stance side Adequate ankle dorsiflexion, knee flexion and hip flexion on the swing side Adequate body balance

Pre-position of the Foot in TSw Requires: Stance side stability, power, and proper position  Swing side 

 Adequate ankle dorsiflexion

 Balance between inverters and everters of the

foot to allow proper foot position  Appropriate knee position



Adequate body balance

An Adequate Step-length Requires: 

A stable and properly positioned stance side



Neutral dorsiflexion, inversion and eversion



Adequate hip flexion



Relatively complete knee extension



Adequate body balance

Energy Conservation Mechanisms: 

The ways that muscles typically work  tend to lengthen during gait rather than shorten  Elastic potential energy (Stretch energy) is returned.

Normally muscles tend to be “pre-stretched” before they fire concentrically.

 Bi-articular muscles can transfer energy from one

body segment to another



Joint stability is provided by the ground reaction force (GRF) in conjunction with ligaments when possible. Optimizing vertical excursion of the center of mass

The Gait Cycle

DS LR

Stance (60%) MST

Swing (40%)

DS TST

ISW

Toe-Off

Stride (100%)

MSW

TSW

Double Support (DS) vs. Double Float (DF)

Walking

Running

Sprinting

During Swing we need to:  

Advance the limb Allow variation in cadence



Allow foot clearance



Conserve energy

Controlled Falling

Midstance Potential

DS Kinetic

Midswing

DS Total

Potential and Kinetic Energy

Power Sources for Walking 



Triceps surae in preswing (A-2) Hip flexors in preswing and initial swing (H-3) Contralateral hip extensors (H-1) pull the body forward

pull

push

Double Support Potential Energy low

Stance Phase (62% of Cycle)



Initial Contact

(double support)

Loading Response

(double support)



Mid Stance

(single support)

Terminal Stance

(single support)



Pre Swing

(double support)

MST

TST

Initial Contact (Double Support)

instantaneous event l initiates gait cycle l

Loading Response (Double Support)



purpose  shock absorption



ankle and knee eccentric muscle action

Midstance

(Single Support) extrinsic stability of the knee provided by eccentric activity of the soleus  relieves the quadriceps reducing the work of walking 

 Plantarflexion/Knee

Extension Couple (PF/KE)

Terminal Stance (Single Support)



Purpose  acceleration



combined concentric action of the soleus and gastrocnemius generates nearly half of the total propulsive force for walking

Pre-swing

(Double Support) 



weight transfer to opposite limb unlock stance limb for swing iliopsoas and rectus femoris have most of their activity

Swing Phase (38% of cycle) 

Initial Swing

Rectus Femoris

Hamstrings

(acceleration of limb)  

Mid Swing Terminal Swing (deceleration of limb)

MSW

TSW

Initial Swing 

Purposes:  Provide sufficient flexion to

clear the plantarflexed toe

 Rapid gait 

Decelerate rate and range of knee flexion

 Slow gait 

Increase the range of knee flexion

Fast Gait

Rectus Femoris

Mid-Swing "Switching Period"



No muscles active across the knee!

Terminal Swing 

Purposes:

Fast Gait

 Knee must achieve full

extension prior to IC

 Rapid gait 

Decelerate rate of knee extension

 Slow gait 

Augment knee extension

Hamstrings

The Gait Cycle

DS LR

Stance (60%) MST

Swing (40%)

DS TST

ISW

Toe-Off

Stride (100%)

MSW

TSW

Intro to Clinical Gait Model Zahra Bassiri, PhD June, 2nd, 2025

Why?

• Understand and treat pathologies: ✓ Diagnose diseases ✓ Identify risk factors ✓ Guide treatments ✓ Monitor the progression of a disease or a therapy

✓ Develop new rehabilitation procedures

Created by AI

Approaches

Inverse dynamics: Measurement of movement • Reconstructing internal forces/torques from measured movements and external forces

Angles

Position Data Force Data

Velocities Accelerations 𝒅

𝒅

𝒅𝒕

Moments

𝐌𝐮𝐥𝐭𝐢𝐛𝐨𝐝𝐲 𝐃𝐲𝐧𝐚𝐦𝐢𝐜𝐬 𝐌𝐨𝐝𝐞𝐥

𝐌𝐮𝐬𝐜𝐮𝐥𝐨𝐬𝐤𝐞𝐥𝐞𝐭𝐚𝐥 Geometry

Internal Body Forces

Approaches 1. Kinematics: Reconstruct the position and orientation of body segments (bones) during movement. 2. Kinetics: Study of the forces that produce movement and resultant energetics. 3. Muscle Modeling: Record and analyze muscular electrical activity considering muscle architecture and geometry

2. KINETICS

1. KINEMATICS

Angles

Position Data Force Data

Velocities Accelerations 𝒅

𝒅

𝒅𝒕

3. MUSCLE MODELING

Moments

𝐌𝐮𝐥𝐭𝐢𝐛𝐨𝐝𝐲 𝐃𝐲𝐧𝐚𝐦𝐢𝐜𝐬 𝐌𝐨𝐝𝐞𝐥

𝐌𝐮𝐬𝐜𝐮𝐥𝐨𝐬𝐤𝐞𝐥𝐞𝐭𝐚𝐥 Geometry

Internal Body Forces

Background • The most common method for collecting kinematic data is using multiple cameras to record the motion of markers affixed to a moving subject. • 3-D global coordinates of each marker can be estimated from 2D camera coordinates using triangulation. • These coordinates are then processed to obtain the kinematic variables that describe movements.

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Bone Motion Reconstruction

• Objective: reconstruct the motion of the skeletal system o Directly possible only with invasive techniques

• Alternative: collect kinematic data using the motion of markers affixed to the skin. The human body can be seen as a set of rigid elements connected at the articular joints. o It is an approximation because of soft tissue artifact

Pose of a Rigid Body • One of the main objectives in kinematics is to calculate the pose of a rigid body (e.g., body segments)

• The pose of a rigid-body can be described with a position vector and an orientation vector. • It involves the definition of: o Global Coordinate System (GCS) o Local Coordinate System (LCS)

• The relative positioning of the LCS axes with respect to the GCS defines the pose of a rigid body in the space

Pose of a Rigid Body • Coordinate systems are used to define linear position of points and angular position of axes, planes, and rigid bodies. • Position and orientation are defined with respect to a reference coordinate system o The position/orientation of a second coordinate system (i.e., local), fixed to the moving object is defined based on the first coordinate system (i.e., global or "world")

Rigid bodies & Reference Frames • A rigid body maintains a constant shape despite applied force and movement. o cannot fracture, expand, distort o cannot change mass, inertia, CoM

• A reference frame can be affixed to each rigid body o The motions of the reference frame and the body are equivalent (both are rigid and affixed to one another)

Global Coordinate System • Inertial or Newtonian frame of reference o Absolute Spatial Reference System o Global Reference System o Global Coordinate System (GCS)

• Defined during a calibration process (e.g., magic wand) • International Society of Biomechanics (ISB) recommendations: o Right-handed orthogonal triad fixed in the ground with: ➢ X axis: antero-posterior, positive forward ➢ Y axis: vertical, positive upward ➢ Z axis: medio-lateral, positive rightward

Local Coordinate System • Second reference frame with origin and axes attached to a body segment, and therefore able to move with it. o Relative coordinate system o Segmental coordinate system o Local coordinate system (LCS)

• Defined using moving objects attached to each body segment (e.g., reflective markers) • International Society of Biomechanics (ISB) recommendations: o Series of right-handed orthogonal triads fixed at the segmental centers of mass with the + Xi axis anterior, + Yi axis proximal, and +Zi being defined by a right-hand rule.

Marker-Set

• Markers are used to define local coordinate system (LCS) • To build a reference frame, we need at

least 3 non-collinear points (i.e., markers) • Many definitions of a LCS, so different marker set can be chosen

Types of Markers • Anatomical Skin Marker: a marker positioned on the skin in a location approximating an anatomical landmark (small area that can be reliably identified within the bone) • Used to define joint centers and anatomical frames: (e.g., placing two markers on the opposite sides of joint, allows one to easily define joint center and axis

Types of Markers

• Technical Marker: a marker positioned in a location which has no anatomical relevance. • Cluster of markers: a set of technical markers associated with a bone Used as additional markers to define anatomical frames or to define technical reference frames

Anatomical landmarks: Lower leg

Around the Hip • Landmarks o ASIS anterior superior iliac spine o PSIS posterior superior Iliac spine o GT prominence of the greater trochanter external surface

• Interesting point o AC center of the acetabulum o FH center of the femoral head

Anatomical landmarks: Lower leg

Around the Knee • Landmarks o LP and MP anterolateral/medial apex of the patellar surface ridge o LE and ME lateral/medial epicondyle of the femur o HF apex of the head of the fibula o TT prominence of tibial tuberosity

• Interesting point o IE intercondile eminence o MLP and MMP most lateral/medial point of the tibial plateau o LC and MC most lateral/medial point of the condyle

Anatomical landmarks: Lower leg

Around the Ankle • Landmarks o CA upper ridge of the calcaneous o LM and MM lateral and medial malleolus o FM, SM and VM dorsal aspect of the First, Second and Fifth metatarsal head

Let's build part of a gait model...

Newington Gait Model basis of the gait models implemented by Vicon, Motion Analysis Corporation, and BTS Davis RB, Õunpuu S, Tyburski DJ, Gage JR. Human Movement Science, 10(5):575-587, 1991.

PSIS R ASIS

L ASIS

Pelvic Anatomical Coordinate System Anatomical Markers require careful alignment with respect to the associated anatomy

Anatomical Frames: Pelvis Statistical Models – Newington Hip & Oxford Hip Harrington ME, Zavatsky AB, Lawson SEM, Yuan Z, Theologis TN. Journal of Biomechanics 2007;40:595.

Mid PSIS

PSIS ASIS

Virtual Marker

Anatomical Frames: Pelvis PSIS

Markers placed on right and left anterior-superior iliac spines (RASI and LASI) and mid point of posterior-superior iliac spines (LPSI and RPSI) • Origin O: Midpoint between the right and left ASISs • Z-axis: line connecting the right and left ASISs, pointing to the right • Y-axis: line ꓕ to a plane formed by the ASIS and the PSISs, pointing cranially • X-axis: line ꓕ to both Y and Z, pointing anteriorly

ASIS

Anatomical Frames: Thigh Markers are placed on lateral (LE) and medial (ME) epicondyles

Hip Center Virtual Marker

of the femur • Position of the femoral head (FH) (hip joint center) is estimated by regression equations (e.g., Bell et al. 1990) • Origin O: midpoint between LE and ME (knee joint center) • Y-axis: line joining O with the FH, pointing proximally • X-axis: line ꓕ to a plane formed by the FH, LE, and ME, pointing anteriorly • Z-axis: line ꓕ to both Y and Z, pointing to the right

Knee Center Virtual Marker

Kinematics – Kristan Pierz

Kinematics: Concepts and Typical Patterns Kristan Pierz, MD Center for Motion Analysis Division of Orthopaedics Connecticut Children’s Medical Center Farmington, Connecticut, USA

Objectives • Following this lecture, participants will know: – Basic methods – Angle definitions – Kinematic plot conventions – Typical joint/segment kinematic patterns

Clinical Gait Analysis: A Focus on Interpretation

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Gait Cycle

Left Right

Connecticut 2025

Kinematics – Kristan Pierz

Calculating Joint Kinematics Reflective joint/segment markers

(skeletal model – angle definition)

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Gait Cycle

Left Right

(joint angle plot)

KINEMATIC DATA JOINT ANGLES DURING MOTION INITIAL CONTACT

DORSIFLEXION

Dor

TOE OFF

INITIAL CONTACT

Plantar-Dorsiflexion

STANCE

SWING

REFERENCE DATA

deg

0 deg PLANTAR FLEXION

Pla -40

25%

50%

Left side = red line

75%

Gait Cycle

Left Right

Right side = green line

GAIT CYCLE Legend

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Motion Capture

marker trajectories

technical coordinate system

skeletal model calibration

anatomical or clinical coordinate system

computation of joint and segment angles

3D kinematic plots

Marker Trajectories

X-Y-Z COORDINATES for each marker

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Multiple Motion Cameras

Marker Trajectories During Gait

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Reflective Markers – Technical - Clinical

Reflective Markers

Technical Coordinate System

Anatomical/Clinical Coordinate System

Technical Coordinate System • Surface Marker based (actual or virtual) • Reference for the following: – Joint center locations – Anatomical coordinate system – Virtual markers

• Three orthogonal directions

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Skeletal Model • Allows computation of joint centers and segment axes (anatomical coordinate system) from the reflective markers • Two primary inputs:

Technical

Anatomical

– positions of reflective markers – anatomical measures (diameters, leg lengths, torsional measures, etc.)

Subject Calibration Trial Surface Markers…

Anatomical Coordinate System

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Anatomical Coordinate System • Joint centered • Joint angles – Make anatomical sense – Consistent with the clinical exam

Static Methods – Joint Centers • Hip Center – Palpation of bony landmarks on pelvis – X-ray/cadaver based fixed offsets from pelvic markers – Measured anthropometry – Regression equations

(Davis et al. Hum Move Sci. 1991)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Static Methods – Joint Centers • Knee Center – Palpation and visualization of knee flexion extension (Bicondylar) axis – Marker Placement • Manual alignment of knee alignment device (KAD) • Medial and lateral knee markers

– Center ½ width between anatomical landmarks (medial and lateral knee markers) from lateral condyle along knee axis

(Davis et al. Hum Move Sci. 1991)

Static Methods – Joint Centers • Ankle Center – Palpation medial and lateral malleoli – Placement of medial and lateral markers – Center ½ width between anatomical landmarks (medial and lateral markers) from lateral malleolus (Davis et al. Hum Move Sci. 1991)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Functional Methods – Joint Centers • Hip center – Measure motion between thigh and pelvis – Mathematically (spherical centering) determine joint center

• Knee axis – Measure motion between tibia and thigh – Mathematically fit a hinged joint

Schwartz and Rozumalski, J of Biomech, 38:107-16, 2005

Functional Methods – Joint Centers • Ankle – Compute virtual markers – Malleoli (circles)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Coordinate Systems • Trunk • Pelvis • Thigh • Tibia • Foot

Gait Model • Standard lower extremity model – 7 rigid segments – pelvis, femora (2), tibiae (2), feet (2)

• Joints – Hips: 3 rotations – Knees: 3 rotations – Ankles: 2 rotations (1-dimensional foot) Davis RB, Ounpuu S, Tyburski D, Gage JR. (1991) "A Gait Analysis Data Collection and Reduction Technique." Human Movement Science, 10: 575-587

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Marker Placement Careless placement = poor kinematic data

THE MOST IMPORTANT STEP

Marker Placement

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

3 Reflective Markers = Plane At least three points are required on an object to know the location and orientation

Thigh, Shank and Foot

One vector Only

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Pelvic Coordinate System

Define a coordinate system relative to that object

Joint Rotations • Relative orientation between two segments – for example, pelvis vs. femur

• Gimbal Joint Articulations – Rotations only (no translation) – Fixed center of rotation (joint center) – Ordered rotations (Cardan angles)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Typical and Pathological Gait – 3 planes 

Coronal: up/down, ab/adduction, varus/valgus



Sagittal: anterior/posterior, flexion/extension, plantar flexion/dorsiflexion



Transverse: internal/external Sagittal

Coronal

Transverse

Typical Rotational Sequence • Flexion/extension (sagittal plane) • Abduction/adduction (coronal plane) • Internal/external rotation (transverse plane)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Trunk Obliquity

Trunk Tilt

Kinematics – Kristan Pierz

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg

-40

Joint Kinematics

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Int

Ant

deg Dn

Pos

Ext

CORONAL

SAGITTAL

-20

20 Add deg

TRANSVERSE

-20

Hip Ab-Adduction

-40

Hip Flexion-Extension

Trunk Obliquity

Trunk Tilt

Int

Flx

Hip Rotation

Int

Ant

Abd

Trunk Rotation

Ext

deg -20

-20

-40

Dn 30

Pos

Knee Varus-Valgus -30

Var deg

Pelvic Obliquity

Knee Rotation

-40

Int

Flx

Val

Pelvic Tilt

Ext

40 Int

Ant

25%

50%

deg

Gait Cycle

-20

75%

-40

Plantar-Dorsiflexion Pos

Pelvic Rotation

Ext

Up -30

Ext

Knee Flexion-Extension -20

Foot Progression Ext

Dor

Int

-20

-40

deg Pla

deg

Hip Flexion-Extension

What Does the Kinematic Data Mean? -40

Add

Ext

Hip Ab-Adduction

25%

50%

25%

Gait Cycle

Ext

-20

50%

Gait Cycle

Flx

Abd

30 Thigh

-40

75%

Var

Int

Ext

Angle Definition

Knee Varus-Valgus

Hip Rotation

40 75%

Knee Flexion-Extension

-40

Knee Rotation

Flx

Int

Ext

deg

Val

Shank -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla

Clinical Gait Analysis: A Focus on Interpretation

-40

Ext

Connecticut 2025

25%

50%

Gait Cycle

75%

-40

15 25%

50% Gait Cycle

75%

Kinematics – Kristan Pierz

Angle definition • The specific body segments that make up the angle • With consideration for the orientation of the “viewer” when looking at the angle

Joint Angle Definitions Coronal Hip Angle = ?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Joint Angle Definitions

Which one?

Joint Angle Definitions

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Joint Angle Definitions – Knee Sagittal Plane Angle?

Which is the angle definition for the sagittal plane knee? A, B or C?

120 Deg

240 Deg A

Clinical Gait Analysis: A Focus on Interpretation

60 Deg C

Connecticut 2025

Add deg

Int

Flx

Kinematics – Kristan Pierz

Abd

Ext

-20

Knee Varus-Valgus

Var

Ext -40

Knee Flexion-Extension

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Knee Rotation

What is this angle definition for the sagittal plane knee?

Gait Cycle

240 Deg

Plantar-Dorsiflexion120 Deg

Dor

60 Deg Foot Progression

Int

deg Pla

Ext

-40

25%

50%

75%

Gait Cycle

-40

25%

50%

75%

Gait Cycle

Two Hip Angle Definitions Thigh vs. vertical

Clinical Gait Analysis: A Focus on Interpretation

Thigh vs. pelvis

Connecticut 2025

Kinematics – Kristan Pierz

Thigh Position versus Hip Angle A

Is there a change in HIP angle between image A and B?

YES

Thigh Position versus Hip Angle A

Thigh position related to the lab coordinate system ≠ hip angle which is a relative angle between the pelvis and thigh segment Is there a change in THIGH angle between image A and B?

NO Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Thigh Position vs. Hip Angle A

Thigh angle (thigh vs. lab coordinate system) ≠ hip angle (pelvis vs. thigh segment)

Joint motion titles……ambiguous • Foot Progression – segment vs. lab = orientation of the foot with respect to the direction of progression – provides no information in regards to the cause of the abnormal position of the foot • Foot/Ankle Rotation – segment vs. segment = relative angle between foot and tibial segments – provides some information in regards to foot deformity

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Know Your Angle Definitions! Visual vs. Actual!

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg

Trunk

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Pelvis

Hip Ab-Adduction

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Add deg

Hip

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg

Knee

Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Ankle

Pla -40

Ext

25%

50%

-40

75%

Gait Cycle

Sagittal

Clinical Gait Analysis: A Focus on Interpretation

25%

50%

75%

Gait Cycle

Coronal

Transverse

Connecticut 2025

Kinematics – Kristan Pierz

Phases of the Gait Cycle • • • • • • •

loading response (LR) / double support (0-10%) mid-stance (MST) (10-30%) terminal stance (TST) (30-50%) pre-swing (PSW) / double support (50-60%) initial swing (ISW) (60-73%) mid-swing (MSW) (73-87%) terminal swing (TSW) (87-100%) (Perry, Normal and Pathological Gait, Slack, 1994)

Phases of the Gait Cycle Double Support (10%)

Stance (60%)

10% Loading Response

Double Support (10%)

30% Midstance

Swing (40%)

50% T erminal Stance

70%

Preswing

Initial Swing

85% Midswing

T erminal Swing

T oe Off Stride (100%)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Typically Developing (Normal) Gait

Trunk

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Trunk Sagittal Plane

Bi-clavicular Line

C7 Lab Coordinates Pelvis

ASIS

PSIS

Angle Definition: • inclination of upper body relative to lab coordinate system

Coronal Plane Motion Angle Definition: C7 Upper Trunk

• inclination of upper body relative to lab coordinate system

Bi-clavicular line

Pelvis ASIS

ASIS

Lab Coordinates

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Trunk Transverse Plane Angle Definition:

Direction of Progression Biclavicular line C7

• motion of the biclavicular line relative to lab coordinate system

Lab Coordinates

Trunk Motion 30

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg

Pelvic Obliquity Sagittal

-40

Pelvic Tilt Coronal

Pelvic Rotation Transverse

Int

Ant

• Minimal range of motion over the gait cycle

deg Dn

Pos

-20

Hip Ab-Adduction

Ext -40

Hip Flexion-Extension

Flx

Int

Abd

Ext

-20

Add

Hip Rotation

deg

-40

Clinical Gait Analysis: A Focus on Interpretation 30 Var deg

Knee Varus-Valgus

80 Flx

Connecticut 2025 Knee Flexion-Extension

40 Int

Knee Rotation

Kinematics – Kristan Pierz

Pelvis

Pelvis Coronal Plane • Angle Definition – Angle of inclination of the right and left anterior superior iliac spine (ASIS) in relation to the horizontal – As viewed from the front of and in the pelvic plane

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz Trunk Obliquity

Trunk Tilt

Ant

deg

Pelvis Coronal Plane • Stance – LR = pelvis rises – MST/TST/PS = pelvis drops • Swing – ISW = pelvis continually drops – MSW/TSW = pelvis rises • Neutral position twice in gait cycle • ROM = 8°

Pos

-30

-20

Pelvic Obliquity

Pelvic Tilt

Ant

deg Dn

Pos

-20

0 20

HipGait Ab-Adduction Cycle (%)

Add

100 60

Hip Flexion-Extension

Flx

deg Abd

Ext

-20

Knee Varus-Valgus

Pelvis Sagittal Plane Var

Knee Flexion-Extension

Flx

deg

• Angle Definition Val

Ext

– inclination (typically -30 -20 25% 50% 75% anterior) of the Gait Cycle pelvic plane with respect to the 40 horizontal Dor – as viewed by an deg observer looking Pla along a line connecting the -40 ASIS's

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Kinematics – Kristan Pierz 30

Trunk Obliquity

Trunk Tilt

Trunk Rotation

Int

Ant

deg

Pelvis Sagittal Plane Kinematic Dn

Pos

• Stance -30 – LR = posterior movement Pelvic – MST/TST = Obliquity 20 anterior movement Up – PS = posterior movement deg • Swing Dn – ISW = posterior movement -20 – MSW = anterior movement Hip Ab-Adduction 20 – TSW = posterior movement Add • ROM = 4° deg

-20

40 Int

Pos

Ext

-20

100

Cycle (%) HipGait Flexion-Extension

(Ant =Flxanterior, Post = Posterior)

-20

Pelvic Rotation

-40 0

-20

Var

Pelvic Tilt

Ant

Ext

Knee Varus-Valgus

-40

Abd

Ext

Hip Rotation

40 Int

Ext -40

Knee Flexion-Extension

Knee Rotation

Pelvis Transverse Plane Flx

Int

•ExtAngle Definition

Ext

deg Val -30

25%

50%

75%

Gait Cycle

– motion of the ASIS to -40 ASIS line relative to the lab coordinate Plantar-Dorsiflexion system (direction of 40 40 progression) Dor Int – as viewed by an observer whose site deg line is perpendicular to Pla the pelvic plane Ext -20

-40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

-40

Foot Progression

25%

50% Gait Cycle

75%

Kinematics – Kristan Pierz 30

Trunk Obliquity

Up deg Dn -20

Trunk Rotation

Int

Pelvis Transverse Plane Kinematic

Ant

deg

-30

Trunk Tilt

Pos

Ext

• Stance -20 – LR/MST = internally Pelvic Obliquity Pelvic Tilt rotates 40 – TST/PS = externally Ant rotates • Swing Pos – ISW/MSW/TSW = internally rotates -20

-40

40 Int

Ext -40

• Neutral position twice Hip Ab-Adduction in gait 60cycleHip Flexion-Extension • ROM =Flx8°

Add

Pelvic Rotation

0 40

100

GaitHip Cycle (%) Rotation

(Int = internal, Ext = External) Int

deg Abd

Ext

-20

-40

Knee Varus-Valgus

Var

Knee Flexion-Extension

Int

Flx

Hip

deg Val -30

Knee Rotation

25%

50%

75%

Ext

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

75%

-40

25%

50%

75%

Gait Cycle

Connecticut 2025

Kinematics – Kristan Pierz

Hip Coronal Plane • Angle Definition – relative angle between long axis of the thigh and a perpendicular to Trunk Obliquity 30 the pelvic plane Up– as viewed from the deg front of and in the pelvic plane

40 Ant

Pos

-30

-20

Pelvic Obliquity

Trunk Tilt

Pelvic Tilt

Ant

deg Dn

Pos

-20

Hip Coronal Plane Kinematic • Stance – LR = adduction – MST/TST/PS = abduction • Swing – ISW = abduction – MSW/TSW = adduction • ROM = 13°

Hip Ab-Adduction

Add

Hip Flexion-Extension

Flx

deg Abd

Ext

-20

-20 0

100

Gait Cycle (%) Knee Varus-Valgus 30 (Add=adduction, abd=abduction) Var

Knee Flexion-Extensio

Flx

deg Val

Clinical Gait Analysis: A Focus on Interpretation

-30

Ext

Connecticut 2025 25%

50%

75%

-20

Gait Cycle

Plantar-Dorsiflexion

Kinematics – Kristan Pierz

Hip Sagittal Plane • Angle Definition

Trunk Obliquity

– relative angle between the long axis of the thigh and a perpendicular to the pelvic plane – as viewed by an observer looking Trunk Tilt 40 along a line connecting the Ant ASIS's

Trunk Rotation

Int

deg Dn

Pos

-30

-20

Pelvic Obliquity

Ext

-40

Pelvic Tilt

Ant

Int

Pos

Ext

Hip Sagittal Plane Kinematic

Pelvic Rotation

deg Dn

• Stance -20 – LR/MST/TST = extensionHip Ab-Adduction 20 – PS = flexion Add • Swing deg – ISW/MSW = flexion Abd – TSW = minimal -20 extension • ROM = 43° 30

Knee Varus-Valgus

-20

-40

Hip Flexion-Extension

Flx

Int

Ext

-20

0 80

Hip Rotation

-40

Knee Flexion-Extension Gait Cycle (%)

(Flex =Flxflexion, Ext = extension)

Var

100 40

Knee Rotation

Int

deg Val

Ext

Clinical Gait Analysis: A Focus on Interpretation -30

25%

50%

75%

-20

Ext

Connecticut 2025

-40

Gait Cycle

Plantar-Dorsiflexion

Foot Progression

Kinematics – Kristan Pierz

Hip Transverse Plane • Angle Definition

Trunk Obliquity

Trunk Tilt

Ant

deg Dn

Pos

-30

-20

Pelvic Obliquity

Ext -40

Pelvic Tilt

Pos

-20

• Stance – LR = internally rotates Hip Ab-Adduction Hip Flexion-Extension 60 – MST/TST = internally rotated Flx – PS = externally rotates • Swing Ext – ISW = internally rotates -20 – MSW/TSW = externally rotates Knee Varus-Valgus Knee Flexion-Extension • ROM80 = 8°

deg

Abd -20

Pelvic Rotation

Hip Transverse Plane Kinematic

Add

40 Int

Ant

deg

– motion of the thigh (as defined by the knee flexion extension axis) relative to the ASIS - ASIS line Trunk Rotation 40 – as viewed by an Int observer above the pelvic plane

Ext

-20

Var

-40

Hip Rotation

Int

Ext -40

0 40

100

Gait Cycle (%) Knee Rotation

(Int = internal, Ext = External)

Flx

Int

Ext

deg

Val -30

25%

Clinical Analysis: -20 A Focus on Interpretation 50% Gait 75%

-40

Connecticut 2025

Gait Cycle

Plantar-Dorsiflexion

Foot Progression

Kinematics – Kristan Pierz

Knee

Knee Coronal Plane • Angle Definition – relative angle between long axis of the shank and the long axis of the thigh – as viewed from the front of and in the thigh plane

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Knee Coronal Plane Kinematic • Motion – negligible

• Position – neutral 0

100

Gait Cycle (%)

(var=varus=adduction, val=valgus=abduction)

Knee Sagittal Plane • Angle Definition – relative angle between the long axis of the thigh and shank segments – as viewed by an observer looking along the knee flexion/extension axis

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

-20

Kinematics – Kristan Pierz Hip Ab-Adduction 20

Add

-40

Hip Flexion-Extension

Hip Rotation

40 Int

Flx

deg

Knee Sagittal Plane Kinematic Abd

Ext

-20

• StanceKnee Varus-Valgus 30 – LR = flexion Var – MST/TST = extension – PS = flexion deg • Swing Val – ISW = flexion – MSW = extension -30 25% 50% 75% – TSW = extension Gait Cycle • ROM = 60°

Ext -40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

-20

-40 0

100

Gait Cycle (%)

Plantar-Dorsiflexion

40 = flexion, Ext = extension) (Flex

Dor

Int

Foot Progression

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

-40

25%

50% Gait Cycle

Knee Transverse Plane • Angle Definition – motion of the shank (as defined by the ankle dorsi/plantar flexion axis) relative to the knee flexion extension axis line – as viewed by an observer above the thigh plane

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

75%

-20

Kinematics – Kristan Pierz 20

Hip Ab-Adduction

Add

Hip Flexion-Extension

Flx

deg

Knee Transverse Plane Kinematic Abd

Ext

-20

• Stance – LR/MST/TST = progressive internal rotation

• Swing – ISW/MSW/TSW = progressive external rotation

• ROM = 11(5)°

Knee Varus-Valgus

Var

Knee Flexion-Extension

Flx

deg Val -30

Ext

25%

50%

75%

-20

Gait Cycle

Gait Cycle (%)

(Flex = flexion, Ext = extension)

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50% Gait Cycle

Ankle/Foot Progression

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

75%

Kinematics – Kristan Pierz Trunk Obliquity

30 Up

Trunk Tilt

Trunk Rotation

Int

Ant

deg Dn

Ankle Sagittal Plane Pos

-30

-20

Pelvic Obliquity

Up deg Dn -20

Ext

Hip Ab-Adduction

Add

-40

• Angle Definition Pelvic Tilt

–40the relative angle Ant between a perpendicular to the long axis of the shank Pos and the plantar aspect -20of the foot – as viewed by looking Hip Flexion-Extension 60along an axis perpendicular to the Flx shank-foot plane

Pelvic Rotation

Int

Ext -40

Hip Rotation

40 Int

deg Abd

Ext

-20

Knee Varus-Valgus

Var

Ext -40

Knee Flexion-Extension

Knee Rotation

40 Int

Flx

Ankle Sagittal Plane Kinematic deg

Val

• Stance -30

Ext

25%

50%

75%

– LR = plantar flexion – MST/TST = dorsiflexion – PS = plantar flexion

Ext

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

• Swing – ISW = continued plantar flexion then dorsiflexion – MSW = dorsiflexion to neutral – TSW = minimal plantar flexion

• ROM = 30°

Clinical Gait Analysis: A Focus on Interpretation

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Gait Cycle (%)

-40

25%

50% Gait Cycle

(Dors = dorsiflexion, Plnt = plantar flexion)

Connecticut 2025

75%

Kinematics – Kristan Pierz 30

Trunk Obliquity

Trunk Tilt

Trunk Rotation

Int

Ant

deg Dn

Pos

-30

-20

Foot Progression Ext

-40

• Angle Definition 20

Pelvic Obliquity

Pelvic Tilt

Ant

deg Dn

Pos

-20

Hip Ab-Adduction

Add

Hip Flexion-Extension

Pelvic Rotation

40 angle between the – Int long axis of the foot (ankle center along to space between 2nd Ext and 3rd metatarsals) and the direction of -40 progression

Hip Rotation

40 Int

Flx

Foot progression angle deg Abd

Ext

-20

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Foot Progression Kinematics

deg Val -30

Ext

25%

50% Gait Cycle

• Stance -20 75% – LR/MST/TST = external rotation Plantar-Dorsiflexion 40 = internally – PS rotates Dor • Swing deg – ISW/MSW = Pla externally rotates – TSW = internally -40 25% 50% 75% rotates Gait Cycle • ROM = 6°

-40

Foot Progression

Int

Ext -40

25%

50%

75%

Gait Cycle

Gait Cycle (%)

(Int = internal, Ext = External)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg

Trunk

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Pelvis

Hip Ab-Adduction

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Add deg

Hip

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg

Knee

Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Ankle

Pla -40

Ext

25%

50%

-40

75%

25%

Gait Cycle

Sagittal

Trunk Obliquity

Coronal

Trunk Tilt

75%

Transverse

Ant

Int

Pos

Ext

-30

-20

50% Gait Cycle

Trunk Rotation

deg

Trunk

Collected using the same marker placement guidelines and skeletal models as the patient data!

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Pelvis

Hip Ab-Adduction

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Add deg

Hip

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg

Knee

Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Ankle

Pla -40

Ext

25%

50%

-40

75%

Gait Cycle

Sagittal

Clinical Gait Analysis: A Focus on Interpretation

25%

50%

75%

Gait Cycle

Coronal

Transverse

Connecticut 2025

Kinematics – Kristan Pierz

Reference vs. Patient Data Coronal

Sagittal Trunk Obliquity

Trunk Tilt

Transverse

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

Trunk

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

Pelvis

deg

Green (solid) = right Red (dashed) = left

Hip Ab-Adduction

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Add

Hip

deg

Knee Varus-Valgus

-40

Knee Flexion-Extension

Var

Knee Rotation

Flx

Int

Ext

Knee

deg Val -30

25%

50%

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Foot Progression

40 Int

Dor

Ankle/Foot

deg Ext

Pla -40

25%

50%

-40

75%

25%

Gait Cycle

50%

75%

Gait Cycle

4642092 10 Left (3/17/2025) 4642092 10 Right (3/17/2025)

Reference vs. Patient Data Coronal

Sagittal 30

Trunk Obliquity

Trunk Tilt

Transverse 40

Ant

Int

Pos

Ext

Trunk Rotation

Trunk

deg Dn -30

-20

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

Pelvic Rotation

Pelvis

deg Dn

Consistency 3 Plots One Side

-16

-20

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-14

-20

Hip

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Knee

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

Ankle/Foot

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

4642092 10 Right (3/17/2025) 4642092 12 Right (3/17/2025) 4642092 13 Right (3/17/2025)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics – Kristan Pierz

Before data interpretation… It is important to understand the following

• Marker placement • Skeletal model • Joint/segment angle definitions • Joint angle vs. clinical exam angle definitions • Anatomical variations and associated marker placement compromises • Motion Lab Specific

THANK YOU

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Clinical Examination for Gait Analysis: Similarities and Differences to Angle Definitions

Jean Stout, PT, MS, PhD

One of the Segments Vital to Gait Analysis Interpretation exam vs. kinematic angles depends on the consistency of definition differences in muscle function between weight-bearing and nonweight bearing conditions

how the model defines and determines joint angles and joint center locations 2

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Important to Know:

Dynamic model is better than static model for 85% of the gait parameters

Components of the Physical Examination Bony Deformity Range of Motion Muscle Strength Spasticity Selective Motor Control Foot Exam

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions CCMC

Physical Examination: CCMC

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions Physical Examination CCMC

Bony Deformity: femoral anteversion tibial torsion leg length discrepancy foot

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

True or False? • Level of Anteversion has a high correlation with internal hip rotation of the hip? A – True B – False

Femoral Anteversion: Ryder Test; Trochanteric Prominence

The amount of internal rotation required to position the greater trochanter in the most lateral position parallel to the frontal plane. 10

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Internal Hip Rotation: Kinematics The motion of the thigh segment (as defined by the flexion-extension axis of the knee and the hip joint center) relative to the pelvis. [3rd order rotation]

Correlation with anteversion about 25%

Gillette Data:

1044 Limbs; Dx: CP; Age: 4-18 yrs. Underwent SEMLS; pre-op data

CI mean observation prediction interval

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Internal Hip Rotation:

Effects of Femoral Anteversion Abduction moment arm of the gluteus medius is affected

20° valgus deformity anteversion of 60° decreases moment arm by 69%! Arnold et al., 1997

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Typical Alignment X=Y

25° Uncompensensated Femoral Anteversion

X=Functional Moment Arm Y=Anatomic Moment Arm

Uncompensated Femoral Anteversion

10° Compensatory Internal Rotation

20° Compensatory Internal Rotation

25° Compensatory Internal Rotation 16

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Favorable Effects of Compensatory Internal Hip Rotation

Arnold et al., 1997

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Points to Ponder: • changes from infancy through 10 years • may persist in children with ligamentous laxity • may manifest itself dynamically in internal rotation of the femur, internal foot progression angle, and/or Trendelenberg • if present, check closely for alignment at other levels which may have developed in compensation.

Tibial Torsion: 3 Measurements

Thigh-Foot Angle

Heel-Thigh Angle

Bi-malleolar axis

Heel-Bisector

Thigh-Foot angle (between longitudinal axis of foot and longitudinal axis of femur, ankle and foot in neutral position) Bimalleolar angle (between bimalleolar axis and bicondylar axis) (knee 90° flexed)

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Kinematic Shank Rotation Bi-malleolar axis

knee joint center

ankle joint center

Points to Ponder (tibial torsion) • Ligamentous laxity may decrease repeatability • TFA includes deformity at the foot, and can vary with through knee joint rotation • BMA measurement eliminates the rotational component of knee movement

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

EOS ® Biplanar Radiography

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Soft Tissue Range of Motion: Hips – Thomas Test

Pelvis is positioned to align ASIS and PSIS vertically.

Pelvic position altered to be aligned with motion measurement data

Physical Exam & Kinematics Hip Sagittal Plane Definition The relative angle between the long axis of the thigh and a perpendicular to the plane of the pelvis along a line connecting the ASIS and PSIS.

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Physical Exam - Knee Hamstring Tightness vs. Hamstring Shift vs. Capsular Contracture

Unilateral Popliteal Angles by Age

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Physical Exam & Kinematics Knee Sagittal Plane Definition

The relative angle between the long axis of the thigh and the shank segments as viewed along the knee flexion-extension axis.

Physical Exam & Kinematics How well does the popliteal angle correlate to crouch in gait?

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Physical Exam - Ankle

Physical Exam & Kinematics Ankle Sagittal Plane Definition

angle - 90°

The relative angle between the long axis of the shank and the plantar aspect of the foot as viewed from an axis perpendicular to the shank foot plane

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions Physical Exam & Kinematics Ankle Sagittal Plane Definition In the presence of foot deformity, restriction of motion at one joint is often compensated by excessive motion at other joints.

Discrepancies between clinical exam & kinematic data can also be related to the force of body weight in stance phase vs. test position on supine.

Physical Exam & Kinematics

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Physical Exam Hip Coronal Plane

why measure abduction both with knee flexed and knee extended?

Hip abduction without influence of hamstring tightness

Physical Exam & Kinematics Hip Coronal Plane Definition The relative angle between the long axis of the thigh and a perpendicular to the plane of the pelvis as viewed from front along a line connecting the ASIS

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Physical Exam Hip Coronal Plane

Tightness of the hip adductors/weakness of the hip abductors is highly influenced by weight-bearing & bony deformity. Kinematics will vary with trunk position, weight bearing strength and compensations.

Physical Exam Hip Coronal Plane Consider: true HF/Add tightness vs. weakness & spasticity impact of HF tightness on pelvic position impact of medial hamstring tightness on adductor measurements

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Special Considerations

Patella Alta Extensor Lag

Patella Alta

supine – knees extended palpate the top of the patella

superior edge of patella is typically one finger breadth above the adductor tubercle

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Extensor Lag The difference between active and passive range of motion for knee extension The insufficiency of the quadriceps for terminal knee extension The position eliminates potential influence of hamstring tightness

Knee Extensor Lag

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Knee Ely Test: Rectus Femoris

Foot Deformity

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Wedges & Blocks

Coleman Block Test • Is this a flexible foot? • Which part of the foot is the cause and which is the compensation?

Hindfoot varus and forefoot adductus…

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Non-Weightbearing vs. Weight-bearing

Forefoot varus

Compensated

Strength & Selectivity

Strength 0 1 22 2+ 33 3+ 4. 5.

Contraction cannot be palpated Evidence of slight contraction of the muscle but joint motion is not visible Initiates motion if gravity is eliminated Complete range of motion in gravity eliminated plane (available ROM, ROM can be slightly decreased because of cocontraction) Initiates motion against gravity Incomplete range of motion against gravity (almost perfect motion against gravity, incomplete range, motion with little help) Perfect motion against gravity (almost full available ROM, ROM can be slightly decreased because of cocontraction) Motion against gravity with minimal resistance (almost full available ROM, ROM can be slightly decreased because of cocontraction) Motion against gravity with some (moderate) resistance (full available ROM) Motion against gravity with maximal resistance (full available ROM)

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions Strength & Selectivity

at Gillette assessed simultaneously

Strength Clinically, strength is actually the ability to produce an adequate moment at a joint: M =Fxd Muscles work in isotonic and eccentric modes but tested isometrically Function in both distal end fixed and distal end free conditions

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Strength Lever-arm dysfunction influences the moment as well, which will influence “strength” M =Fxd

Hip

20° valgus deformity anteversion of 60° decreases moment arm by 69%!

Arnold et al., 1997

Knee

Hicks et al. 2007

Strength

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Selectivity: Selective Control Assessment of the Lower Extremity

Spasticity Spasticity Modified Ashworth Scale (Ashw.) for grading spasticity 0 no increase in muscle tone 1 slight increase in muscle tone, manifested by catch and release, or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension (or ab/adduction) (only small catch, or no catch, easy to move) 1+ slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM (quick catch, with some increase of muscle tone after catch - and/or - clonus, difficult to start and with quick stop) 2 more marked increase in muscle tone through most of ROM, but affected part(s) easily moved (quick catch with some difficulty to move after catch - and/or - quick clonus with slow stop) 3 considerable increase in muscle tone, passive movement difficult (no catch anymore, or clonus without stop) 4 affected part(s) rigid in flexion or extension (or ab/adduction) (no motion)

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Non-Spastic Hypertonia

Clinical Exam for Gait Analysis – CCMC 2025

Clinical Exam for Gait Analysis: Relationship to Angle Definitions

Other Physical Exam Issues Balance & Motor Planning

Thank You!

jstout@gillettechildrens.com

Clinical Exam for Gait Analysis – CCMC 2025

Kinematics Review

Objectives

Part 1: Kinematics and Clinical Exam Review

Angle Definition • The specific body segments that make up the joint or segment angle of interest • Depends primarily on skeletal model used for computing kinematic data • Must have clinical relevance and be consistent with clinical exam measures

Ankle Sagittal Plane Motion

• Describe angle definitions and typically developing (normal) gait • Understand key concepts for the interpretation of joint kinematics • Understand the relationship between kinematic abnormalities and specific joint level impairments as measured during the clinical exam

Draw Angle Definition & Normal Kinematic Plot?

• Ankle Sagittal Plane Definition

• Ankle Sagittal Kinematic Plot Plantar-Dorsif lexion

40 Dor deg Pla -40

25%

50%

75%

Gait Cycle

Typically Developing Ankle Sagittal Plane

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics Review

Ankle Sagittal Plane Motion

Ankle Sagittal Plane Motion • List at least 10 kinematic parameters/variables/events that could describe ankle motion • Include phase of the gait cycle or time point for each • For example: ankle angle at initial contact

Ankle Sagittal Plane Motion (key points in the gait cycle)

Ankle Plantar-Dorsiflexion

Dors

Dors 10

-10

Plnt -30

Plnt

50 % Gait Cycle

-30

100

Ankle Sagittal Plane Motion (peaks and range of motion)

30 Dors

-10

Plnt

Plnt -30

50 % Gait Cycle

100

Ankle Plantar-Dorsiflexion

Dors

50 % Gait Cycle

Ankle Sagittal Plane Motion (peaks and range of motion)

Ankle Plantar-Dorsiflexion

-30

100

Clinical Gait Analysis: A Focus on Interpretation

50 % Gait Cycle

Connecticut 2025

100

Kinematics Review

Ankle Sagittal Plane Motion (peaks and range of motion)

Ankle Sagittal Plane Motion (timing - when)

Ankle Plantar-Dorsiflexion

Dors

-10

Plnt

-30

50 % Gait Cycle

-30

100

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Gait Cycle

Left Right

Ankle Sagittal Plane Motion 40

• List/mark 5 kinematic parameters/variables/events that could describe this pathological ankle motion • Include phase of the gait cycle or time point for each • Consider possible joint level impairment from the clinical exam that caused the kinematic deviation • For example: increased plantar flexion in mid-swing due to…?

Plantar-Dorsiflexion 40 Dor

deg

Pla

Pla -40 25%

50%

50 % Gait Cycle

100

Plantar-Dorsiflexion

40 Dor deg Pla -40

25%

50%

75%

Gait Cycle

Left Right

Gait Pathology Ankle Sagittal Plane

Dor

-40

Ankle Sagittal Plane Motion

Gait Pathology Ankle Sagittal Plane

75%

Gait Cycle

Left Right

Clinical Gait Analysis: A Focus on Interpretation

Plantar-Dorsiflexion

25%

50%

75%

Gait Cycle

Left Right

Connecticut 2025

Kinematics Review

Knee Sagittal Plane Motion

Draw Angle Definition & Normal Kinematic Plot?

• Knee Sagittal Plane Definition

• Knee Sagittal Kinematic Plot 80

Knee Flexion-Extension

Flx

Ext -20

100

% Gait Cycle

Knee Sagittal Plane Motion • List/mark 10 kinematic parameters/variables/events that could describe knee motion • Include phase of the gait cycle or time point for each • For example: knee angle at …?

Knee Sagittal Plane Motion

Knee Flexion-Extension

Flx

Ext -20

Typically Developing Knee Sagittal Plane

Knee Flexion-Extension

Flx

Ext -20

Knee Sagittal Plane Motion

Knee Flexion-Extension

Flx

Ext -20

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics Review

Knee Sagittal Plane Motion • List/mark 5 kinematic parameters/variables/events that Knee Flexion-Extension 80 could describe pathological knee motion • Include phase of the gait cycle or time Flx point for each • Consider possible joint level impairment that caused the kinematic Ext deviation • For example: flexed knee angle at -20 initial contact due to hamstring spasticity

Gait Pathology Knee Sagittal Plane

Knee Flexion-Extension

Knee Sagittal Plane Motion

Knee Flexion-Extension

Flx

Ext -20

Draw Angle Definition & Normal Kinematic Plot?

• Hip Sagittal Plane Definition

• Hip Sagittal Kinematic Plot 60

Flx

Ext

-20

Hip Sagittal Plane Motion

Hip Flexion-Extension

100

% Gait Cycle

Typically Developing Hip Sagittal Plane Motion • List/mark 5 kinematic 60 parameters/variables/even ts that could describe hip Flx motion • Include phase of the gait cycle or time point for each • For example: hip angle at Ext …?

Hip Flexion-Extension

-20

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics Review

Typically Developing Hip Sagittal Plane Motion

Typically Developing Hip Sagittal Plane

Hip Flexion-Extension

Flx

Ext

Ext -20 0

-20

Pathological Hip Motion • List/mark 5 kinematic parameters/variables/even ts that could describe this hip motion • Include phase of the gait cycle or time point for each • Consider possible joint level impairment that caused the kinematic deviation • For example: hip angle at …?

100

Gait Cycle (%)

Pathological Hip Motion

Hip Flexion-Extension

Flx

Ext

-20

Hip Coronal Plane Motion

Draw Angle Definition & Normal Kinematic Plot?

• Hip Coronal Plane Definition

Hip Flexion-Extension

• Hip Coronal Kinematic Plot Hip Ab-Adduction

20 Add deg Abd -20

100

% Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinematics Review

Typically Developing Hip Coronal Plane • List/mark 5 kinematic parameters/variables/e vents that could describe knee motion • Include phase of the gait cycle or time point for each • For example: hip angle at…?

Typically Developing Hip Coronal Plane

Hip Ab-Adduction

Add

deg

Abd

-20

100

Gait Cycle (%)

Kinematics

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

Hip Ab-Adduction

-20

100

Gait Cycle (%)

Trunk Rotation

deg Dn -30

• Know your angle definitions • View all plots/planes on one page • Reference data must be collected using the same data collection methods

-20

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Int

Ant

deg Dn

Pos

-20

Ext

-20

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Int

Ext

Part 2: Kinematic Data Interpretation Challenges

Hip Rotation

F lx

deg Abd -20

-20

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

40 Int

F lx

deg Val -30

Ext

25%

50%

Ext

-20

75%

-40

Gait Cyc le

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

-40

75%

Gait Cyc le

25%

50%

75%

Gait Cycle

Misconceptions in Interpretation

Plotting Pelvic Kinematics L

R Internal

Real Time Pelvic Motion

L R

External 1st LIC

1st RIC

2nd LIC

2nd RIC

Right vs. Left Pelvic Motion Normalized to 100% Gait Cycle

Internal 10 Pelvic Rotation -10 External -30

• Visual vs. actual – resolving inconsistencies • Complex interactions across multiple joints within a plane of motion

50 75 % Gait Cycle

100

Clinical Gait Analysis: A Focus on Interpretation

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Kinematics Review

Toe Walking versus Equinus

Toe Walking vs. Equinus

• Toe walking may be a result of • greater than normal plantar flexion • and/or knee flexion

• Normal ankle position with excessive knee flexion may = toe walking • Foot position (relative to floor) ≠ ankle angle • Passive ankle range of motion may ≠ available ankle motion during gait

Ankle & Pelvic Motion - Barefoot

Toe Walking vs. Equinus 80

Knee Flexion-Extension

Flx

Ext

-20

40 Dor

Earwalker 119685

Plantar-Dorsiflexion

Dor

deg

Pla

-40

Knee Flexion-Extension

-20

Plantar-Dorsiflexion

videos

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Ankle & Pelvic Motion – Left PLS

Ankle Motion Can Impact Pelvic Motion barefoot

PLS

• Increasing anterior pelvic tilt in stance due to excessive plantar flexion knee extension couple which delays forward progression of the tibia and requires anterior shift of the pelvis to move the center of gravity forward during barefoot walking (left column) • In brace walk pelvic motion in stance is normal (right column)

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Kinematics Review

Hip Internal Rotation & Crouch

Hip Internal Rotation & Crouch • Due to out of plane motion (hip transverse and/or coronal plane motion), sagittal view (view seen from video) of knee motion can be distorted

336309

Knee Flexion-Extension

Flx

Ext -20

Hip Rotation

Int

Ext

C36309

-40

Thigh Position vs. Hip Extension

Single Bump Pelvic Tilt & Hip Motion

• Thigh position in space is not a good estimate of hip angle

Single Bump Pelvic Tilt & Hip Motion Right involved = solid Left non-involved = dashed • Increased hip ROM on noninvolved left side • increased hip flexion in swing when pelvis is in most anterior position • increased hip extension in stance when pelvis is in most posterior position

Pelvic Tilt

Coronal Plane

Ant

Visual Versus Kinematic (Apparent Inconsistencies)

Pos -20

Misconceptions in Interpretation

Hip Flexion-Extension

Flx

Ext -20

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Kinematics Review

Circumduction

Pelvic Hiking in Swing

• “Circumduction” has been conventionally thought of as a combination of (Perry J, Slack, 1992):

Visual circumduction is always secondary to increased hip abduction. A) true B) false

pelvic rotation + pelvic hiking + hip abduction • Joint kinematics will tell you exactly what is happening in terms of hip motion during gait.

Pelvic Hiking in Swing

Pelvic Drop in Swing

• Visual assessment = “circumduction” • Kinematic shows hip = neutral

Hip Neutral Pelvic drop in swing is typically associated with simultaneous hip abduction. A) true B) false

Pelvic Drop in Swing

Misconceptions in Interpretation Transverse Plane Hip Abduction Visual Versus Kinematic (Apparent Inconsistencies)

• Visual assessment of hip angle = “typical” • Kinematic = abduction to keep thigh vertical

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Kinematics Review

1. Knees Pointing Straight Versus Asymmetrical Pelvic and Hip Rotation

Visual impression of this patient is of typical (normal) hip rotation bilaterally

Pelvic Rotation

Int

• Visual impression of symmetry in “knee” rotation and therefore hip rotation • Kinematic data indicate asymmetrical pelvic and hip rotations

Ext -40

Hip Rotation

Int

Ext

C41637-3

-40

Pelvic Rotation

Int

Ext

2. Bilateral Internal Foot Progression

-40

Visual impression of this patient is of bilateral internal hip and foot progression

Hip Rotation

Int

• Kinematic data indicate asymmetrical pelvis and hip rotations • Internal hip rotation on the right results in internal right foot progression • Internal pelvic rotation on the left results in internal left foot progression

Ext -40 40

Knee Rotation

Int

Ext -40

Foot Progression

Int

Ext -40

25%

50%

75%

Pelvic Rotation

Int

Ext

3. Neutral Foot Progression vs. Internal Hip Rotation & External Tibial Torsion Visual impression of this patient is of neutral foot progression

3. Neutral Foot Progression vs. Internal Hip Rotation & External Tibial Torsion

• Atypical rotations of the pelvis, hip, knee, and tibia can “cancel” each other out • Excessive external tibial torsion on the right is masked by internal hip rotation on the right.

-40

Hip Rotation

Int

Ext -40 40

Knee Rotation

Int

Ext -40

Foot Progression

Int

Ext -40

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25%

50%

75%

Kinematics Review

THANK YOU

Clinical Gait Analysis: A Focus on Interpretation

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Joint Kinetics – Sylvia Õunpuu

Kinetic Concepts and Typical Patterns Sylvia Õunpuu, MSc Center for Motion Analysis Division of Orthopaedics Connecticut Children’s Medical Center Farmington, Connecticut, USA

Objectives – To Better Understand • Theory needed to understand joint kinetic data • Presentation format of joint kinetic data • Typically developing and common atypical kinetic patterns – Ankle – Knee – Hip

• Relationship between EMG, kinematic and kinetic data

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Documenting Human Gait • Joint angles kinematics • Muscle activity – EMG • Joint “loads” – kinetics

Joint Kinetics • Help in the understanding of the ocause of gait abnormalities obiomechanical impact of pathology obiomechanical basis for treatment • Joint kinetics may direct surgical treatment owithin the context of the philosophy of the physician • Focus ointernal joint moments and power

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

• Typically developing muscle activity during level walking gait • Muscles turn on and off depending on when they are needed during walking • Muscle activity and joint kinetics are linked (Bleck E, Orthopaedic Management, 1987)

STANCE

SWING

Gait – Typically Developing • Muscle activity o Quadriceps? o Plantar flexors?

• Joint – kinetics o Moments o Powers

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Joint Kinetics – Sylvia Õunpuu

Gait – CP GMFCS II • Muscle activity o Quadriceps? o Plantar flexors?

• Joint – kinetics o Moments o Powers

Joint Kinetics • During gait muscles contract to oProvide stability, that is, counter gravity oPropel body segments forward through controlled rotations

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

How? • Muscles are attached to bones! • When they contract they cause the bones to move! • This causes a joint moment (or torque)! • We can measure joint moments!

What is a “Moment”? • A moment is a force’s ability to cause the rotation of an object

• Synonymous with torque

moment = force x distance

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Joint Kinetics – Sylvia Õunpuu

Joint Moments

F d

Muscles contract at a distance “d” from the joint center Joint Moment = force (F) x distance (d) What happens when the quadriceps contract?

• The body produces internal joint moments in response to external forces that produce external joint moments

Internal Hip Extensor Moment

Clinical Gait Analysis: A Focus On Interpretation

A knee extensor moment

External GRF Force

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Joint Kinetics – Sylvia Õunpuu

External Forces • Forces from “outside” the body oGround reaction force (GRF) oGravity (segment weight or mass) oInertia (segment resistance to movement)

Internal Forces • Active forces: muscle contractions • Passive forces: ligaments, muscle/tendon contractures • A joint moment is produced by anything that constrains joint motion

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Joint Kinetics – Sylvia Õunpuu

Internal Joint Moments A proxy for muscle strength • Muscle contractions/strength is needed to walk • Muscles must respond also to gravity and associated external loads • In gait pathology there are “constraints” that require modification of movement such as weakness, contracture and/or bony deformity and pain • Joint moments represent the body’s capacity to function within those constraints 15

Moment due to the Ground Reaction Initial Contact

GRF

Free Body Diagram

GRF d MomentGRF = FGRF x d

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Joint Kinetics – Sylvia Õunpuu

Moment due to Mass of Segment Initial Contact Free Body Diagram

Fweight MomentWT = FWT x d Segment Weight

Moment due to Muscle Initial Contact Free Body Diagram

Momentmuscle = Fmuscle x d

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Knee Sagittal Plane Moment

Net Internal Moment • Net Internal Moment = body’s response to external loads • Correlates with EMG data • Results in desired motion and stability • Calculated through a process called Inverse Dynamics

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Hip-Knee-Ankle Moments

Plantar Flexor

Dorsiflexor

Anatomy of a Joint Moment Plot

Plantar-Dorsiflexion

Dor

Deg Pla

-40

2.0

Ankle Moment

Ext

Nm/kg Flx

-1.0

3.0

Ankle Power

Gen

W /kg Abs

-2.0

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Ankle Sagittal Plane Moment

2.0

PLANTAR FLEXOR MOMENT (strength plantar flexors) DORSIFLEXOR MOMENT (strength dorsiflexors)

ABILITY OF THE MUSCLES TO GENERATE A MOMENT (RELATED TO STRENGTH)

Ankle Moment

Plantar Ext flexor

Nm/kg Flx Dorsi flexor

-1.0 0

* * 25

GAIT CYCLE

100

REFERENCE DATA

What is Joint “Power” • Power is the rate at which the net moment is able to rotate the segment • Power = Moment x Angular Velocity • Require joint power to move! • Provides information about type of muscle contraction

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Joint Kinetics – Sylvia Õunpuu

Muscle Contraction?

• Tibia is rotating forward over the plantar grade foot (2nd Rocker) • Plantar flexors are contracting • How?

Eccentrically!

Hip-Knee-Ankle Powers

Plantar Flexor

Dorsiflexor

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Anatomy of a Joint Power Plot

Plantar-Dorsiflexion

40 Dor

Deg Pla

-40

Ankle Moment

2.0 Ext

Nm/kg Flx

-1.0

Ankle Power

3.0 Gen

W /kg Abs

-2.0

ANKLE SAGITTAL PLANE JOINT POWER

POWER GENERATION (concentric) POWER ABSORPTION (eccentric)

REFERENCE DATA

Ankle Power

3.0 Gen

W /kg Abs

-2.0 0

GAIT CYCLE

Clinical Gait Analysis: A Focus On Interpretation

100

ABILITY OF THE MUSCLES TO GENERATE/ABSORB POWER

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Joint Kinetics – Sylvia Õunpuu

Power Absorption and Generation • an eccentric contraction = power absorption • a concentric contraction = power generation

Second Rocker

Third Rocker

Ankle Dorsiflexion

Kinematic Plantar flexion

Plantar flexor

Moment Dorsiflexor

Power = Moment x Angular Velocity 1. Determine angular velocity by looking at the slope of the kinematic curve 2. Assess the amplitude and type (plantar flexor or dorsiflexor) of the moment

Gen

Power

3. Calculate the power Abs

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Normal Moment Patterns (ankle, knee and hip)

NOTE – ground reaction force illustration – not complete computation of joint kinetics

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Typically Developing (Normal) Ankle Kinetics

Ankle

Ankle Dorsiflexion

• First Rocker • Following heel initial contact • Minimal ankle plantar flexion – mostly forward rotation of tibia while foot rotates to plantar grade position • Dorsiflexor moment • Negligible power

Plantar Flexio n Plantar Flexor

Dorsiflexor

Gen

Abs

% Gait Cycle

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Ankle • Second Rocker

• Weight bearing progresses distally under foot • Eccentric ankle plantar flexor activity allows for controlled ankle dorsiflexion • Progressively larger ankle plantar flexor moment • Power absorption

Ankle Dorsiflexion

Plantar Flexion

Plantar Flexor

Dorsiflexor

Gen

Abs

% Gait Cycle

Ankle • Third Rocker

• Ankle plantar flexes • Ankle plantar flexors contract concentrically to provide propulsion • Increasing plantar flexor moment • Power generation until the end of single stance

Ankle Dorsiflexion

Plantar Flexion

Plantar Flexor

Dorsiflexor

Gen

Abs

% Gait Cycle

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Joint Kinetics – Sylvia Õunpuu

Ankle

Ankle Dorsiflexion

• Swing o Negligible moment power due to small mass of the foot

Plantar Flexion

Plantar Flexor

Dorsiflexor

Gen

Abs

% Gait Cycle

Examples of atypical ankle moments….. • Allows us to test our understanding of concepts

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

What abnormal contact pattern does this suggest?

• Sagittal plane ankle moment (3 trials vs. typical)

Plantar flexor

Dorsiflexor

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Resultant Ground Reaction Force Loading Response

Mid Stance

Terminal Stance

Foot flat initial contact pattern • Absence of dorsiflexor moment during loading response • Early and gradual development of a plantar flexor moment • Normal peak plantar flexor moment in terminal stance

Plantar flexor

Dorsiflexor

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

What abnormal contact pattern does this suggest? Plantar flexor

• Sagittal plane ankle moment (3 trials vs. typical) Dorsiflexor

Resultant Ground Reaction Force Loading Response

Mid Stance

Clinical Gait Analysis: A Focus On Interpretation

Terminal Stance

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Joint Kinetics – Sylvia Õunpuu

Toe initial contact pattern • Absence of dorsiflexor moment during loading response • Rapid development of a plantar flexor moment • Reduced peak plantar flexor moment in terminal stance

Plantar flexor

Dorsiflexor

What abnormal contact pattern does this suggest? Plantar flexor

• Sagittal plane ankle moment (3 trials vs. typical)

Dorsiflexor

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Heel only weight bearing pattern • Absence of dorsiflexor moment during loading response • Negligible plantar flexor moment through out stance

Plantar flexor

Dorsiflexor

Typically Developing (Normal) Knee Kinetics

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Knee Initial Contact • GRF passes through or in front of the knee joint Loading Response • Knee flexes and GRF passes behind the knee • Eccentric quadriceps activity provides a knee extensor moment and power absorption • Shock absorption for loading

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Joint Kinetics – Sylvia Õunpuu

Knee • Mid Stance to Terminal Stance

• Relatively small moments • Knee extends and GRF passes slightly in front of the knee joint • Small flexor moment is provided by gastrocnemius – which provides knee stability through a plantar flexion knee extension couple

Knee • Pre swing

oRapid flexion of the knee along with unweighting of the lower extremity oGRF passes behind the knee assisting with knee flexion resulting in a small knee extensor moment and power absorption

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Knee • Swing oRapid knee extension in terminal swing oProgressive flexor moment and power absorption as knee is decelerated by eccentric hamstring activity oTwo joint muscles (hamstrings) provide hip extensor moment to decelerate thigh (extends knee) and flexor moment at knee to control rate of extension

Examples of atypical knee moments…..

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

What knee motion does this knee moment suggest?

• Sagittal plane knee moment (3 trials vs. typical)

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Resultant Ground Reaction Force Loading Response

Mid Stance

Terminal Stance

Increased knee flexion gait • Knee flexion through out stance • Knee extensor moment through out stance

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

What knee motion does this knee moment suggest?

• Sagittal plane knee moment (3 trials vs. typical)

Resultant Ground Reaction Force Loading Response

Mid Stance

Clinical Gait Analysis: A Focus On Interpretation

Terminal Stance

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Joint Kinetics – Sylvia Õunpuu

Knee extension gait • Rapid knee extension to hyperextension in loading response and mid-stance • Knee flexor moment through out stance

Typically Developing (normal) Hip Kinetics

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Joint Kinetics – Sylvia Õunpuu

Hip • Initial Contact to Loading response oGRF passes in front of the hip oConcentric gluteal activity provides hip extension, a hip extensor moment and power generation

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Joint Kinetics – Sylvia Õunpuu

Hip • Mid-stance

oGRF passes through the hip resulting in a zero moment and power

Hip • Terminal Stance

o GRF passes behind the hip o Passive stretch of anterior soft tissues provides a flexor moment and power absorption

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Hip • Pre-swing to Initial Swing oHip flexor activity initiates rapid hip flexion and provides power generation

• Mid to Terminal Swing oProgressive extensor moment provided by hamstrings to decelerate the thigh

Examples of atypical hip moments……

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

What abnormal motion does this hip moment suggest?

• Sagittal plane hip moment (3 trials vs. typical)

Resultant Ground Reaction Force Loading Response

Mid Stance

Clinical Gait Analysis: A Focus On Interpretation

Terminal Stance

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Joint Kinetics – Sylvia Õunpuu

Hip flexion gait • Hip motion skewed towards flexion (secondary to crouch) • Increased and prolonged hip extensor moment in stance

Coronal Plane

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Joint Kinetics – Sylvia Õunpuu

Coronal Plane Hip & Knee Kinetics • Mid to Terminal Stance • GRF passes medial to the hip and knee • Hip abductor moment is provided by the hip abductors which contract eccentrically during LR • Small hip power absorption • Knee abductor moment is provided by the lateral soft tissue structures of the knee

Hip Ab-Adduction

Add

30 Var

Deg

Abd

Val

-20

-30

2.0

Hip Moment

2.0

Abd

Val

Nm/kg

Add

Var

-1.0

3.0

Knee Varus-Valgus

Hip Pow er

3.0

Gen

W/kg

Abs

-2.0

Knee Moment

Knee Pow er

Putting it All Together!

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Plotting Format Kinematic

Plantar Flexor

Moment (internal) Dorsiflexor

Power

Understanding Relationships Between Kinematics and Kinetics

Plantar Flexor

Dorsiflexor

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Comprehensive Assessment of Gait function! Multiple data sources of data! 60

Left Gastrocnemius

V -5 5

Left Gastrocnemius*

V % Gait Cycle

Left Anterior Tibialis

V -5

-5 5

Left Hamstrings

-5 5

% Gait Cycle

Left Anterior Tibialis*

-5 5

Left Hamstrings*

-5 5

-5

% Gait Cycle

Left Vastus Medialis

V -5 5

-5 5

% Gait Cycle

Left Rectus Femoris

-5 5

-5

% Gait Cycle

40 Dor

Plantar-Dorsiflexion

deg

Trunk Obli quity

Ext

Pla

-20

-40

Trunk T ilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

-5 5

Left Rectus Femoris*

-5 5

% Gait Cycle

2.0

Hip Moment

2.0

Knee Moment

2.0

Ankle Moment

-5

Pelvic Obl iqui ty

Pel vi c Ti lt

Pel vi c Rotati on

Ant

Int

Left Vastus Medialis**

% Gait Cycle

Left Vastus Lateralis**

Ext

deg

Nm/kg

Flx

Left Rectus Femoris**

-1.0

Pos

-20

% Gait Cycle

-1.0

V % Gait Cycle

-40

Left Hamstrings**

V % Gait Cycle

Knee Flexion-Extension

Flx

% Gait Cycle

Left Anterior Tibialis**

V % Gait Cycle

Left Vastus Lateralis*

V -5

% Gait Cycle

Left Vastus Medialis*

V % Gait Cycle

Left Vastus Lateralis

V -5

Flx

V % Gait Cycle

-5 5

Left Gastrocnemius**

V % Gait Cycle

Hip Flexion-Extension

Left Side EMG 5

Add % Gait Cycle

3.0

Hip Pow er

3.0

Gen

W/kg

Abs

Knee Pow er

3.0

Ankle Pow er

-2.0

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

-40

W/kg 30

Knee Varus-Valgus

Var

-2.0

Ext

-20

Hip Ab-Adducti on

Knee Flexion-Extension

Flx

Knee Rotation

40 Int

-2.0 deg

CLINICAL EXAM (range of motion/strength)

Val -30

Ext

25%

50%

75%

Ext

-20

-40

Gait Cycle

Plantar-Dorsi flexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

-40

25%

50%

75%

Gait Cycle

References • Davis RB, Kaufman KR, Kinetics of Normal Walking. in Human Walking, J Rose, JG Gamble (editors), Lippincott Williams & Wilkins, Philadelphia, pp. 53-76, 2006. • Davis RB, Ounpuu S. Kinetics of Normal Gait. In The treatment of Gait problems in Cerebral Palsy, JR Gage (editor), MacKeith Press, London, pp. 120-134, 2004. • Ounpuu S, Gage JR, Davis RB. Three dimensional lower extremity joint kinetics in normal pediatric gait. Journal of Pediatric Orthopedics, 11:341-349, 1991. • Ounpuu S, Davis RB, DeLuca PA. Joint kinetics: methods, interpretation and treatment decision-making in children with cerebral palsy and myelomeningocele. Gait and Posture, 4(1):62-78, 1996. • Ounpuu S, Joint Kinetics: Interpretation and Clinical Decision Making for the Treatment of Gait Abnormalities in Children with Neuromuscular Disorders. In Human Motion Analysis: Current Applications and Future Directions, GF Harris and PA Smith (editors), IEEE Press, NJ, 268-302, 1996.

Clinical Gait Analysis: A Focus On Interpretation

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Joint Kinetics – Sylvia Õunpuu

Thank You

Clinical Gait Analysis: A Focus On Interpretation

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Clinical gait analysis A Focus on Interpretation

Intro to EMG data and typical patterns Kaat Desloovere Clinical Motion Analysis Laboratory University Hospital Leuven Belgium

Overview • EMG signal • EMG data collection • EMG signal quality check and trouble shooting • “Typical” EMG patterns in adults and children • “Pathological” EMG patterns and clinical decision making

Definition Electromyography Electro-Myo-Gram (EMG) Surface EMG (sEMG) Measurement of electrical activity of a contracting muscle

Definition The contracting muscle produces muscle action potentials

Definition The EMG signal represents the summation of all muscle action potentials

EMG systems

Electrode mounted amplifier

Muscle contraction => force • If there is an EMG signal, there is muscle fiber action that can generate a force • To initiate movement • To control movement

• If there is no EMG signal • There is no muscle contraction • A muscle force may be present due to contracture

Skin preparation

Improve electrode-skin contact => reduce noise  shaving and cleaning When done properly, the skin typically receives a light red color.

Electrode placement and fixation of sensor

• Electrode selection: • Shape: circular/rectangular • Size: ~ 10 mm diameter • Pre-gelled to improve conductivity

• Electrode distance: centre to centre • Large muscle: 20 mm • Small muscles: ¼ of fibre length

• Electrode orientation: Line between two electrodes with respect to the direction of the muscle fibres

• Reference electrodes on electrically inactive tissue

Sensor locations • Position of the centre of two electrodes in a bipolar arrangement on the muscle • To obtain a good and stable sEMG • Guidelines take into account: • Avoid presence of motor endplates • Between endplate and tendon (if possible) • Avoid muscle tendons • Avoid other muscles (cross talk)

• EMG guidelines  European Recommendations for Surface Electromyography

(sEMG = surface EMG)

Tibialis anterior M. Tibialis Anterior at 1/3 on the line between the tip of fibula and the tip of the lateral malleolus

Test contraction: apply resisted pressure and ask for dorsiflexion and inversion

Most likely sources of cross-talk are from Extensor Digitorum and Peroneus Longus

Peroneus longus

M. Peroneus Longus at 1/4 on the line between the tip of fibula and the tip of the lateral malleolus Test contraction: apply resisted pressure and ask for eversion (without dorsiflexion to exclude cross-talk with Extensor Digitorum)

Cross-talk check

Cross-talk from peroneus longus on tibialis anterior Cross-talk Tibialis anterior

Corrected Tibialis anterior

Gastrocnemius M. Gastrocnemius Lateralis at 1/3 of the line between the tip of the head of the tibia and the heel (Comparable guidelines for M. Gastrocnemius medialis) Test contraction: ask plantar flexion of the foot under resistance

Soleus

M. Soleus at 2/3 on the line between the tip of medial femoral condyle and the tip of the medial malleolus Test contraction: manually push the (flexed) knee downwards and ask to lift the heel upwards

Palpation!

Rectus femoris

M. Rectus Femoris at 1/2 of the line of the ASIS and superior edge of the patella Test contraction: apply resisted pressure at the ankle and ask for knee extension (avoid thigh rotation)

Palpation!

Vastus lateralis

M. Vastus Lateralis at 2/3 of the line of the ASIS and the lateral side of the patella Test contraction: apply resisted pressure at the ankle and ask for knee extension (avoid thigh rotation)

Rectus Femoris on Vastus lateralis

Isolation test Rectus femoris

Vastus lasteralis

Rectus femoris

Vastus lasteralis

Knee extension

Hip flexion

Rectus AND Vastus Lateralis

Rectus WITHOUT Vastus Lateralis

Medial hamstrings

M. Semitendinosus and M. Semimembranosus at 1/2 of the line of the ischial tuberosity and the medial epicondyle of the tibia Test contraction: apply resisted pressure at the ankle and ask for knee flexion

Lateral hamstrings

M. Biceps Femoris at 1/2 of the line of the ischial tuberosity and the lateral epicondyle of the tibia Test contraction: apply resisted pressure at the ankle and ask for knee flexion

Gluteus medius

M. Gluteus Medius at 1/2 of the line of the iliac crest and the great trochanter Test contraction: Side-lying: hip abduction against resistance at the ankle

Or in stance

Signal quality checks • Does muscle and electrode channel match? • No muscle activity at rest (few exceptions) • Signal when muscle contracts • Cross-talk tests – confirm activity on electrode is consistent with desired muscle – when isolated movement is not possible: quick stretch on specific muscle

Right Tibialis Anterior

Right Rectus Femoris

Right Gastrocnemius

Right Vastus Lateralis

Contributing factors for artefacts/noisy signal • Poor knowledge of anatomy • High skin impedance • Poor electrode connection • Electrodes touched by wires or patient

High skin impedance

High skin impedance Due to high BMI Bad signal to noise ratio

Electrode touched by patient

Soleus: touch of contra-lateral foot

Signal artefacts rectus femoris

Signal artefacts soleus

Cross talk Tibialis anterior

• Neighboring muscles can produce significant EMG • Cross-talk can be identified by synchronysing matching peaks in the data, and can be reduced by decreasing the inter-electrode distance

Gastrocnemius

Problem of electrode attachment Tibialis anterior

un-corrected

corrected

Problem of electrode distance Tibialis anterior

un-corrected

corrected

• Problem: Variable muscle firing of Tibialis Anterior (change of signal content) • Replacement with reduced inter-electrode distance and further cleaning of skin

Variable Muscle Firing Tibialis anterior

un-corrected

corrected

• Be aware of change of signal content! • The majority of the patients present with a repetitive EMG pattern (except for walking with severe balance problems and for dystonia)

“Typical” Muscle Function Some concepts • Most muscles are active at transition times => silent in midstance and midswing • Onset and termination of muscle activity is gradual • Muscle activity is present prior to the need for force generation • Time activation bars indicate the on-phases for a typical gait cycle

“Typical” Muscle Function and Variability

• EMG patterns vary • Stride to stride • Person to person • Author to author

• Plasticity (Winter, 1990) • Many combinations of EMG result in similar motion

• Mainly described for adult gait

Typical patterns Gait cycle muscle sequence

Concentric Eccentric

(Perry, 1988, 1992)

Which muscles Muscle activity Response to external moments caused by: • Ground reaction force (GRF) • Segment’s rotational inertia • Gravity To provide the desired motion/condition: • Stability • Acceleration • Deceleration

GRF

Ground reaction force

Simplification

GRF r

Muscles for Ankle Motion

Normal ankle: three rockers

1° rocker

2° rocker

3° rocker

First rocker (Loading response)

• Heel initial contact • Short/small internal ankle dorsiflexor moment • Eccentric tibialis anterior activity Do not forget gravity of foot

• To control foot position

Second rocker (Midstance)

• Internal plantar flexor moment • Eccentric ankle plantar flexor activity • To controll gradual ankle dorsiflexion

Third rocker (Terminal stance)

• Internal plantar flexor moment • Concentric plantar flexor activity • To create push off (accelleration)

Muscles for Knee and Hip Motion

Knee (Loading response)

• Knee flexes and GRF passes behind the knee • Internal knee extensor moment • Eccentric quadriceps activity to control flexion motion (followed by concentric activity later on)

Knee (Midstance to terminal stance)

• Knee extends and GRF passes slightly in front of the knee joint • Internal knee flexor moment • Passive strech of posterior soft tissues (i.e. joint capsule)

Muscles for Hip Motion

Hip (Loading response)

• GRF passes in front of the hip • Internal hip extensor moment • Concentric activity of glutei and hamstrings • To create hip extension

Hip (Mid and Terminal stance)

• GRF passes behind the hip • Internal hip flexor moment • Passive stretch of anterior soft tissues provides a flexor moment

Hip in coronal plane

• GRF passes medial from hip • Internal hip abductor moment • Mainly eccentric during pelvic drop (loading response & midstance) • Isometric/Eccentric at terminal stance

Interpretation guides • Start with raw – unfiltered EMG • Observe multiple strides • Knowledge of typical EMG patterns! • Knowledge of frequently observed atypical EMG patterns for different pathologies • Integration with kinematics and kinetics A single biomechanical finding, even if measured accurately, is worthless if not integrated to the total system

Interpretation guidelines • Focus on timing of EMG activity • No absolute information on how much the muscle is active • The relation to strength requires a normalisation to a reference value, such as maximum voluntary contraction

How is EMG activity ‘described’ versus typical

• Early onset (premature activity) • Prolonged • Continuous • Out of phase • Lack of activity • Co-activity – Simultaneous agonist and antagonist

Hamstrings in crouch

How is EMG activity ‘described’ versus typical

• Early onset (premature activity) • Prolonged • Continuous • Out of phase • Lack of activity • Co-activity – Simultaneous agonist and antagonist

Tibialis anterior in drop foot

How is EMG activity ‘described’ versus typical

• Early onset (premature activity) • Prolonged • Continuous • Out of phase • Lack of activity • Co-activity – Simultaneous agonist and antagonist

Gastrocnemius at forefoot contact

How is EMG activity ‘described’ versus typical

• Early onset (premature activity) • Prolonged • Continuous • Out of phase • Lack of activity • Co-activity – Simultaneous agonist and antagonist

Rectus in severe crouch with stiff knee

How is EMG activity ‘described’ versus typical

• Early onset (premature activity) • Prolonged • Continuous • Out of phase • Lack of activity • Co-activity – Simultaneous agonist and antagonist

How is EMG activity ‘described’ versus typical

• Early onset (premature activity) • Prolonged • Continuous • Out of phase • Lack of activity • Co-activity – Simultaneous agonist and antagonist

‘Atypical’ EMG: Next question is why? • Is atypical muscle activity • Primary (muscle control issue)? • Result of position (crouch in stance)? • Result of joint motion (response to quick strech)?

• Cause or effect? Not always easy to determine.

Questions ? Sources • • • • • • •

Basmajian JV, De Luca CJ, ‘Muscles alive’ (1985) Literature review on use of EMG for gait analysis Seniam guidelines (http://www.seniam.org/) The ABC of EMG (http://www.noraxon.com/emg/emg.php3) Surface electromyography: detection & recording (https://www.delsys.com/Attachments_pdf/WP_SEMGintro.pdf) Previous EMG courses by Sylvia Ounpuu, Jean Stout, Jaap Harlaar, Adam Shortland, Yves Blanc Examples from clinical practice and unpublished EMG studies

Kinetics Review

Objectives • To understand • joint kinetic principles • the link between joint kinetics and muscle activity • typically developing joint kinetic patterns

Joint Kinetics Review

Sylvia Ounpuu and Kaat Desloovere

Joint Kinetics • During gait muscles contract to • Provide stability, that is, counter gravity • Propel body segments forward through controlled rotations

Muscle activity and joint kinetics are linked! Know normal muscle activity during gait! (Bleck E, Orthopaedic Management, 1987)

Ankle Rockers

STANCE

SWING Initial Contact

Toe Off

Initial Contact

Ankle Sagittal Plane

1st

2nd

3rd

(Perry, Normal and Pathological Gait, Slack, 1994)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinetics Review

What is the “normal” activity patterns? Initial Contact

Ankle Rockers

Toe Off

Initial Contact

Anterior Tibialis Gastroc -nemius 0

50 % Gait Cycle

100

Place “X’s” at points in the gait cycle where each muscle is active in normal gait.

• First Rocker

• plantar flexion (loading response) • eccentric contraction dorsiflexors • controlled lowering of foot to floor

Ankle Rockers

• Second Rocker

• Third Rocker

• dorsiflexion (mid stance and terminal stance) • eccentric contraction plantar flexors • control of forward motion of shank over foot

• plantar flexion (pre swing) • concentric contraction plantar flexors • ankle plantar flexion

Ankle Sagittal Plane Moment Plot Format Ankle Moment

2.0

PLANTAR FLEXOR MOMENT (strength plantar flexors) DORSIFLEXOR MOMENT (strength dorsiflexors)

Draw the ankle sagittal plane moment Ankle Moment

2.0

Plantar Ext flexor

Plantar Ext flexor Nm/kg

Nm/kg

Dorsi Flx flexor -1.0

100

Dorsi Flx flexor

% GAIT CYCLE

-1.0 0

Clinical Gait Analysis: A Focus on Interpretation

50 % GAIT CYCLE

Connecticut 2025

100

Kinetics Review

Normal Ankle Sagittal Plane Moment • Mark at least 5 variables/events that could describe ankle sagittal plane moment • Include phase of the gait cycle or time point for each • For example: peak ankle plantar flexor moment during…

Normal Ankle Sagittal Plane Moment Ankle Moment

2.0 Ext

Ext

Nm/kg

Flx -1.00

Ankle Moment

2.0

Flx 25

Normal Ankle Sagittal Plane Power

50 % GAIT CYCLE

100

Plantar-Dorsiflexion

-1.00

50 % GAIT CYCLE

Normal Ankle Sagittal Plane Power

Dor

deg

Answers • Second Rocker (red box)

Pla

• Kinematic (dorsi or plantar flexion)? ________________ • Moment (dorsiflexor or plantar flexor)? ______________ • Which muscle is contracting? _____________________ • Type of contraction (eccentric or concentric)? ________ • Power (generation or absorption)?

-40

• Kinematic = dorsiflexion • Moment = plantar flexor • Muscle is contracting = plantar flexors • Type of contraction = eccentric • Power = absorption*

Ankle Moment

2.0 Ext Nm/kg

• Third Rocker (green box)

Flx

• Kinematic? ____________________ • Moment? _____________________ • Which muscle is contracting? ______________ • Type of contraction? ________________ • Power? ____________________

-40

? ?

Nm/kg Flx -1.0

25%

50%

Knee Sagittal Plane

W/kg

-2.0

75%

Gait Cycle

Ankle Pow er

3.0 Gen

Abs

Abs -2.0

Ankle Moment

2.0 Ext

• Kinematic = plantar flexion • Moment = plantar flexor • Muscle is contracting = plantar flexors • Type of contraction = concentric • Power = generation*

Ankle Pow er

3.0

W/kg

Pla

• Third Rocker (green box)

-1.0

Gen

Plantar-Dorsiflexion

Dor

deg

• Second Rocker (red box)

100

* 25%

50%

75%

Gait Cycle

Knee Sagittal Plane

Muscle activity and joint kinetics are linked! Know normal muscle activity during gait! (Bleck E, Orthopaedic Management, 1987)

STANCE

SWING

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinetics Review

What is the “normal” activity patterns? Initial Contact

Knee Sagittal Plane Moment Plot Format

Toe Off

Initial Contact

Rectus Femoris

Knee Extensor MOMENT (strength quadriceps)

Vasti (med & lat)

Knee Flexor MOMENT

Hamstrings

50 % Gait Cycle

100

Knee Moment

2.0

Extensor Ext Nm/kg Flx Flexor -1.0

(strength hamstrings)

100

% GAIT CYCLE

Place “X’s” at points in the gait cycle where each muscle is active in normal gait.

Knee Sagittal Plane Moment

Draw the knee sagittal plane moment Knee Moment

2.0

• Mark at least 5 variables/events that could describe knee sagittal plane moment

Extensor

Ext

Nm/kg Flexor Flx

• Include phase of the gait cycle or time point for each

-1.0

• For example: peak knee extensor moment during…

50 % GAIT CYCLE

100

Knee Moment

2.0 Ext Nm/kg Flx -1.0 0

100

% GAIT CYCLE

Knee Sagittal Plane Moment

Normal Knee Sagittal Plane Power

Knee Flexion-Extension

80 Flx deg Ext

Knee Moment

2.0

• Loading Response (red box) • Kinematic (flexion or extension)? __________________ • Moment (extensor or flexor)? _____________________ • Which muscle is contracting? _____________________ • Type of contraction (eccentric or concentric)? ________ • Power (generation or absorption)? _________________

Ext

-20

Knee Moment

2.0 Ext Nm/kg Flx

Nm/kg

-1.0

Knee Pow er

3.0

Flx

Gen

W/kg

-1.00

100

% GAIT CYCLE

Abs -2.0

25%

50%

75%

Gait Cyc le

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinetics Review

Knee Flexion-Extension

Hip Sagittal Plane

Flx deg Ext

Answers

-20

• Loading Response (red box)

Knee Moment

2.0

• Kinematic = flexion • Moment = extensor • Which muscle is contracting = quadriceps • Type of contraction = eccentric • Power = absorption*

Ext Nm/kg Flx -1.0

Knee Pow er

3.0 Gen W/kg

Muscle activity and joint kinetics are linked! Know normal muscle activity during gait!

Abs -2.0

25%

50%

75%

STANCE

(Bleck E, Orthopaedic Management, 1987)

Gait Cyc le

SWING

What is the “normal” activity patterns?

Hip Sagittal Plane

Initial Contact

Toe Off

Initial Contact

Hip Flexors Hip Extensors

50 % Gait Cycle

100

Place “X’s” at points in the gait cycle where each muscle is active in normal gait. 27

Hip Sagittal Plane Moment Plot Format

Hip Flexor MOMENT (strength hip flexors)

Hip Moment

2.0

Hip Moment

2.0

Hip Extensor MOMENT (strength hip extensors)

Draw the hip sagittal plane moment

Ext Ext

Nm/kg

Flx

Flx -1.00

100

% GAIT CYCLE

Clinical Gait Analysis: A Focus on Interpretation

-1.00

100

% GAIT CYCLE

Connecticut 2025

Kinetics Review

Hip Sagittal Plane Moment • Mark at least 5 variables that could describe hip sagittal plane moment • Include phase of the gait cycle or time point for each

Hip Sagittal Plane Moment Hip Moment

2.0 Ext

Ext

Nm/kg

Flx

• For example: peak hip extensor moment during…

-1.0 0

100

% GAIT CYCLE

Flx

deg

Ext

Answers

-20

• Kinematic (flexion or extension)? __________________ • Moment (extensor or flexor)? _____________________ • Which muscle is contracting? _____________________ • Type of contraction (eccentric or concentric)? ________ • Power (generation or absorption)? _________________

-20

• Loading Response (red box)

Hip Moment

2.0

• Kinematic = flexion • Moment = extensor • Which muscle is contracting = hamstrings/gluteus medius • Type of contraction = concentric • Power = generation*

Ext Nm/kg Flx -1.0

Nm/kg Flx -1.0

Gen

W/kg

Abs

25%

50%

Hip Pow er

3.0

-2.0

Hip Moment

2.0 Ext

Hip Pow er

3.0 Gen

Hip Flexion-Extension

Normal Hip Sagittal Plane Power

Flx

• Loading Response/Mid Stance (red box)

100

% GAIT CYCLE

Hip Flexion-Extension

Normal Hip Sagittal Plane Power

Hip Moment

2.0

-2.0

75%

25%

Gait Cycle

Trunk Tilt

Sagittal Plane Kinematics & Kinetics

Coronal Plane Kinematics & Kinetics

Ant deg Pos

Trunk Obliquity

Up deg

-30

Pelvic Tilt

Ant

deg

Pos

-20

Pelvic Obliquity

-20

Hip Flexion-Extension

Knee Flexion-Extension

Plantar-Dorsif lexion

Hip Ab-Adduction

Knee Varus-Valgus

Flx

Dor

Add

Var

deg

Ext

-20

Pla

-20

Hip Moment

2.0

Abd

- 40

Knee Moment

2.0

Val

-20

Ankle Moment

2.0

Val

-30

Hip Moment

2.0

-30

Knee Moment

2.0

Ext

Abd

Val

Nm/kg

Flx

- 1.0

Hip Pow er

3.0

Add

Var

-1.0

Knee Pow er

3.0

Ankle Pow er

3.0

Var

-1.0

Hip Pow er

3.0

-1.0

Knee Pow er

3.0

Gen

W/kg

Abs

25%

50% Gait Cyc le

75%

- 2.0

25%

50% Gait Cycle

75%

-2.0

Abs

25%

50%

75%

Gait Cyc le

Clinical Gait Analysis: A Focus on Interpretation

-2.0

Abs

25%

50%

75%

-2.0

Gait Cycle

Connecticut 2025

Ankle Pow er

3.0

Gen W/kg Abs

Ankle Moment

2.0

Ext

-1.0

Ankle Var/Val

Flx

-2.0

75%

-20

50% Gait Cycle

25%

50% Gait Cyc le

75%

-2.0

25%

50%

75%

Gait Cyc le

Kinetics Review

Hip in coronal plane

Joint Kinetics in Pathological Gait • A review of patient examples to reinforce concepts

• GRF passes medial to the hip center • Internal hip abductor moment • Mainly eccentric during pelvic drop (loading response & mid-stance) • Isometric/Eccentric at terminal stance

Gait Problems & Diagnosis?

Plantar-Dorsif lexion

Gait Problems & Diagnosis?

Dor

• Data – three gait cycles one side barefoot • Mark the gait variables that are abnormal (kinematic and kinetic)? • List the joint level impairment(s) that may be the cause? • Possible diagnosis?

deg

Pla

• Data – three gait cycles one side barefoot

-40

Ankle Moment

2.0 Ext Nm/kg

• Mark the gait variables that are abnormal (kinematic and kinetic)? • List the joint level impairment(s) that may be the cause?

Flx -1.0

Ankle Pow er

3.5

• Possible diagnosis?

Ext -20

Nm/kg Flx -1.0

W/kg

W/kg Abs

25%

50%

-2.0

75%

25%

50%

75%

Gait Cyc le

Gait Cycle

Knee Pow er

3.0 Gen

Abs

Gait Problems & Diagnosis?

Knee Moment

2.0 Ext

Gen

-1.5

Knee Flexion-Extension

Flx

Hip Flexion-Extension

Gait Problems & Diagnosis?

Flx deg

• Data – three gait cycles one side barefoot

Ext -20

Hip Moment

1.5

• Mark the gait variables that are abnormal (kinematic and kinetic)?

Ext Nm/kg Flx -1.5

• List the joint level impairment(s) that may be the cause?

Hip Pow er

3.0 Gen

• Possible diagnosis?

W/kg Abs -2.0

25%

50%

75%

Gait Cyc le

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Kinetics Review

Gait Changes?

Gait Problems & Diagnosis? • Data – three gait cycles one side barefoot • Mark the gait variables that are abnormal (kinematic and kinetic) • What joint level impairment(s) may be the cause? • Possible diagnosis?

• Data – three gait cycles one side barefoot and AFO • Describe changes barefoot to AFO • Why do the kinetic plots change barefoot to AFO conditions?

Barefoot

AFO

Gait Problems & Diagnosis?

Comprehensive Assessment of Gait function!

Multiple data sources of data! • Data – three gait cycles one side barefoot • Mark the gait variables are abnormal (kinematic and kinetic)? • What joint level impairment(s) may be the cause? • Possible diagnosis?

Left Gastrocnemius

V -5 5

Left Hamstrings

Left Gastrocnemi us*

-5 5

Left Hamstri ngs*

-5 5

-5

Knee Flexion-Extens ion

Plantar-Dorsiflexion Trunk Obliqui ty

% Gait Cycle

T runk T i lt

D or Ant

Int

deg

Ext

Pla

Pos

Ext

-20

-40

-30

-20

Trunk Rotati on

Flx

deg

% Gait Cycle

Left Anterior Tibialis**

-5 5

Left Hamstrings**

V % Gait Cycle

Left Vastus Mediali s*

-5 5

% Gait Cycle

-5 5

% Gait Cycle

2.0

Knee Moment

2.0

Ankle Moment

Pelvic T ilt

Pelvic Rotation

Ant

Int

Ext

deg

Nm/kg

Pos

Ext

-20

Flx

-40

% Gait Cycle

Left Rectus Femoris**

-1.0

V % Gait Cycle

Pelvic Obli quity

Ext Nm/kg

Flx

-5 5

Hip Moment

Ext

Left Vastus Lateralis**

V % Gait Cycle

Left Rectus Femoris*

2.0

-40

N m/kg

Left Vastus Medialis**

V % Gait Cycle

Left Vastus Laterali s*

V % Gait Cycle

Flx Left Gastrocnemius**

-5

V % Gait Cycle

Left Rectus Femoris

5 V

% Gait Cycle

Left Anterior Tibialis*

V % Gait Cycle

Left Vastus Lateralis

V -5

-5

V % Gait Cycle

Left Vastus Medi alis

-5

V % Gait Cycle

V -5

-5

5 V

% Gait Cycle

Left Anterior Tibialis

Hip Flex ion-Extension

Left Side EMG 5 V -5

-5

Hip Ab-Adducti on

Add % Gait Cycle

3.0

Hip Pow er

3.0

Gen

W/kg

Abs

-2.0

Knee Pow er

3.0

Ankle Pow er

Hip Flexion-Extension

Hip Rotati on

F lx

Int

Ext

deg Abd -20

-20

-40

W/kg 30

Knee Varus-Valgus

Var

Knee Flexion-Extensi on

Knee Rotation

F lx

Int

Ext

-2.0 deg

CLINICAL EXAM (range of motion/strength/muscle tone/selectivity)

Val -30

25%

50%

75%

-20

-40

G ait Cycle

Plantar-Dorsiflexion

D or

Foot Progressi on

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

G ait Cycle

THANK YOU

Questions?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Case Study #1 A Method of Gait Data Interpretation Sylvia Õunpuu, MSc and Kristan Pierz, MD

Center for Motion Analysis Division of Orthopedics Connecticut Children’s Medical Center Farmington, Connecticut

Objectives • Demonstrate a method for the interpretation of motion analysis data and treatment decision-making using comprehensive motion analysis components – Patient history – Video – Clinical exam findings – Gait data (kinematics/kinetics/EMG)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Objectives • Framework to review all the DATA! – Patient history including primary gait issues – Identify • Compromised pre-requisites of gait from video

• Gait abnormalities that negatively impact pre-requisites of gait • Joint level impairments specific to the gait abnormality • Treatment decision and indications for specific gait deviation and associated compromised pre-requisite of gait • Expected gait changes and associated impact on pre-requisites of normal gait

Objectives • Framework to review all the DATA! – Evaluation of treatment outcomes – Identify changes in gait • Pre-requisites of gait from video • Kinematics and kinetics • Clinical exam

– Review treatment indications • Clarify • Modify if need

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Patient History • 5+8 years • Cerebral palsy, asymmetric spastic diplegia (left side primarily involved) • 6 weeks premature • Birth weight 4 pounds, 11 ounces • Maternal toxemia, maternal fetal transfusion syndrome, fetal distress during delivery

Patient History • First began independent walking at 2 years • Left ankle casting at 1and ½ years and 4 years • Will not tolerate night time bracing • Bilateral ankle foot orthoses (posterior leaf spring design) after school only • No orthopedic surgeries

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Primary Problems • Parent Report – Trouble keeping up with peers – Limited endurance – Frequent tripping and falling – In-toeing left side

Primary Problems • Gait by Observation – Asymmetric involvement (left > right) – Posturing left upper extremity – Left internal knee & foot progression – Reduced sagittal plane motion left side – Toe initial contact left – Possible vault on the right for clearance – Poor clearance left foot initial swing – Good static balance though reduced dynamic balance – GMFCS Level II

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pre-requisites of Typical Gait • Stance phase stability • Swing phase clearance • Appropriate pre positioning of the foot at initial contact • Adequate step length • Energy conservation Framework for the Assessment of Pathological Gait Perry, J. Gait Analysis: Normal and Pathological Function, Slack, 1992

Stance Phase Stability Okay?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

What gait kinematic(s) contribute to reduced stance phase instability?

What joint level impairment(s) contribute those abnormal kinematics?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Swing Phase Clearance Ok?

What gait kinematic(s) contribute to reduced swing phase clearance?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

What joint level impairment(s) contribute those abnormal kinematics?

Appropriate Pre-positioning at Initial Contact?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

What gait kinematic(s) contribute to atypical Pre-positioning at Initial Contact?

What joint level impairment(s) contribute those abnormal kinematics?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

What Can Be Learned in Standing?

Pre-requisites of Typical Gait Which are compromised? • Stance phase stability • Swing phase clearance • Appropriate pre positioning of the foot at initial contact • Adequate step length • Energy conservation

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pre-requisites of Typical Gait Which are compromised? • Stance phase stability = YES • Swing phase clearance = YES • Appropriate pre positioning of the foot at initial contact = YES • Adequate step length = YES • Energy conservation = YES

Do the Bilateral PLS’s Help?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pre-requisites of Typical Gait How did the orthoses help? • Stance phase stability? • Swing phase clearance? • Appropriate pre positioning of the foot at initial contact? • Adequate step length? • Energy conservation?

Do the Bilateral PLS’s Help? • Pre-requisites of gait improved but still a problem with – Stance phase stability – Pre-positioning at initial contact – Clearance in swing

• Confirm that gait deviations are multi-level

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Clinical Examination • What does the clinical exam add to our understanding of the causes of gait abnormalities? • Identify joint level impairments: – contractures – bony deformity – increased muscle tone – weakness – reduced isolated voluntary control – anatomical abnormalities, e.g. leg length

Clinical Examination – ankle (range of motion) Ankle dorsiflexion (knee at 0 deg) Ankle dorsiflexion (knee at 90 deg) Ankle plantar flexion Forefoot inversion Forefoot eversion

Right

Left

20°

5°

25°

15°

full

full full

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Clinical Examination – ankle (strength) Ankle dorsiflexion (knee at 0 deg) Ankle dorsiflexion (knee at 90 deg) Ankle plantar flexion Forefoot inversion Forefoot eversion

Right

Left

4/5

3/5

4/5

4/5*

4/5

2/5

4/5 4/5

4/5 2/5

* in synergy

Clinical Examination – ankle (other) Right

Left

sustained

20°

15°

Foot thigh angle

10°

-5°

Confusion test (flexor synergy) Heel bisector

negative

positive

normal

4th toe

none

moderate

Plantar flexor clonus Tibial torsion

Gastroc/posterior tibialis spasticity

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Clinical Examination – knee (range of motion) Knee extension (hip 0 deg) Knee Extension (hip 90 deg) Flexion

Right 5°

Left 0°

-25°

-35°

full

Clinical Examination – knee (strength and other) Knee extension (hip 90 deg) Knee Flexion (hip 90 deg) Ely (spasticity 1-4/4) Hamstring Spasticity

Right 4/5

Left 4/5

4/5

3/5

0/4 none

1/4 mild

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Clinical Examination – hip (range of motion and strength) Right

Left

Hip extension

full

Hip flexion

full

Passive internal rotation

75°

90°

Passive external rotation

60°

45°

50°

55°

4/5

3/5

Femoral anteversion (palpation) Hip flexors Hip extensors (knee at 0°)

Gait Analysis • What does this add to our understanding of the causes of gait abnormalities? • Documents joint and segment function during motion – Provides dynamic ROM in 3 dimensions for LE joints and segments (pelvis, foot, etc.) – Allows examination of relationship of motion between joints and across planes of motions – Information about the forces that cause motion – Information about which muscles are causing motion – Etc………

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right Side Repeatability Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

25%

50%

75%

Gait Cycle

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Left Side Repeatability Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

50%

Gait Cycle

Pelvic Obliquity

Pelvic Tilt

75%

Gait Cycle

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

25%

50%

75%

Gait Cycle

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Stance Phase Stability? • Video: – Toe walking on left – Early heel rise on right – Bilateral plantar grade standing

• Why?

Kinematic Data What kinematics contribute to toe-walking?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Val

Ext

-30

-20

deg

25%

50%

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

50%

75%

Gait Cycle

Left Side Ankle – 3 gait cycles • Increased equinus in stance • Causes? (joint level impairments) – Plantar flexor spasticity – Plantar flexor tightness

Clinical Gait Analysis: A Focus on Interpretation

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Gait Cycle

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Right Side Ankle – 3 gait cycles • Increased equinus in mid-stance • Causes? – Voluntary ankle plantar flexion (compensation) – Vault • Normal ankle isolated movement • Normal ankle dorsiflexion at initial contact

Plantar-Dorsiflexion

40 Dor deg Pla

Ext

-40

25%

50%

75%

Gait Cycle

Right Side Kinetics Barefoot • Other evidence of vaulting pattern: – Ankle dorsiflexor moment in loading response – Power generation in terminal stance

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Left Side Kinetics Barefoot • Evidence of ankle pathology – No dorsiflexor moment in loading response – Minimal ankle power generation in terminal stance

Kinematic Data What other kinematics contribute to toewalking?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Val

Ext

-30

-20

deg

25%

50%

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

25%

50%

75%

Gait Cycle

Bilateral Knee • Increased knee flexion in mid stance NOT a contribution to toe walking

Knee Flexion-Extension

Flx

Ext -20

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Appropriate prepositioning at initial contact? • Video: – Toe initial contact on the left – Heel initial contact on right – Internal foot progression

• Why?

Kinematic Data What kinematics contribute to toe initial contact and internal foot rotation?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Val

Ext

-30

-20

deg

25%

50%

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

25%

50%

75%

Gait Cycle

Bilateral Knee and Ankle • Increased knee flexion at initial contact left • Causes? (joint level impairment) – Left hamstring spasticity

• Increased plantar flexion at initial contact left • Causes? (joint level impairment) – Left plantar flexor tightness and spasticity

Knee Flexion-Extension

Flx

Ext -20

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Val

Ext

-30

-20

deg

25%

50%

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

25%

50%

75%

Gait Cycle

Left Hip and Foot Progression • Increased internal hip rotation left • Cause? (joint level impairment) – Femoral anteversion

• Increased internal foot progression • Cause? – Internal hip rotation (secondary deviation)

Hip Rotation

40 Int

Ext -40

Knee Rotation

40 Int

Ext -40

Foot Progression

Int

Ext -40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Swing Phase Clearance? • Video: – Toe drag initial swing on the left – Normal clearance on the right

• Why?

Kinematic Data What kinematics contribute toe drag?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

Pre Operative Kinematics

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Barefoot

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Val

Ext

-30

-20

deg

25%

50%

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

50%

75%

Gait Cycle

Bilateral Knee and Ankle • Decreased knee flexion in swing left • Causes? (joint level impairment) – Left rectus femoris spasticity (Ely and response to rapid stretch) and activity in mid swing

• Increased plantar flexion in swing on left • Causes? (joint level impairment) – Left plantar flexor tightness and spasticity

Knee Flexion-Extension

Flx

Ext -20

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Left EMG

Bilateral PLS AFO’s – Benefits?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

Pre Operative Kinematics

deg

Hip Ab-Adduction

-40

Hip Flexion-Extension

Add

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Posterior Leaf Spring Orthosis

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla

Ext

-40

25%

50%

-40

75%

Gait Cycle

25%

50%

75%

Gait Cycle

Ankle 40

Plantar-Dorsiflexion

Dor

deg

Pla -40

Ext

25%

50%

75%

Plantar-Dorsiflexion

Pla -40

25%

50%

75%

Gait Cycle

Right vs. Left Barefoot

Right vs. Left AFO

IMPROVED LEFT ANKLE STANCE AND SWING RIGHT ANKLE STANCE AND SWING?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

20 Up

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

Pre Operative Kinematics

deg

Hip Ab-Adduction

20 Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Posterior Leaf Spring Orthosis

deg

Knee Varus-Valgus

30 Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

-40

75%

Gait Cycle

25%

50%

75%

Gait Cycle

Knee 80

Knee Flexion-Extension 80

Flx

Knee Flexion-Extension

Flx

Ext

-20

Ext -20

Right vs. Left Barefoot

Right vs. Left AFO

NO CHANGE

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

Pre Operative Kinematics

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Right vs. Left Posterior Leaf Spring Orthosis

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

40 Dor

Foot Progression

Int

deg Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

25%

50%

75%

Gait Cycle

Transverse Plane Hip Rotation

40 Int

Int

Ext

NO CHANGE

-40

Foot Progression

Ext -40

Int

Ext

-40

Hip Rotation

25%

50%

75%

Gait Cycle

Right vs. Left Barefoot

Clinical Gait Analysis: A Focus on Interpretation

-40

Foot Progression

25%

50%

75%

Gait Cycle

Right vs. Left AFO

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Benefits of PLS • Eliminates excessive equinus in swing • Still toe walks due to continued excessive knee flexion in loading response • Still has clearance problems related to continued decreased peak knee flexion in swing • Provides further basis for need to intervene surgically

Justification for Orthopaedic Surgical Treatment • Prerequisites of typical gait compromised in both barefoot and orthosis ambulation • Risk of injury due to falling • Current treatment no longer providing continued improvement • Orthopaedic intervention next step – procedures – indications – hypothesis

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

What would you do?

Why? What is your outcome goal?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Steps • Orthopedic Surgical Procedure • Joint Level Impairments – Clinical examination – EMG

• Indications – Kinematics (primary and secondary)

• Prerequisite(s) of Typical Gait Compromised

Surgical Decision-Making • Left gastrocnemius lengthening - indications – Plantar flexor spasticity – clinical examination – Excessive plantar flexion in swing – kinematics – Excessive plantar flexion in stance – kinematics

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Surgical Decision-Making • Left gastrocnemius lengthening - indications – Plantar flexor spasticity – clinical examination – Plantar flexor tightness – clinical examination – Excessive plantar flexion in swing – kinematics – Excessive plantar flexion in stance – kinematics

Plantar-Dorsiflexion

Dor deg Pla -40

25%

50%

75%

Ext

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Plantar-Dorsiflexion

Dor deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Left gastrocnemius lengthening Pre-requisites of typical gait – hypothesis/goal = IMPROVED • Clearance in swing • Pre-positioning at initial contact • Stance phase stability

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Surgical Decision-Making • Left femoral derotation osteotomy indications – Femoral anteversion – clinical assessment – Internal hip rotation – kinematics – Internal foot progression – kinematics

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Surgical Decision-Making • Left femoral derotation osteotomy - indications – Femoral anteversion – clinical assessment – Internal hip rotation – kinematics – Internal foot progression – kinematics Hip Rotation

Int

Ext -40

Foot Progression

Ext -40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Left femoral derotation osteotomy Pre-requisites of typical gait – hypothesis/goal = IMPROVED • Pre-positioning for initial contact • Clearance in swing (tripping on stance foot)

Surgical Decision-Making • Left hamstring lengthening - indications – Hamstring spasticity – clinical examination – Hamstring contracture – clinical examination • Minimal impact on treatment decision for patient

– Increased knee flexion at initial contact – kinematics – Increased knee flexion in stance – kinematics

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

– Increased knee flexion at initial contact – kinematics – Increased knee flexion in stance – kinematics

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

– Increased knee flexion at initial contact – kinematics – Increased knee flexion in stance – kinematics

Knee Flexion-Extension

80 Flx

* Ext

Ext

-20

– Increased knee flexion at initial contact – kinematics – Increased knee flexion in stance – kinematics

Knee Flexion-Extension

80 Flx

Ext

-20

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Left hamstring lengthening Pre-requisite of typical gait – hypothesis/goal = IMPROVED • Pre-positioning for initial contact • Stance phase stability – toe initial contact • Energy consumption

Surgical Decision-Making • Left rectus femoris transfer - indications – Rectus femoris spasticity – clinical examination – Decreased peak knee flexion at in swing – kinematics – Delayed peak knee flexion in swing – kinematics – Rectus femoris activity in swing – EMG data

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Knee Flexion-Extension

Flx

Ext

* Ext

-20

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Knee Flexion-Extension

Flx

Ext

-20

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Left rectus femoris procedure (transfer) Pre-requisite of typical gait – hypothesis/goal = IMPROVED • Clearance in swing

Phases of Care – Post Surgery • Acute Phase (2-3 days post) • Healing Phase (1 to 6 weeks) • Strengthening Phase (6 to 12 weeks) • Health and Fitness Phase (6 to 12+ months)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Next Step = Treatment Evaluation • Standard of Care • Repeat gait analysis procedures one year post treatment • Provides objective feedback • Where lots of learning takes place!

Pre-op Barefoot

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Post-op Barefoot

Post-op Close-up

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pre-requisites of Typical Gait What was the impact of surgery? • Stance phase stability • Swing phase clearance • Appropriate pre positioning of the foot at initial contact • Adequate step length • Energy conservation

Pre-requisites of Typical Gait What was the impact of surgery? • Stance phase stability – how? • Swing phase clearance – how? • Appropriate pre positioning of the foot at initial contact – how? • Adequate step length • Energy conservation – how?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotati on

Ant

Int

Pos

Ext

-20

-40

Pre vs. Post Operative Kinematics

deg

Hip Ab-Adduction

Add

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

-40

Left Barefoot (pre – dashed post – solid)

deg

Knee Varus-Valgus

Var

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

-20

-40

deg Val

-30

25%

50%

75%

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

40 Int

deg Pla

-40

Ext

25%

50%

75%

-40

25%

50%

Gait C ycle

Pelvic Obliqui ty

Pelvic Ti lt

75%

Gait C ycle

Pelvic Rotation

Ant

Int

Pos

Ext

-20

-40

Pre vs. Post Operative Kinematics

deg

Hip Ab-Adducti on

Add

Hip Flexion-Extensi on

Hip Rotation

Flx

Int

Abd

Ext

-20

-40

Right Barefoot (pre – dashed post – solid)

deg

Knee Varus-Valgus

Var

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

-20

-40

deg Val

-30

25%

50%

75%

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla

-40

Ext

25%

50%

75%

-40

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

25%

50%

75%

Gait Cycle

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Surgical “Hypotheses” Tested • Gastrocnemius lengthening – Improved dorsiflexion in stance AND swing

• Hamstring lengthening – Improved knee extension at initial contact

• Rectus femoris transfer – Increased peak knee flexion in swing

• Femoral derotation osteotomy – Improved hip rotation AND foot progression

• Post treatment evaluation leads to improvements in treatment outcomes

Voluntary Compensations? • Premature plantar flexion in stance eliminated on RIGHT side • Confirmed compensation to assist in clearance of opposite side • What was the impact of the right PLS?

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Clinical Examination (range of motion pre-post) Ankle dorsiflexion (knee at 0 deg)

Ankle dorsiflexion (knee at 90 deg)

Knee extension (hip at 90 deg)

Internal rotation External rotation Femoral anteversion Ely

Left Pre

Left Post

5°

15°

20°

-35°

-25°

90° 45° 55° 1

65° 70° 30° -

How did the motion analysis help? • Documented pre operative dynamic function which was had inconsistencies with clinical exam data • Clarified contribution of ankle joint to toe contact walking • Clarified impact of orthosis • Documented treatment outcomes for primary abnormalities (stance and swing changes) and secondary compensations

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

Benefits of this Approach • Comprehensive and objective patient assessment using motion analysis • Treating all gait related issues at one point in time – Single surgery and rehabilitation (time/cost) – Maximizing patient specific outcomes

• Ability to learn from experience and objective documentation of outcomes

Thank You

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

References •

• • •

• •

•

• •

•

Adolfsen Stephen, Õunpuu Sylvia, Bell Katharine and DeLuca Peter, Kinematic and Kinetic Outcomes After Identicle Multi-level Soft Tissue Surgery in Children with Cerebral Palsy, Journal of Pediatric Orthopaedics, 27(6):658-667, September 2007. DeLuca, P., S. Õunpuu, et al. (1998). "Effect of hamstring and psoas lengthening on pelvic tilt in patients with spastic diplegic cerebral palsy." J Ped Orthop 18: 712-718. Gage, J. R. and T. F. Novacheck (2001). "An update on the treatment of gait problems in cerebral palsy." J Pediatr Orthop B 10(4): 265-74. Goldberg, S, R., Õunpuu, S., Arnold, A. S., Gage, J., Delp, S.L., Kinematic and kinetic factors that correlate with improved knee flexion following treatment for stiff-knee gait, Journal of Biomechanics, 39:689-698, 2006 Lee, E. H., J. C. Goh, et al. (1992). "Value of gait analysis in the assessment of surgery in cerebral palsy." Arch Phys Med Rehabil 73(7): 642-6. McGinley, J. L. Dobson, F. Ganeshalingam, R. Shore, B. J. Rutz, E. Graham, H. K Single-event multilevel surgery for children with cerebral palsy: a systematic review Dev Med Child Neurol, 54(2) 117-28, 2011. Novacheck, T. F., J. P. Trost, et al. (2002). "Intramuscular psoas lengthening improves dynamic hip function in children with cerebral palsy." Journal of Pediatric Orthopaedics 22: 158-164.

Õunpuu, S., P. DeLuca, et al. (2002). "Long-term effects of femoral derotation osteotomies: an evaluation using three-dimensional gait analysis." Journal of Pediatric Orthopaedics 22: 139-145. Õunpuu, S., J. M. Keggi, et al. (1996). "A long-term follow-up of the effects of heel cord surgery on the ankle in persons with cerebral palsy." Gait and Posture 4(2): 184. Saraph, V., E. B. Zwick, et al. (2002). "Multilevel surgery in spastic diplegia: evaluation by physical examination and gait analysis in 25 children." J Pediatr Orthop 22(2): 150-7. Schwartz, M. H., E. Viehweger, et al. (2004). "Comprehensive treatment of ambulatory children with cerebral palsy: an outcome assessment." J Pediatr Orthop 24(1): 45-53. Stefko, R. M., R. J. de Swart, et al. (1998). "Kinematic and kinetic analysis of distal derotational osteotomy of the leg in children with cerebral palsy." J Pediatr Orthop 18(1): 81-7. Zwick, E. B., V. Saraph, et al. (2001). "[Single event multilevel surgery to improve gait in diplegic cerebral palsy - a prospective controlled trial]." Z Orthop Ihre Grenzgeb 139(6): 485-9. Aristides I. Cruz, Jr. Sylvia Õunpuu and Peter A. DeLuca, Rectus Femoris Intramuscular Lengthening for the Treatment of Stiff Knee Gait in Children with Cerebral Palsy, J Pediatric Orthopaedics, 2011, 31 (5), 541-547.

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Case #1 – Guided, Sylvia Ounpuu and Kristan Pierz

•

• • •

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Patikas D, Wolf SI, Armbrust P, et al. Effects of a postoperative resistive exercise program on the knee extension and flexion torque in children with cerebral palsy: a randomized clinical trial. Arch Phys Med Rehabil. 2006;87(9):1161-1169. Patikas D, Wolf SI, Mund K, et al. Effects of postoperative strength-training program on walking ability of children with cerebral palsy: a randomized controlled trial. Arch Phys Med Rehabil. 2006;87:619-626. Seniorou M, Thompson N, Harrington M, Theologis T. Recovery of muscle strength following multi-level orthopaedic surgery in diplegic cerebral palsy. Gait Posture. 2007;26(4):475-481. Damiano D. A systematic review of the effectiveness of treadmill training and body weight support in pediatric rehabilitation. JNPT. 2009;33:27-44. Dodd K. A systematic review of the effectiveness of strength-training programs for people with Cerebral Palsy. Arch Phys Med Rehabil. 2002;83(8):1157-1164. Mockford M, Caulton JM. Systematic review of progressive strength training in children and adolescents with Cerebral Palsy who are ambulatory. Pediatr Phys Ther. 2008;20(4):318-333. Mutlu A, Krosschell K, Spira D. Treadmill training with partial body-weight support in children with cerebral palsy: a systematic review. Dev Med Child Neurol. 2009;51:268-275.

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Connecticut Children's Medical Center Center for Motion Analysis 399 Farmington Ave │ Farmington, CT 06032 Phone: (860) 837-9201│Fax: (860) 837-9213

Place Patient Label Here

Gait Analysis Review Sheet Name:

MRN:

Primary Concern:

Date of Analysis:

Reviewing Physician/Clinician:

Review Date:

CMLA Review: Video/Clinical

Prepositioning for Initial Contact

Stability in Stance

Forward Progression

Swing Clearance

Changes Post op/Previous analysis:

Kinematic/Kinetics

EMG/Pedo

Braced

Recommendations

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #1 PRE-OPERATIVE GAIT ANALYSIS AGE AT PRE-OP: 5 + 8 years DX: Cerebral palsy, asymmetric spastic diplegia (left side primarily involved); GMFCS: Level I HISTORY:   

6 weeks premature, birth weight 4 pounds, 11 ounces Maternal toxemia, maternal fetal transfusion syndrome, fetal distress during delivery First began independent walking at 2 years

TREATMENT:    

No previous surgeries Left ankle casting at 1½ years and 4 years Wears bilateral ankle foot orthoses (posterior leaf spring design) after school only (3 hours per day) Night brace left side (will not tolerate)

PATIENT AND FAMILY CONCERNS:    

In-toeing on left side Instability with associated tripping and falling Limited endurance Occasional complaints of hip pain

FUNCTIONAL ABILITIES/PARTICIPATION:    

Independent community ambulator with or without braces for limited distances Uses a stroller for long-distances Can negotiate stairs, curbs, and in and out of chairs independently Has trouble keeping up with peers with limited endurance

GAIT BY OBSERVATION:       

Asymmetric involvement with the left side greater than the right Posturing of left upper extremity Left internal knee and foot progression Reduced sagittal plane motion of the left side Toe initial contact on the left and possible vault on the right side for clearance Poor clearance left foot initial swing Good static balance though reduced dynamic balance

Barefoot pre-op Page 1

Connecticut Children’s Medical Center Center for Motion Analysis CCMC, Gait Analysis Report Range of Motion and Strength

Pre-Operative

HIPS

Flexion Extension with knee @ 0 Extension with knee @ 90 Straight leg raise Abduction with hips @ 0 Abduction with hips @90 Adduction Internal rotation External rotation Femoral anteversion

Motion Right Left

Strength Right Left

F 0

4+ 3 3-

4+ 32+

80 35 60 F 75 60 50

70 25 40 F 90 45 55

KNEES:

Extension with hips @ 0 +5 0 Extension with hips @ 90 (unilateral) -25 -35 4+ 4 Hamstring tightness (-,M,L,B) B M>>L Flexion total F F 4 3+ Internal rotation (knee @ 90) not tested (1=minimal; 2=moderate;3=severe) External rotation (knee @ 90) not tested

ANKLES:

Dorsiflexion with knee @ 0 Dorsiflexion with knee @ 90 Plantar flexion

20 25 F

5 15 F

FOREFEET Inversion (F, L, 0) Eversion (F, L, 0)

F F

4+ 4

4+ 2+

HINDFEET

F F F F +10 -15 not tested +20 +15 not tested

Inversion (F, L, 0) Eversion (F, L, 0) Foot/thigh angle (+ ext, - int) Heel/thigh angle (+ ext, - int) Bi-malleolar axis (+ ext, - int) Heel bisector

REFLEXES: Ely test (-,1,2,3,4) 1 Gastroc-soleus clonus (1,2,3,C,-) + + Confusion test without resistance (-,M,P,S) M Confusion test with resistance (-,M,P,S) LEG LENGTHS (mm) 495 490 Abdominal strength 3LIGAMENTOUS LAXITY minimal knee rotation. B. fingers

M not tested

F=full motion; L=limited motion; U=unable to isolate; UA=unable to assess accurately; N=not fully isolated; W=within available range; - = none: M=midline; P=pronated; S=supinated; C=continuous

Barefoot pre-op Page 2

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Pre-Op)

Pelvic Obliquity

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Flx

Int

Abd

Ext

-20

Hip Rotation

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Flx

Int

Ext

Knee Rotation

deg Val -30

Time

-20

-40

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Left (10/2/1997)

Barefoot pre-op Page 3

Ext

Time

Right (10/2/1997)

-40

Time

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Pre-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Right (10/2/1997)

Barefoot pre-op Page 4

Right (10/2/1997)

25%

50% Gait Cycle

Right (10/2/1997)

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Left (10/2/1997)

Barefoot pre-op Page 5

Left (10/2/1997)

25%

50% Gait Cycle

Left (10/2/1997)

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Left (10/2/1997)

Barefoot pre-op Page 6

Right (10/2/1997)

-40

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Pre-Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Right (10/2/1997)

Barefoot pre-op Page 7

Right (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Pre-Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Left (10/2/1997)

Barefoot pre-op Page 8

Left (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Pre-Op) 30

Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Right (10/2/1997)

Barefoot pre-op Page 9

Right (10/2/1997)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Pre-Op) 30

Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Left (10/2/1997)

Barefoot pre-op Page 10

Left (10/2/1997)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Pre-Op) 40

Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Left (10/2/1997)

Barefoot pre-op Page 11

Right (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Pre-Op) 30

Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Left (10/2/1997)

Barefoot pre-op Page 12

Right (10/2/1997)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left Side EMG 5

Left Gastrocnemius

Left Gastrocnemius*

-5

% Gait Cycle

Left Anterior Tibialis

% Gait Cycle

Left Anterior Tibialis*

-5

% Gait Cycle

Left Hamstrings

% Gait Cycle

Left Hamstrings*

-5

Left Vastus Medialis

% Gait Cycle

Left Vastus Medialis*

-5

% Gait Cycle

Left Vastus Lateralis

% Gait Cycle

Left Vastus Lateralis*

-5

% Gait Cycle

Left Rectus Femoris

% Gait Cycle

Left Rectus Femoris*

-5

% Gait Cycle

Left Anterior Tibialis**

% Gait Cycle

Left Hamstrings**

-5

% Gait Cycle

Left Gastrocnemius**

% Gait Cycle

Left Vastus Medialis**

% Gait Cycle

Left Vastus Lateralis**

% Gait Cycle

Left Rectus Femoris**

% Gait Cycle

Right Side EMG 5

Right Gastrocnemius

Right Gastrocnemius*

-5

% Gait Cycle

Right Anterior Tibialis

% Gait Cycle

Right Anterior Tibialis*

-5

% Gait Cycle

Right Hamstrings

% Gait Cycle

Right Hamstrings*

-5

% Gait Cycle

Right Vastus Medialis

V -5

% Gait Cycle

Right Vastus Medialis*

V % Gait Cycle

Right Vastus Lateralis

-5

% Gait Cycle

Right Vastus Lateralis*

-5

Right Rectus Femoris

% Gait Cycle

Right Rectus Femoris*

-5

% Gait Cycle

Right Anterior Tibialis**

% Gait Cycle

Right Hamstrings**

% Gait Cycle

Right Vastus Medialis**

-5

% Gait Cycle

-5

% Gait Cycle

Right Gastrocnemius**

% Gait Cycle

Right Vastus Lateralis**

% Gait Cycle

Right Rectus Femoris**

BAREFOOT 1 - 10/2/97 Barefoot pre-op Page 13

% Gait Cycle

Connecticut Children’s Medical Center Center for Motion Analysis

Temporal/Stride BAREFOOT Pre-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

A49595M02.c3d 0.38 m 0.79 m 60.0 % 0.67 s 180 steps/min 1.18 m/s

A49595M02.c3d 0.42 m 0.85 m 57.1 % 0.70 s 171 steps/min 1.21 m/s

A49595M03.c3d 0.42 m 0.86 m 58.3 % 0.80 s 150 steps/min 1.07 m/s

A49595M02.c3d 0.43 m 0.82 m 50.0 % 0.67 s 180 steps/min 1.24 m/s

A49595M03.c3d 0.40 m 0.82 m 52.1 % 0.73 s 164 steps/min 1.07 m/s

A49595M04.c3d 0.33 m 0.66 m 57.3 % 0.77 s 157 steps/min 0.87 m/s

Barefoot pre-op Page 14

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Braces Pre-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Dor

Int

deg

Pla

Ext

-40

Left (10/2/1997)

Braces pre-op Page 15

Plantar-Dorsiflexion

Right (10/2/1997)

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Right (10/2/1997)

Braces pre-op Page 16

Right (10/2/1997)

25%

50% Gait Cycle

Right (10/2/1997)

75%

Connecticut Children’s Medical Center Center for Motion Analysis L side consistency kinematics (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Left (10/2/1997)

Braces pre-op Page 17

Left (10/2/1997)

25%

50% Gait Cycle

Left (10/2/1997)

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs Left representative trial (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Right (10/2/1997)

Braces pre-op Page 18

Left (10/2/1997)

-40

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Braces Pre-Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Right (10/2/1997)

Braces pre-op Page 19

Right (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Braces Pre-Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Left (10/2/1997)

Braces pre-op Page 20

Left (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Braces Pre-Op) 30

Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Right (10/2/1997)

Braces pre-op Page 21

Right (10/2/1997)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Braces Pre-Op) 30

Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Left (10/2/1997)

Braces pre-op Page 22

Left (10/2/1997)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Braces Pre-Op) 40

Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Left (10/2/1997)

Braces pre-op Page 23

Right (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Braces Pre-Op) 30

Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Left (10/2/1997)

Braces pre-op Page 24

Right (10/2/1997)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis

Temporal/Stride B PLS Pre-op Right Side Step Length Stride Length Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Cycle Time Cadence Walking Speed

A49595M06.c3d 0.42 m 0.80 m 0.87 s 138 steps/min 0.92 m/s

A49595M07.c3d 0.55 m 0.94 m 0.83 s 144 steps/min 1.13 m/s

A49595M08.c3d 0.39 m 0.76 m 0.83 s 144 steps/min 0.91 m/s

A49595M06.c3d A49595M07.c3d 0.38 m 0.39 m 0.81 m 0.94 m 0.87 s 0.83 s 138 steps/min 144 steps/min 0.94 m/s 1.13 m/s

A49595M08.c3d 0.39 m 0.78 m 0.80 s 150 steps/min 0.98 m/s

Braces pre-op Page 25

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #1 POST-OPERATIVE GAIT ANALYSIS AGE AT POST-OP: 7 + 1 years DX: Cerebral palsy, asymmetric spastic diplegia (left> right)

GMFCS: Level I

TREATMENT:    

Surgery at 6 + 0 years old: Left femoral derotational osteotomy, left hamstring lengthening, left rectus femoris transfer, left gastrocnemius lengthening No longer wears ankle foot orthoses in day Uses night braces (ankle-foot) Receives physical therapy once per week

PATIENT AND FAMILY CONCERNS: 

Weakness, fatigue and reduced balance

FUNCTIONAL ABILITIES/PARTICIPATION:     

Independent community ambulator without braces for limited distances Uses stroller occasionally for long distances Can negotiate stairs, curbs, in and out of chairs independently Improved ability to keep up with peers Parents report she is more functional now, falling less, running faster and is safer on stairs

GAIT BY OBSERVATION:   

Independent ambulator without orthoses or assistive devices Mild external rotation of the left trunk and pelvis Limited second rocker due to remaining gastrocnemius tightness

Barefoot post-op Page 26

Connecticut Children’s Medical Center Center for Motion Analysis CCMC, Gait Analysis Report Range of Motion and Strength

Post Operative

HIPS

KNEES:

Flexion Extension with knee @ 0 Extension with knee @ 90 Straight leg raise Abduction with hips @ 0 Abduction with hips @90 Adduction Internal rotation External rotation Femoral anteversion

Motion Right Left

Strength Right Left

F F

5 3+ 3

4 3U

85 35 60 F 80 55 45

85 30 50 F 65 70 30

External rotation (knee @ 90)

0 -25 5 5 L>M F 5 3+ 1 (1=minimal; 2=moderate;3=severe) -

Dorsiflexion with knee @ 0 Dorsiflexion with knee @ 90 Plantar flexion

10 25 F

5 20 F

FOREFEET Inversion (F, L, 0) Eversion (F, L, 0)

F F

F L

5 5

5 3-

HINDFEET

F F F F +10 +10 not tested +20 +20 not tested

ANKLES:

Extension with hips @ 0 +5 Extension with hips @ 90 (unilateral) -30 Hamstring tightness (-,M,L,B) M>L Flexion total F Internal rotation (knee @ 90) 2

Inversion (F, L, 0) Eversion (F, L, 0) Foot/thigh angle (+ ext, - int) Heel/thigh angle (+ ext, - int) Bi-malleolar axis (+ ext, - int) Heel bisector

REFLEXES: Ely test (-,1,2,3,4) Gastroc-soleus clonus (1,2,3,C,-) 3 Confusion test without resistance (-,M,P,S) Confusion test with resistance (-,M,P,S) LEG LENGTHS (mm) 540 Abdominal strength 3 LIGAMENTOUS LAXITY NONE

C 540

+ +

F=full motion; L=limited motion; U=unable to isolate; UA=unable to assess accurately; N=not fully isolated; W=within available range; - = none: M=midline; P=pronated; S=supinated; C=continuous

Barefoot post-op Page 27

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Post-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Dor

Int

deg

Pla

Ext

-40

Left (1/21/1999)

Barefoot post-op Page 28

Plantar-Dorsiflexion

Right (1/21/1999)

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Right (1/21/1999)

Barefoot post-op Page 29

Right (1/21/1999)

25%

50% Gait Cycle

Right (1/21/1999)

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Post-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

Left (1/21/1999)

Barefoot post-op Page 30

Left (1/21/1999)

25%

50% Gait Cycle

Left (1/21/1999)

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Post-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Left (1/21/1999)

Barefoot post-op Page 31

Right (1/21/1999)

-40

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Post-Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Right (1/21/1999)

Barefoot post-op Page 32

Right (1/21/1999)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Post-Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Left (1/21/1999)

Barefoot post-op Page 33

Left (1/21/1999)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Post-Op) 30

Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Right (1/21/1999)

Barefoot post-op Page 34

Right (1/21/1999)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Post-Op) 30

Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Left (1/21/1999)

Barefoot post-op Page 35

Left (1/21/1999)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Post-Op) 40

Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Left (1/21/1999)

Barefoot post-op Page 36

Right (1/21/1999)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Post-Op) 30

Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

2.0

Hip Moment

2.0

Knee Moment

2.0

Abd

Val

Var

Nm/kg

Add

Var

Val

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Left (1/21/1999)

Barefoot post-op Page 37

Right (1/21/1999)

Ankle Var/Val

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis

Temporal/Stride BAREFOOT Post-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

A49595M24.c3d 0.41 m 0.89 m 57.1 % 0.70 s 171 steps/min 1.28 m/s

A49595M25.c3d 0.36 m 0.81 m 59.6 % 0.78 s 153 steps/min 1.03 m/s

A49595M26.c3d 0.39 m 0.79 m 57.9 % 0.63 s 189 steps/min 1.24 m/s

A49595M21.c3d 0.39 m 0.76 m 59.2 % 0.82 s 147 steps/min 0.93 m/s

A49595M22.c3d 0.36 m 0.71 m 59.6 % 0.78 s 153 steps/min 0.90 m/s

A49595M23.c3d 0.46 m 0.83 m 57.1 % 0.70 s 171 steps/min 1.18 m/s

Barefoot post-op Page 38

Connecticut Children’s Medical Center Center for Motion Analysis

Post operative comparison to Pre operative

Connecticut Children’s Medical Center Center for Motion Analysis Right side comparison (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Right (1/21/1999)

Barefoot (kinematics) Page 39

Right (10/2/1997)

-40

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side comparison (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Left (1/21/1999)

Barefoot (kinematics) Page 40

Left (10/2/1997)

-40

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Post Op vs Pre Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Right (1/21/1999)

Barefoot (sagittal kinetics) Page 41

Right (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Post Op vs Pre Op) 40

Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Left (1/21/1999)

Barefoot (sagittal kinetics) Page 42

Left (10/2/1997)

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Sagittal Plane Typical Deviations and Possible Causes Kristan Pierz, MD Center for Motion Analysis Division of Orthopaedics Connecticut Children’s Medical Center Farmington, Connecticut, USA

Problem Possible Causes Lectures • Develop a SYSTEMATIC process of interpreting gait data – Individual joint/segment level – Within a plane of motion – Across planes of motion

• Help us to determine relationships between what we see and what is actually happening to joint/segments (plotted data) during gait • Determine possible primary causes (joint level impairments) and ultimately secondary causes of atypical gait

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 1

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Process 1) Review angle definition 2) Observe video of patient with focus on specific gait deviation (kinematics) 3) Discuss possible causes (joint level impairments) while observing video 4) Review kinematic plot for specific gait deviation

Sagittal Plane 30

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Hip Ab-Adduction

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Add deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

-40

25%

50%

75%

Gait Cycle

Connecticut 2025

Page 2

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Upper Body - Trunk • Angle definition:

Bi-clavicular Line

Lab Coordinates Pelvis PSIS

ASIS

Sagittal View

– the anterior or posterior inclination of the upper body measured relative to the global (lab) coordinate system – as viewed by an observer looking along a line connecting the right and left clavicle markers

Upper Body: Increased Tilt

Insert video – D829 – 4 Samuel L. 110166

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 3

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Upper Body: Increased Tilt • Primary Causes Trunk Obliquity –30Assist in forward progression Up – Position required degwith ambulatory Dn aids*

• Secondary Causes -30

Trunk Tilt

Ant

Trunk Rotatio

Int

Pos

Ext A10166

-20

-40

– Anterior pelvic tilt 20

Pelvic Obliquity

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotatio

deg

-40

Hip Flexion-Extension Pelvis 60

Hip Ab-Adduction

Add

Flx

Int

Abd(typically anterior) of

Ext

-20the pelvic plane

-20

• Angle Definition

Hip Rotation

deg – the inclination -40

measured relative to theKnee global (lab) Varus-Valgus Knee Flexion-Extension 30coordinate system 80 40 Var Flx Int – as viewed by an degobserver looking along a line connecting the Val Ext Ext ASIS's -30

25%

50% Gait Cycle

75%

-20

Clinical Gait Analysis: A Focus on Interpretation Dor

Knee Rotatio

-40

Plantar-Dorsiflexion

Connecticut 2025

40 Int

Foot Progressi Page 4

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Pelvis: Anterior Tilt

Insert video – D824-4 # 345926

Trunk Obliquity

Up deg

Trunk Tilt

40 Ant

Trunk Rotati

Int

Pelvis: Anterior Tilt

Dn **correlated with relaxedPosstanding position** -30

-20

• Primary Causes – Hip extensor and Pelvic Obliquity 20 abdominal weakness* Up – Hip flexor contracture – Hip flexor spasticity deg

• Secondary Causes Dn

– Distal deformity -20 – Excessive plantar flexion knee extension couple Hip Ab-Adduction

Ext -40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Add

C45926

Hip Flexion-Extension

Flx

Pelvic Rotat

-40

Hip Rotatio

Int

deg Abd

Ext

-20

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Ext Page 5

-40

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Pelvis: Posterior Tilt

188387

Pelvis: Posterior Tilt • Primary Causes – Hip extensor tightness – Severe medial and lateral hamstring tightness*

• Secondary Causes – Spinal deformity – Age – post adolescent growth spurt – Male>female

Clinical Gait Analysis: A Focus on Interpretation

A88387

Connecticut 2025

Page 6

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Pelvis: Single Bump Pattern

Insert video D816-5 # 341657

Trunk Obliquity

Trunk Tilt

Ant

Trunk Rotatio

Int

Pelvis: Single Bump Pattern

deg Dn

Pos

-30 • Primary Causes

– Reduced dissociation Pelvic Obliquity between pelvis and femur 20 (involved side) Up • Hip flexor spasticity/

Ext

-20

-40

Pelvic Tilt

Ant

Int

contracture

Pos

Ext

• Secondary Causes -20

-20

Pelvic Rotatio

contracture

deg• Hip extensor spasticity/ Dn

– Distal deformity – Excessive plantar flexion Hip Ab-Adduction 20 knee extension couple

Add

C41657

Hip Flexion-Extension

-40

Flx

Int

Ext

Hip Rotation

deg Abd

Clinical Gait Analysis: -20A Focus on Interpretation-20

Connecticut 2025

-40 Page 7

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Pelvis: Double Bump Pattern

Insert video D815-9 #223804

deg

T runk Obliquity

• Primary Causes

deg

T runk T ilt

T runk Ro

Pelvis: Double Bump Pattern

-30 20

– Reduced disassociation Pelvic Obliquity between pelvis and femur, bilaterally*

-20 40

-40

Pelvic T ilt

Pelvic R

• Hip flexor and hamstring spasticity/contracture

• Secondary Causes -20 20

– excessive plantar flexion knee extension couple, bilaterally Hip Ab-Adduction

-20 60

B23804 Hip Flexion-Extension

-40 40

Hip Rot

deg

-20 Clinical Gait Analysis: A Focus on Interpretation -20 30

Knee Varus-Valgus

Connecticut 2025 Knee Flexion-Extension

-40 Page 8 40

Knee Ro

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Hip • Angle Definition – the relative angle between the long axis of the thigh and a perpendicular to the pelvic plane – as viewed by an observer looking along a line connecting the ASIS's

Hip: Delayed/Decreased Extension in Stance

Insert video D

343222 Weza Tito

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 9

-30

-20

Sagittal Plane Problems/Possible Causes – Kristan Pierz 20

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Pelvic Rotatio

Int

deg

Hip:DnDelayed/DecreasedPos Extension in Stance Ext -20 • Primary Causes – Hip extensor Hip Ab-Adduction weakness* 20 –Add Hip flexor tightness/spasticity deg • Secondary Causes Abd – Anterior pelvic tilt –-20 Excessive knee flexion* Knee Varus-Valgus – Ankle plantar flexor 30 weakness Var

-20

-40

Hip Flexion-Extension

Flx

Hip Rotation

Int

Ext

Ext C43222

-20

-40 Knee Flexion-Extension

Flx

Int

Ext

Knee Rotatio

deg Val -30

25%

50% Gait Cycle

75%

-20

-40

Plantar-Dorsiflexion

Hip: Flexion Bias 100% GC Dor

Foot Progressi

Int

deg Pla -40

Ext 25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

343222 Left146612 (12/19/2002) 343222 3 Right (12/19/2002) Insert3video

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 10

-30

-20

-40

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Pelvic Obliquity

Up deg Dn

Pelvic Tilt

Ant

Var

-20

Ext -40

Hip Flexion-Extension

Flx

Hip Rotatio

Int

Ext

Ext A46612

-20

Pelvic Rotat

Int

Hip: Flexion Bias 100% GC Pos

•-20Primary Causes – Hip flexion Hip Ab-Adduction 20 contracture – Hip extensor Add weakness* deg • Secondary Causes Abd – Increased anterior pelvic tilt* -20 – Forward trunk – Excessive knee Knee Varus-Valgus 30 flexion

-40

Knee Flexion-Extension

Flx

Int

Ext

Knee Rotat

deg Val -30

25%

50% Gait Cycle

75%

-20

-40

Hip: Increased Flexion in Swing (1) 40

Plantar-Dorsiflexion

Dor

Foot Progres

Int

deg Pla Insert video-40 165798

Ext 25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

146612 32 Left (9/25/2002) 146612 32 Right (9/25/2002)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 11

Pos

Ext

-30 -20 Sagittal Plane Problems/Possible Causes – Kristan Pierz 20

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Pelvic Rotatio

Int

deg Increased Flexion in Swing (1) Hip: Dn

Pos

– Flexor synergy for forward progression* Hip Ab-Adduction

-20

– Single bump pelvic tilt Add

Flx

Int

– Voluntary compensation to aid in clearance Abd – Anterior pelvic tilt

Ext

-20

• Primary Causes

20 • Secondary Causes

Ext -40

Hip Flexion-Extension

Hip Rotation

deg

Knee Varus-Valgus

Var

A65798

-40

Knee Flexion-Extension

Flx

Int

Ext

Knee Rotatio

deg Val -30

25%

50% Gait Cycle

-20

75%

-40

Hip: Increased Flexion in Swing (2) Plantar-Dorsiflexion 40 Dor

Foot Progressi

Int

deg Pla -40 121910

Ext 25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

165798 44 Left (11/13/2002) 165798 44 Right (11/13/2002)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 12

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Hip: Increased Flexion in Swing (2)

• Primary Causes – Flexor synergy

• Secondary Causes – Compensation for excessive equinus in swing (solid line)* – Simultaneous increased anterior pelvic tilt (dashed line)*

A21910

Hip: Reduced Range of Motion

Inset video 110166

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 13

Pos

Ext

-30 Sagittal Plane Problems/Possible Causes – Kristan-20 Pierz

Pelvic Obliquity

-40

Pelvic Tilt

Ant

deg

Hip: Reduced Range of Motion

Pos

-20 – Reduced disassociation between pelvis and femur, Hip Ab-Adduction 20 bilaterally

-20

• Primary Causes

Add

• Hip flexor and hamstring spasticity/contracture

Ext

• Secondary Causes

-20 – Crouch* – Reduced step lengths

-20

Knee Varus-Valgus

Var

Pelvic Rotati

Int

Ext -40

Hip Flexion-Extension

Flx

deg – Lower extremity Abd weakness*

Hip Rotatio

Int

A10166

Ext -40

Knee Flexion-Extension

Flx

Int

Ext

Knee Rotati

deg Val -30

25%

50% Gait Cycle

75%

• Angle Definition

-20

-40

Knee 40

Plantar-Dorsiflexion

Dor

Foot Progress

Int

– the relative angle deg between the long Ext axis of the thigh and Pla shank segments -40 -40 25% 50% 75% 25% 50% 7 Gait Cycle Gait Cycle – as viewed by an observer110166 looking42 Left (3/11/2003) 110166 42 Right (3/11/2003) along the knee flexion/extension axis

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 14

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Knee: Increased Flexion at Initial Contact

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Hip Ab-Adduction

-40

Hip Flexion-Extension

Hip Rotation

Knee:AddIncreased FlexionFlxat Initial Contact Int deg

• Primary Abd Causes – Spasticity or contracture -20 of the hamstrings* – Knee flexion contracture Knee Varus-Valgus 30 – Poor quadriceps control Var • Secondary Causes

– Excessive equinus at deg initial contact Val – Poor motor control -30length 25% 50% 75% – Leg discrepancy Cycle (contralateral Gait limb short)

Ext

-20

-40 Knee Flexion-Extension

Flx

Int

Ext

-20

C04010

Plantar-Dorsiflexion

Dor

Knee Rotation

-40

Foot Progressio

Int

deg Pla

Clinical Gait Analysis: A Focus on Interpretation

Ext

-40 Connecticut 25% 50% 2025 75% Gait Cycle

-40 Page 15 25%

50% Gait Cycle

75%

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Knee: Increased Flexion in Stance

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg 307435

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Hip Ab-Adduction

-40

Hip Flexion-Extension

Knee: in Stance Add Increased Flexion Flx

Hip Rotation

Int

deg

• Primary Abd Causes – Hamstring -20 contracture/spasticity* – Hip extensor Knee Varus-Valgus 30 weakness* – Var Co-spasticity of the quadriceps and deg hamstrings* Val • Secondary Causes -30 25% plantar 50% 75% – Excessive flexor Gait Cycle weakness* and/or length*

Ext

-20

-40 Knee Flexion-Extension

Flx

Int

Ext

-20

C07435

Plantar-Dorsiflexion

Dor

Knee Rotation

-40

Foot Progressio

Int

deg Pla

Clinical Gait Analysis: A Focus on Interpretation

Ext

-40 Connecticut 25% 50% 2025 75% Gait Cycle

-40 Page 16 25%

50% Gait Cycle

75%

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Knee: Hyper-extension in Stance

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

deg

Trunk Rotation

281586

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Hip Ab-Adduction

-40

Hip Flexion-Extension

Add Flx Knee: Hyper-extension in Stance

Hip Rotation

Int

deg

• Primary Abd Causes – Excessive ankle plantar -20 flexion Knee Varus-Valgus (spasticity/tightness) 30 – Poor quadriceps Var control/weakness deg – Passive knee Val hyperextension ROM -30 25% 50% 75% • Secondary Causes Gait Cycle – Forward trunk/pelvic lean

Ext

-20

-40 Knee Flexion-Extension

Flx

Int

Ext

-20

B81586

Plantar-Dorsiflexion

Dor

Knee Rotation

-40

Foot Progressio

Int

deg Pla

Clinical Gait Analysis: A Focus on Interpretation

Ext

-40 Connecticut 25% 50% 2025 75% Gait Cycle

-40 Page 17 25%

50% Gait Cycle

75%

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Knee: Reduced Flexion in Swing

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

Trunk Rotation

deg Dn

325783

-30

-20

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Flx

Int

Ext

Knee: Reduced Flexion in Swing deg • Primary Abd Causes – Rectus femoris activity in -20 swing phase* – Increased “stiffness” Knee Varus-Valgus associated with age 30

• Secondary Causes Var – Hipdeg flexor weakness – Ankle plantar flexor Val weakness* – Excessive knee 50% flexion75%in -30 25% Gait Cycle stance – Rotational abnormalities – Leg length discrepancy (opposite limb long)

-20

-40 Knee Flexion-Extension

Flx

Int

Ext

-20

Hip Rotation

C25783

Plantar-Dorsiflexion

Dor

Knee Rotation

-40

Foot Progressio

Int

deg Pla

Ext

Clinical Gait Analysis: A Focus on Interpretation -40 Connecticut 25% 50% 2025 75% Gait Cycle

-40 Page25% 18

50% Gait Cycle

75%

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Trunk Obliquity

Trunk Tilt

Knee: Delayed Peak Ant Flexion in Swing

Int

Pos

Ext

-30

-20

Trunk Rota

deg

Pelvic Obliquity 165798

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rota

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Flx

Int

Knee: Delayed Peak Ext Flexion in Swing

Ext

Hip Rotat

deg Abd -20

• Primary Causes

-20

-40

– Flexor synergy for Knee Varus-Valgus Knee Flexion-Extension 80 forward progression* Var Flx – Rectus femoris deg spasticity

Int

Val

Ext

• Secondary Causes

-30

25% 50% 75% – Lower extremity Gait Cycle weakness

Ext -20

A65798

Knee Rota

-40

Plantar-Dorsiflexion

Dor

Foot Progre

Int

deg Pla Clinical Gait Analysis: A Focus on Interpretation -40

Connecticut 2025 25%

50%

75%

Ext Page 19 -40

25%

50%

Sagittal Plane Problems/Possible Causes – Kristan Pierz

Ankle • Angle Definition – the relative angle between perpendicular to the long axis of the shank and the plantar aspect of the foot – as viewed by an observer looking along an axis perpendicular to the shank-foot plane

Ankle: Increased Dorsiflexion in Stance

265198

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 20

Knee Varus-Valgus

Knee Flexion-Extension

Sagittal Plane 30 Problems/Possible Causes – Kristan 80 Pierz

Var

Flx

Knee Rota

Int

deg Val -30

Ankle: Increased Ext Dorsiflexion Stance Ext 25% 50%Causes 75% • Primary Gait Cycle

– Ankle plantar flexor weakness* – Excessive ankle plantar flexor length*

-20

-40

Plantar-Dorsiflexion

Dor

Foot Progre

Int

deg Pla

Ext B65198

-40

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

265198 11 Left (3/4/2003) 265198 11 Right (3/4/2003)

Ankle: Premature Plantar Flexion Stance

304007

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 21

-20 -20 Sagittal Plane Problems/Possible Causes – Kristan Pierz Knee Varus-Valgus Knee Flexion-Extension 30 80 Var

-40

Flx

Knee Rotati

Int

deg Ankle: Premature Plantar Flexion in Stance Val -30

Ext 25%

50%

Ext

-20

75%

Gait Cycle • Primary Causes

– Spasticity of the ankle plantar flexors* – Voluntary vault on non-involved side

-40

Plantar-Dorsiflexion

40 Dor

Foot Progress

Int

deg Pla

Ext C04007

• Secondary Causes

-40

25%

50% Gait Cycle

-40

75%

25%

– Rapid knee extension 304007 4 Left (2/4/2003) 304007 4 Right (2/4/2003)

Trunk Obliquity

30 Up

Dn deg Up -30

Pos

Dn deg Up

Pelvic Obliquity deg

Trunk Tilt

Pelvic Dn Obliquity

Ant

-40Ext

Pelvic Tilt Ant -20Pos

Ant

-30

Ant

Pelvic Tilt

-40

Pelvic Tilt Pos

Ext

-20

-40

Pelvic Rotation

Int

Trunk Rotation

Trunk Rotation Pos

Pelvic Int Ext Rotation

-30 40

-20

40 Int

Int

deg -40Ext 40

-20Pos

Trunk Tilt

Trunk Rotation

Int

UpExt

Ant

-30

Int

Trunk Tilt

-20 Trunk Obliquity

Pelvic Up Dn Obliquity

Trunk Rotation

Trunk Rotation Trunk Obliquity

Ant

Pos

-30 Dn deg 20 Up

Trunk Obliquity

Trunk Rotation 40

Int

Trunk Tilt

Ant

Trunk Tilt

Ant

Trunk Obliquity

Trunk Tilt

Trunk Obliquity

deg Up

-40

Pelvic Pelvic Obliquity Ext Rotation

Pelvic Tilt

Pelvic Rotation

Ankle: Increased Plantar Flexion Toe Off deg Up

Dn deg Up

-20 Dn deg

-20 Dn deg 20

Pelvic Obliquity -30

Pos

Hip Ab-Adduction deg -20

Ant

Hip Ab-Adduction -20

Ext

Ant

Pos

Hip Rotation Int -40Ext

-20

Pelvic Rotation

Ext -40

Hip Rotation

-40

Int

Hip Flexion-Extension Hip Hip Ab-Adduction Pos Ext RotationHip Flexion-Extension 20

Int

Hip Flexion-Extension -20

Int

-40Ext

-20 40

-20

Flx

-40

Pelvic Tilt

Hip Flexion-Extension 60

Pelvic Rotation

deg -40Ext

-20

Flx

Int

UpExt

Hip Flexion-Extension Ant Pos 60

Flx

Hip Ab-Adduction Dn

Abd degAdd 20 Add -20Abd deg -20Abd deg

-20

-20Pos 60

Int

Pelvic Tilt

Ant

Pos

-20

degAdd 20

-20 Pelvic Obliquity

Hip Ab-Adduction Up Dn

Add 20

Hip Rotation

-40

Int

AddExt

Flx

deg -40Ext Hip Flexion-Extension Hip Rotation 60 40 Abd Ext Ext -20Ext -40Ext Knee Flexion-Extension Knee Rotation Flx Int -20Ext -40Ext -20 40 -20 -40 Knee Varus-Valgus Knee Flexion-Extension Knee Rotation deg -20 -20 -40 Var 30 Flx 80 Int 40 KneeAbd Varus-Valgus Knee Flexion-Extension Knee Knee Varus-Valgus Knee Flexion-Extension Ext Ext Rotation 30 80 40 Flx 80 Int 40 degVar 30 Knee Varus-Valgus Knee Flexion-Extension Knee Rotation -20 -20 -40 Flx Flx 80 Int 40 VarExt Int Val degVar 30 Ext 30

Ext

-20 Hip Ab-Adduction

KneeAbd Varus-Valgus Add -20

223799

Var Flx Ext -30Val deg 25% 50% 75% Knee -20 Varus-Valgus Gait Cycle 30 -30Val deg -20Ext 25%

-30Val -30

50% 75% Gait Cycle Var -20Ext 25% 50% 75% 40 Gait Cycle deg -20 25% 50% Dor 75% 40 Gait Cycle

Int deg -40Ext Knee Flexion-Extension Val -40Ext

Plantar-Dorsiflexion Flx

-30

degDor

Int

Plantar-Dorsiflexion Ext

25% Pla 50% 75% 40 degDor Gait Cycle

Foot Progression Int

-30 40 25% -40Ext 50%

Plantar-Dorsiflexion

Val

Hip Rotation

Int

Plantar-Dorsiflexion -20

Ext

75%

25%

50%

Foot Progression -40

Int

-40Ext

223799 -40 6 Right (9/9/2002)

-40

223799 6 Right Pla (9/9/2002) 223799 -40 6 Right (9/9/2002) 25%

50% Gait Cycle

-40

Foot ExtProgressionPlantar-Dorsiflexion

25%

50% 75% Gait Cycle deg 25% 50% 75% Gait Cycle

Ext

-20

-40

75%

25%

Knee Rotation Ext

Foot Progression

Gait Cycle

Dor Int -40Pla deg -40Ext 25% 25% 50% 75% Plantar-Dorsiflexion 50% 75% Gait Cycle 40 Gait Cycle 40 -40Pla deg -40Ext Cycle Dor 223799 -40 6 Right (9/9/2002) Pla Gait

Knee Rotation

Dor

-40

75%

Foot Progression

deg

Foot Progression Pla

50% 75% GaitInt Cycle 25% 50% -40 75% 25% Gait Cycle 25% 50% 75% Gait Cycle

Ext

40 Int

Ext 50% Gait Cycle

75%

-40

25%

50% Gait Cycle

75%

223799 6 Right (9/9/2002) 25%

50% Gait Cycle

75%

223799 6 Right (9/9/2002)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 22

50% Gait Cycle

Abd

Ext

-20 -20 Sagittal Plane Problems/Possible Causes – Kristan Pierz 30

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Flx

Knee Rotati

Int

Ankle: Increased Plantar Flexion Toe Off deg Val

• Primary Causes -30 25% 50% 75% – Increased Gaitlower Cycle extremity weakness* – Foot drag at toe off* – Plantar flexor contracture and/or spasticity*

Ext

-20

-40

Plantar-Dorsiflexion

Dor

Foot Progress

Int

deg Pla

Ext B23799

-40

25%

50% Gait Cycle

75%

-40

25%

223799 6 Right (9/9/2002)

Ankle: Increased Dorsiflexion in Swing

307435

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 23

50% Gait Cycle

Knee Varus-Valgus

Knee Flexion-Extension

Sagittal Plane30 Problems/Possible Causes – Kristan 80Pierz

Var

Flx

Knee Rota

Int

deg Val

Ext Ankle: Increased Dorsiflexion Swing Ext

-30

25%

50% Gait Cycle

75%

• Primary Causes – Excessive dorsiflexion in stance* – Anterior tibialis contracture * – Flexor synergy

-20

-40

Plantar-Dorsiflexion

Dor

Foot Progre

Int

deg Pla -40

Ext 25%

50%

C07435 Gait Cycle

75%

-40

25%

307435 28 Left (6/25/2002)

Ankle: Increased Plantar Flexion Swing

344951

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 24

50% Gait Cycle

-20

-40

Sagittal Plane Problems/Possible Causes – Kristan Pierz Knee Varus-Valgus Knee Flexion-Extension 30 80

Var

Flx

Knee Rotatio

Int

deg Ankle: Increased Plantar Flexion Swing Val

Ext

•-30Primary Causes 25% 50% 75%

Ext

-20

-40

Gait Cycle

– Anterior tibialis weakness* – Plantar flexor contracture – Plantar flexor spasticity

Plantar-Dorsiflexion

Dor

Foot Progress

Int

deg

• Secondary Causes

Pla -40

Ext 25%

C44951 50%

75%

– Foot drag at toe off Gait Cycle (due to lower 344951 2 Right (1/13/2003) extremity weakness)

-40

25%

Ankle: Increased Plantar Flexion 100% GC

D21516

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 25

50% Gait Cycle

-20

Knee Varus-Valgus

-40

Knee Flexion-Extension

80 Sagittal30 Plane Problems/Possible Causes – Kristan Pierz

Knee Rot

deg

Ankle: Increased Plantar Flexion 100% GC -30

25%

50% Gait Cycle

-20

75%

• Primary Causes – Plantar flexor contracture – Plantar flexor spasticity*

-40

Plantar-Dorsiflexion

Foot Progr

deg

-40

25%

50% D21516 Gait Cycle

-40

75%

421516 6 Left (4/19/2006) 421516 6 Right (4/19/2006)

Thank You

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Page 26

25%

50% Gait Cyc

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Problem Possible Causes Lectures • Develop a SYSTEMATIC process of interpreting gait data

Coronal and Transverse Planes: Common Gait Features and Interpretation Jean Stout, PT, MS, PhD Sylvia Ounpuu, MSc Center for Motion Analysis Division of Orthopaedics Connecticut Children's Medical Center Farmington, Connecticut USA

– Individual joint/segment level – Within a plane of motion – Across planes of motion

Sagittal Plane 30

Trunk Obliquity

Trunk Tilt

Trunk Rotation

Coronal Plane

Coronal Plane Motion

Int

Ant

deg Dn

Pos

-30

20 Up

Angle definition

Ext

-20

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

deg Dn -20

-20

Hip Ab-Adduction

Add

Upper Trunk

-40

Hip Flexion-Extension

- The lateral (side to side) inclination of the long axis of the torso in relation to the lab coordinate system - As viewed from the front of the subject, perpendicular to the plane formed by the long axis of the torso and the biclavicular line

Pelvic Rotation

Hip Rotation

40 Int

Flx

deg Abd

Ext

-20

30 Var

Bi-clavicular line

Ext

-20

Knee Varus-Valgus

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Pelvis

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

ASIS

Lab Coordinates

Pla -40

ASIS

Foot Progression

Int

deg Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis Course: A Focus on Interpretation

Connecticut 2025

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Upper Body: Increased Excursion

Trunk: Increased Excursion • Primary Causes – Hip abductor weakness* – Used to assist with lateral weight transfer onto the stance limb

• Secondary Causes – Motion required with assistive devices (crutches)

Upper Body: Fixed Lateral Lean

30 Up deg Dn -30

– Scoliosis* – Lateral trunk musculature tightness

• Secondary Causes – Asymmetrical arm flexion when using a walker – Leg length discrepancy

Angle Definition - The angle of inclination of the right and left anterior superior iliac spine (ASIS) in relation to the horizontal

C46593-3

Trunk: Fixed Lateral Lean • Primary Causes

Pelvis – up/down

Trunk Obliquity

Up deg Dn -30

A66657-20

Pelvis: Fixed Obliquity

Pelvis Angle - up

- As viewed from the front of and in the pelvis plane (formed by the right and left ASIS and point on line connecting the right and left posterior superior iliac spines (PSIS) markers)

Clinical Gait Analysis Course: A Focus on Interpretation

Connecticut 2025

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Pelvis: Fixed Obliquity • Primary Causes – Adductor tightness – Scoliosis – Lateral trunk tightness/spasticity

Pelvis: Increased Upward Position in Swing - right

Pelvic Obliquity

Up deg Dn

• Secondary Causes

-20

B24432-22

– Leg length discrepancy* (actual/functional) - hip dislocation

Pelvis: Increased Upward Position in Swing • Secondary Causes – Hiking pattern to assist with clearance*

Pelvis: Increased Excursion

Pelvic Obliquity

Up deg Dn

A65798-42

-20

Pelvis: Increased Excursion

Hip – Abduction/Adduction Angle definition

• Primary Cause – Hip abductor weakness*

Pelvic Obliquity

Up deg Dn

C04010-14

-20

Clinical Gait Analysis Course: A Focus on Interpretation

- The relative angle between long axis of the thigh and a perpendicular to the pelvic plane

- As viewed from

the front of and in the pelvic plane

Connecticut 2025

Hip Angle - adduction

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Hip: Increased Abduction in Stance

Hip: Increased Abduction in Stance • Primary Causes – Abductor tightness – Adductor weakness/insufficiency (after obturator neurectomy)

deg

• Secondary Causes – External hip rotation – Pelvic obliquity (down side) – Poor Balance* – Counterbalance for trunk lateral lean

Hip: Increased Adduction in Stance

Abd -20

B81586-13 Knee Varus-Valgus

Hip: Increased Adduction in Stance • Primary Causes – Adductor tightness/spasticity – Abductor weakness*

• Secondary Causes – Internal hip rotation and crouch – Pelvic obliquity (up side)

Hip: Increased Abduction in Swing

Hip Ab-Adduction

20 Add deg Abd -20

A46612-32

Hip: Increased Abduction in Swing • Secondary Causes – Pelvic drop (depression) in swing – Circumduction to aid in clearance* – Poor balance

Clinical Gait Analysis Course: A Focus on Interpretation

Hip Ab-Adduction

Add

Connecticut 2025

Hip Ab-Adduction

Add deg Abd -20

C37824-2

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Ankle/Foot: Pes Planus (forefoot abduction+ midfoot collapse + hindfoot valgus)

Foot 1. Video based 2. Foot model challenges

Ankle/Foot: Hindfoot Varus

Ankle/Foot: Pes Planus (forefoot abduction+ midfoot collapse + hindfoot valgus)

• Ankle plantar flexor tightness • Peroneal spasticity/tightness • Posterior tibialis weakness

• “Shortened” lateral column

Ankle/Foot: Forefoot Supination

Ankle/Foot: Hindfoot Varus • Posterior tibialis tightness/spasticity • Plantar flexed first ray • Achilles tendon tightness • Increased plantar flexion • Internally rotated foot progression (roll over varus)

Clinical Gait Analysis Course: A Focus on Interpretation

Connecticut 2025

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Ankle/Foot: Forefoot Supination

Ankle/Foot: Forefoot Adduction

• Anterior tibialis “over pull” (imbalance between anterior tibialis versus toe extensors) • Posterior tibialis spasticity 2

• Abnormal bony midfoot coalition

Ankle/Foot: Forefoot Adduction • Metatarsus Adductus • Abductor hallucis tightness • Tight plantar fascia • Posterior tibialis spasticity/tightness

Transverse Plane 2

Sagittal Plane 30

Trunk Obliquity

Trunk Tilt

Trunk Rotation

TRUNK – internal/external

Angle Definition:

Int

Ant

- the motion of the bi-clavicular line relative to a line perpendicular to the direction of progression

deg Dn

Pos

-30

Ext

-20

Pelvic Obliquity

Angle of rotation - external

-40

Pelvic Tilt

Ant

Int

Pos

Ext

Pelvic Rotation

deg Dn -20

-20

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Int

Ext

Angle of rotation internal

Hip Rotation

Flx

deg Abd -20

-20

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Angle of rotation – 0 deg

Bi-clavicular line

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

Clinical Gait Analysis Course: A Focus on Interpretation

Left

Connecticut 2025

Right

- as seen by an observer looking down the long axis of the torso from above

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Upper Body: Asymmetrical Rotation

Trunk: Asymmetrical Rotation (Internal rotation of one side and external rotation of the other side)

• Primary Causes – Scoliosis – Asymmetrical trunk/upper extremity tightness/spasticity (hemiplegia)*

Upper Body: Increased Excursion

Trunk Rotation

Int

Ext -40

A57082

Upper Body: Increased Excursion • Primary Causes – Aid in forward progression – Similar to pelvic motion

Trunk Rotation

Int

• Secondary Causes – Required for use of assistive devices (crutches)*

PELVIS – internal/external

Ext -40

B29057

Pelvis: Increased External Rotation

Angle Definition - The motion of the ASIS to ASIS line relative to a line perpendicular PSIS to the direction of progression - As viewed by an observer whose site line is ASIS-ASIS line PSIS perpendicular to the pelvic plane

Angle of rotation - external

Angle of rotation internal Angle of rotation – 0 deg Left

PSIS

Right

Clinical Gait Analysis Course: A Focus on Interpretation

Connecticut 2025

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Pelvis: Increased External Rotation

• Primary Causes

• Secondary Causes

– Retraction pattern on involved hemiplegic side*

Pelvic Rotation

Int

• Secondary Outcome – Obligatory internal rotation resulting from retraction pattern on the contralateral side*

Ext -40 C41637-3

Pelvis: Increased Excursion

– Asymmetrical femoral anteversion (compensation for ipsilateral internal hip rotation) – Asymmetrical foot progression (compensation for ipsilateral internal tibial torsion)

Pelvic Rotation

Int

Ext -40 C41637-3

Pelvis: Increased Excursion • Primary Causes – Increase step lengths – Compensation for reduced sagittal plane excursion of motion* – Decreased knee extension at initial contact

Pelvic Rotation

Int

Ext -40

B81586-18

Hip: Increased Internal Rotation

Hip – internal/external Angle Definition - The motion of the thigh (as defined by the knee flexion extension axis) relative to the pelvis ASIS - ASIS line

Internal Rotation Angle

- As viewed by an observer above the pelvic plane

Clinical Gait Analysis Course: A Focus on Interpretation

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Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Hip: Increased Internal Rotation

Hip: Increased External Rotation

• Primary Causes – Excessive internal femoral anteversion* – Internal rotator tightness/spasticity

• Secondary Causes – Unilateral internal hip rotation can be compensation for external pelvic rotation

Hip Rotation

40 Int

Ext -40

C36309-2

Hip: Increased External Rotation • Primary Causes – Femoral retroversion – Poor balance – Increased thigh girth

• Secondary Causes – Unilateral external rotation can be compensation for internal pelvic rotation – Compensatory to internal tibial torsion*

Hip Rotation

Int

Ext -40

B96889-13

Foot Progression Angle Definition - The angle between the long axis of the foot (ankle center along to space between 2nd and 3rd metatarsals) and the direction of progression - As seen from above Angle of Rotation - external

Foot: Increased External Progression

Foot: Increased External Progression • Primary Causes – Midfoot break (forefoot 40 abduction) Int • Secondary Causes – Increased external tibial torsion* Ext – External hip rotation -40 – External pelvic rotation – Circumduction of the foot for clearance (swing) – External rotation in the transverse plane through the knee joint

Clinical Gait Analysis Course: A Focus on Interpretation

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Foot Progression

25%

A64496-6 50% Gait Cycle

75%

Problems/Possible Causes – Coronal/Transverse Planes, Jean Stout

Foot: Increased Dynamic External Progression at Toe-Off

Foot: Increased Dynamic External Progression at Toe-Off • Primary Causes – Foot drag in swing due to clearance problems*

Foot: Increased Internal Progression

Foot Progression

Int

Ext -40

C36309-2 25%

50% Gait Cycle

75%

Foot: Increased Internal Progression • Primary Causes – Posterior tibialis spasticity – Anterior tibialis spasticity/ peroneal 40 weakness – Forefoot adductus Int

Foot Progression

• Secondary Causes – Internal tibial torsion* – Internal hip rotation – Internal pelvic rotation – Foot drag with internal rotation – Internal rotation in the transverse plane through the knee joint

Transverse Plane Abnormalities

Ext -40

25%

B07771-13 50% Gait Cycle

75%

Thank You

• The entire transverse plane profile must be assessed (trunk, pelvis, hip, knee, and foot) simultaneously to determine at which level and/or levels the rotational abnormalities are present. • Both transverse plane motion plots and clinical examination estimations of bony torsions are required. Visual assessment not adequate to understand rotational profile!

Clinical Gait Analysis Course: A Focus on Interpretation

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Lever Arm Dysfunction in Pathologic Gait Tom F Novacheck, MD Medical Director, Integrated Care Services Chair Cerebral Palsy Institute Gillette Children’s St Paul, MN, USA Professor of Orthopedics University of MN

What are the problems? How do we detect them? How can they accurately be treated?

Remember! • The two primary purposes of moments (muscle force X lever arm distance) • stance phase stabilization (support moment) • propulsion (acceleration) • of body segments • of body mass

A brief review of ambulation • How does movement occur?

• skeleton = levers required for movement • Muscles and ground reaction forces = forces provide the required power • The joints serve as the hinges

What is a “lever-arm” or “moment-arm”? • It is one of the components of a moment • Moment = Force x lever-arm • It is a “Distance” from a point to a force • Perpendicular to line of action of the force

It’s the moment that matters!

M1 = F x d1

F M2 = F x d2 F constant

d1 > d2 > d3 M1 > M2 > M3

M3 = F x d3

Type I lever dload

deffort Effort

Load

Body Weight

Abductor Force

Type II lever Effort

Ftriceps

Wbody

Load dload deffort

Type III lever Effort

Load

deffort dload

Fbiceps/brachialis Fload

How is erect posture maintained? • David Winter

• The plantarflexors contribute ~ 50% of the total support • The hip and knee extensors contribute the remaining 50%, but their relative contributions vary depending upon speed, terrain, fatigue, etc.

Plantarflexion/Knee Extension Couple

Plantarflexion/knee extension coupling

Inappropriate Moments • Abnormal ankle moment (too much or too little)

• excessive second rocker (inadequate muscle moment) • weak triceps surae • inadequate lever arm (midfoot break)

• overactive triceps surae (restricted second rocker)

Too little

Plantarflexion/ knee extension coupling

Quadriceps EMG

The “lever-arm” portion of the moment is abnormal.

What is “lever-arm dysfunction”?

Several types of lever-arm dysfunction exist. • Short lever-arm • Flexible lever-arm • Mal-rotated lever-arm • Unstable fulcrum • Positional lever-arm dysfunction

Short Lever-arm: • Examples

• Midfoot amputation • Coxa Valga or coxa breva

• Effect -- M = F x d, If the leverarm length is cut in half (d/2), then M is cut in half as well

dtrans

Flexible Lever-arm: • Example -- Pes planovalgus • The rubber crowbar

Malrotated lever-arm: • Examples

• External tibial torsion • Femoral anteversion

• Effect

• Desired moment is reduced (knee extension moment) • Unwanted moments introduced • external rotation • valgus

Unstable fulcrum: • Example -Dislocated or subluxated hip • Effect -- Since there is no stable pivot point, no effective moment can be generated

Positional lever-arm dysfunction • Upright vs Crouch gait • Examples

• bi-articular hamstrings (hip and knee) • ankle plantarflexors

Positional lever-arm dysfunction

bi-articular hamstrings (hip and knee) dhip

dknee

dhip

dknee

d(hip)/d(knee) > d(hip)/d(knee)

Positional lever-arm dysfunction Dorsiflexion

Plantarflexion

Compensation Abductor Demand

dabductor

dweight Weight

Force Reduction

dabductor

dweight

Weight shift

What happens when a child has cerebral palsy? either inadequate force and/or “lever-arm dysfunction”

neurological impairment with loss of selective motor control, spasticity, balance problems, etc inability to stretch muscles through nl play Muscle contractures Abnormal skeletal forces Bone and joint deformity

Remember! • The two primary purposes of moments (M X D) • stance phase stabilization (support moment) • propulsion (acceleration) • of body segments • of body mass

Cross Plane Interactions – Sylvia Õunpuu

Cross Plane Interactions: Primary, Secondary and Compensatory Gait Features

Sylvia Õunpuu, MSc Center for Motion Analysis Division of Orthopaedics Connecticut Children’s Medical Center Farmington, Connecticut

Official pediatric teaching hospital of

Ultimate Goal To understand gait pathology in persons with neuromuscular disorders in terms of primary, secondary and compensatory deviations.

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

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Cross Plane Interactions – Sylvia Õunpuu

Pathological Gait is Complex How do you treat? Lots of “abnormal” gait patterns! • All? • Some? • Primary deviations? • Secondary deviations? • Compensations? • Does one impact the other? Official pediatric teaching hospital of

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

deg Dn

Pos

-20

Hip Ab-Adduction

Add

Ext

Secondary Deviation

Compensation

-40

Hip Flexion-Extension

Flx

Hip Rotation

Primary Deviation

Int

deg Ext Primary -20 Deviation

Abd -20

Primary Knee Varus-Valgus Deviation

Var

Ext -40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Secondary Deviation

deg Val -30

25%

50%

75%

Primary -40 Deviation

-20

Gait Cycle

Compensation

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Primary Deviation

Pla -40

Official pediatric teaching hospital of

Ext

25%

50% Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

75%

-40

25%

50%

75%

Gait Cycle

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Objectives: • Define joint kinematic interactions across planes in the context of primary and secondary deviations and compensations • Understand that when primary deviations are addressed, secondary deviations/compensations may resolve • Understand common multi-level/plane gait patterns in CP • Describe how motion analysis can help us understand interactions across planes

Assumptions

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Trunk Rotation

deg

• Participants understand joint and segment angle definitions and plotting conventions.

Trunk Obliquity

Official pediatric teaching hospital of

Pelvic Obliquity

-40

Pelvic Tilt

Ant

Int

Pos

Ext

-20

Pelvic Rotation

deg

Hip Ab-Adduction

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Add deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

CORONAL

Clinical Gait Analysis: A Focus on Interpretation

Ext

25%

50%

75%

-40

25%

50%

75%

Gait Cycle

SAGITTAL

TRANSVERSE

Connecticut 2025

Official pediatric teaching hospital of

Cross Plane Interactions – Sylvia Õunpuu

Definition

Pelvic Obliquity

Interactions across planes: Evaluation of the relationships between motion from one plane to another. o Differentiate between primary and secondary gait deviations and compensations o Determine possible causes of gait abnormalities

Pelvic Tilt

Pelvic Rotation

Ant

Int

deg Dn

Pos

-20

Hip Ab-Adduction

Add

Secondary Deviation Hip Flexion-Extension

60 Flx

Ext

Compensation

-40

Hip Rotation

Primary Deviation

Int

deg Abd -20

30 Var

Primary Deviation Primary Deviation Ext

Ext

-20

Knee Varus-Valgus

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Secondary Deviation

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Compensation

Plantar-Dorsiflexion

Dor

Primary Deviation

Primary Deviation Foot Progression

Int

deg

Official pediatric teaching hospital of

Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

Definition con’t: Sequence of data interpretation: 1. Individual joint 2. Joints and segments within a single plane of motion 3. Joints and segments across multiple planes of motion 4. Ultimately understood in the context of the primary gait deviation

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Definitions • Primary Deviation okinematic abnormality related to the joint level impairment

• Secondary Deviation okinematic abnormality at another joint that is a direct result of a primary deviation

• Compensation okinematic abnormality that is voluntary that helps reduce impact of primary deviation Note: we can debate these definitions, but it is important to consider that all gait deviations may not originate from a joint level impairment at the same joint Official pediatric teaching hospital of

Definitions • Joint Level Impairment oAbnormality at the joint of interest – Contracture – Torsional or other boney deformity – Weakness – Spasticity – Abnormal EMG signal for specific phase of the gait cycle

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

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Cross Plane Interactions – Sylvia Õunpuu

Primary Deviation • Kinematic abnormality related to the joint level impairment • For example: oImpairment – internal femoral torsion/femoral anteversion (65 internal)

oPrimary Deviation – excessive internal hip rotation (kinematic) Official pediatric teaching hospital of

Secondary Deviation • Kinematic abnormality related to the impairment at the joint • For example: oImpairment

– internal femoral torsion/femoral anteversion (65 internal)

oPrimary Deviation

– excessive internal hip rotation (kinematic)

oSecondary Deviation

– excessive internal foot progression (kinematic)

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Compensation • Voluntary kinematic abnormality that reduces impact of primary gait deviation • Examples: o Vault

– early plantar flexion in mid stance – to aid in clearance of the contralateral (swing) limb

o Circumduction

– hip abduction in swing – to aid in clearance of the ipsilateral limb

o Increased pelvic transverse plane range of motion over the full gait cycle – to increase step length

o Increased hip flexion in swing

– to aid in clearance of the ipsilateral limb

Official pediatric teaching hospital of

Stance vs. Swing 80

Knee Flexion-Extension

rectus femoris

Flx

hamstring Ext -20

40 Dor

Plantar-Dorsiflexion

gastrocnemius

deg Pla -40

25%

50%

75%

gastrocnemius anterior tibialis

• Primary Deviation • Consider point in the gait cycle – stance vs. swing • Joint level impairments impact different parts of the gait cycle depending on the demands at that point in the gait cycle Official pediatric teaching hospital of

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Evidence • 35+ years of systematic review of motion analysis data as part of the “standard of care” pre and post surgery • Understanding of motion analysis kinematics (angle definitions) • Our own and others published treatment outcomes documented with comprehensive gait analysis techniques oSurgical oBracing oEtc. Official pediatric teaching hospital of

Case Examples • Sagittal Plane oBuild distal to proximal oPrimary and secondary deviations

• Coronal/Transverse Plane oPrimary and secondary deviations

• Compensations • Full Case

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

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Cross Plane Interactions – Sylvia Õunpuu

Phases of the Gait Cycle • Stance oLoading response oMid stance oTerminal stance oPre-swing

• Swing oInitial swing oMid swing oTerminal swing Official pediatric teaching hospital of

(Perry, Gait Analysis: Normal and Pathological Function, 1992)

Primary Deviation - Increased Equinus in Swing

Plantar-Dorsiflexion

Dor deg Pla -40

Right Side

25%

50%

75%

Gait Cycle

Joint Level Impairment: ankle dorsiflexor weakness E73375

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Official pediatric teaching hospital of

Cross Plane Interactions – Sylvia Õunpuu

Primary Deviation – Increased Equinus Stance/Swing 40

Plantar-Dorsiflexion

Dor deg Pla -40

Ext

25%

50%

75%

Gait Cycle

D87396

Joint Level Impairment: ankle plantar flexor contracture

Official pediatric teaching hospital of

Primary Deviation

Left side

• Primary Deviation: increased equinus and knee extension in midstance

Impairment: Increased ankle plantar flexor spasticity and tightness Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Secondary Deviation • Secondary Deviation: increased anterior pelvic tilt

Left side Impairment: Increased ankle plantar flexor spasticity and tightness

Official pediatric teaching hospital of

Primary Deviation

Right side

• Primary Deviation: increased equinus and knee hyper extension in stance (solid)

Impairment: Increased ankle plantar flexor spasticity and tightness

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Secondary Deviations

Right side

• Secondary Deviations: ipsilateral increased anterior pelvic tilt in stance (solid), increased contralateral pelvic anterior tilt and increased contralateral hip flexion in swing (dashed)

A21910

Impairment: Increased ankle plantar flexor spasticity and tightness

Official pediatric teaching hospital of

Pel vic Rotation

Primary Deviation

Int

Ext -40

Hip Rotation

40 Int

• Primary Deviation: increased internal hip rotation

Ext -40

Knee Rotation

40 Int

Ext -40

Right side Impairment: internal femoral torsion (anteversion), limited passive external hip rotation, increased passive internal hip rotation

Foot Progression

Int

Ext

Official pediatric teaching hospital of

-40

25%

50%

75%

Gait Cycle

(3 gait cycles right side)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Rotation

Secondary Deviation

Int

Ext -40

Hip Rotation

40 Int

Ext -40

Knee Rotati on

40 Int

Ext -40

Right side

Impairment: internal femoral torsion (anteversion), limited passive external hip rotation, increased passive internal hip rotation

Foot Progression

Int

• Secondary Deviation: internal foot progression

Ext

Official pediatric teaching hospital of

-40

25%

50%

75%

Gait Cycle

(3 gait cycles right side)

Primary Deviation 20

Pelvic Obliquity

Up deg Dn -20

Hip Ab-Adduction

Add deg

Impairments: Hip abductor weakness

• Primary Deviation: Increased hip adduction in loading response, bilaterally

Abd Official pediatric teaching hospital of

-20

Right (solid) vs. Left (dashed)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Secondary Deviations Pelvic Obliquity

20 Up deg Dn -20

Hip Ab-Adduction

20 Add deg

Impairments: Hip abductor weakness

• Secondary deviations: increased pelvic range of motion and increased hip abduction in swing (contralateral side)

Abd Official pediatric teaching hospital of

-20

Right (solid) vs. Left (dashed)

Compensations • Voluntary kinematic abnormality that reduces impact of primary gait deviation • The body’s mechanism to make walking easier/possible • Can occur on ipsilateral and contralateral “uninvolved or lesser involved” side Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Primary Deviation

• Primary Deviation: increased equinus in swing (solid)

Right side

Impairment: Anterior tibialis weakness and plantar flexor tightness

Official pediatric teaching hospital of

Compensation

• Compensation: increased hip flexion in swing (solid)

Right side

A21910

Impairment: Anterior tibialis weakness and plantar flexor tightness

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Tilt

Primary Deviation

Ant

Pos

Ext

-20

Hip Flexion-Extension

• Primary Deviation: increased equinus in swing and reduced knee flexion in swing (involved side – left)

Flx

Ext

-20

Knee Flexion-Extension

Flx

Ext

-20

Plantar-Dorsiflexion

40 Dor

Impairments: Plantar flexor contracture and rectus femoris spasticity

deg Pla

Official pediatric teaching hospital of

Ext

-40

25%

50%

Left

75%

Gait Cycle

Pelvic Tilt

Compensation

Ant

Pos

Pos Ext

-20

Hip Flexion-Extension

Flx

Ext

ExtExt

-20

Knee Flexion-Extension

Flx

Ext

ExtExt

-20

Plantar-Dorsiflexion

deg

Pla

ExtPla

-40

Ext

Hip Flexion-Extension

• Compensation: vault - voluntary equinus in stance on the non-involved (right column)

Ext

Knee Flexion-Extension

Ext

Plantar-Dorsiflexion

Dor

Left

Flx

Pelvic Tilt

25%

50% Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

75%

-40

Right Ext

25%

50%

Official pediatric teaching hospital of

75%

Gait Cycle

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Compensation – more details • Confirmation of compensation: (typically developing side) o Normal isolated voluntary control at ankle o Normal plantar flexor strength at ankle o Ability to easily heel rise in single limb standing o Kinematics – normal ankle dorsiflexion at initial contact – normal ankle dorsiflexion in mid-swing

Official pediatric teaching hospital of

Primary Deviation

Pelvic T ilt

40 Ant

Pos -20

Hip Flexion-Extension

Flx

Ext -20

Knee Flexion-Extension

• Primary deviation: limited and delayed peak knee flexion in swing

Flx

Ext -20

Impairment: rectus femoris activity in mid-swing

Plantar-Dorsiflexion

Dor deg

Official pediatric teaching hospital of

Pla -40

25%

50%

75%

(3 gait cycles left side)

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Compensation

Pelvic Obliqui ty

Pelvic T ilt

Ant

deg Dn

Pos

-20

Hi p Ab-Adducti on

Add

Ext

Hip Flexi on-Extensi on

Flx

deg Abd

Ext

-20

Knee Varus-Valgus

Var

Ext

Knee Flexion-Extension

Flx

deg Val -30

Ext

25%

50%

Impairment: rectus femoris activity in mid-swing

Ext

-20

75%

Gait Cycle

• Compensation: increased hip abduction in swing (circumduction) • Goal: to aid in clearance of the ipsilateral limb during swing phase

Pl antar-Dorsiflexion

Dor deg Pla

(3 gait cycles left side)

-40

Official pediatric teaching hospital of

Ext

25%

50%

75%

Gait Cycle

Primary Deviation 40

Pelvic Rotation

Int

Ext -40

Right side Impairment: Increased femoral anteversion

Hip Rotation

Int

• Primary Deviation: increased internal hip rotation (solid right)

Ext -40

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

(right solid/left dashed)

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Transverse Plane Pelvis & Hip 40

• Compensation: increased ipsilateral external pelvis rotation (solid) and increased contralateral internal pelvic rotation (dashed) • Goal: forward pointing knees/feet

Pelvic Rotation

Int

Ext -40

Right side

Hip Rotation

40 Int

Impairment: Increased femoral anteversion

Ext -40

Official pediatric teaching hospital of

(right solid/left dashed)

Primary Deviation

Pelvic Tilt

40 Ant

Ext

Pos -20

Hip Flexion-Extension

Flx

• C93511 –

Ext

Ext -20

Knee Flexion-Extension

Flx

Ext

• Primary deviation: decreased knee extension at initial contact

-20

Plantar-Dorsiflexion

Dor

Impairment: spasticity of hamstrings and reduced passive range of knee extension

deg Ext

Pla -40

25%

50%

75%

Official pediatric teaching hospital of

Gait Cycle

(right solid, left dashed)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Compensation

Pelvic Tilt

Int

Pos

Ext

-20

Hip Flexion-Extension

Ext

-20

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

-20

Impairment: spasticity of hamstrings and reduced passive range of knee extension

Hip Rotation

40 Int

• Compensation: increased transverse plane pelvic range of motion • Goal: to increase step length and associated walking velocity

-40

Flx

Pelvic Rotation

Ant

-40

Plantar-Dorsiflexion

Foot Progression

40 Int

Dor deg

Ext

Pla -40

25%

50%

-40

75%

25%

Gait Cycle

50%

Official pediatric teaching hospital of

75%

Gait Cycle

(right solid, left dashed)

Primary Deviation 20

Pelvic Obli qui ty

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

-40

deg

Hip Ab-Adduction

Add

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

• Primary deviations: internal hip rotation and increased knee flexion 100% gait cycle

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extensi on

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Impairments: Increased femoral anteversion, increased hamstring tightness/spasticity, hip extensor/plantar flexor weakness

Plantar-Dorsi flexion

Dor

Foot Progression

Int

deg Pla -40

Official pediatric teaching hospital of

Ext

25%

50%

75%

-40

Gait Cycle

25%

50%

75%

Gait Cycle

(3 gait cycles left side)

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Secondary Deviation – Cross Plane Interaction 20

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

-40

• Secondary deviations: increased hip adduction 100% gait cycle

deg

Hip Ab-Adduction

Add

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Impairments: Increased femoral anteversion, increased hamstring tightness/spasticity, hip extensor/plantar flexor weakness

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Official pediatric teaching hospital of

Ext

25%

50%

75%

-40

Gait Cycle

25%

50%

75%

Gait Cycle

(3 gait cycles left side)

Secondary Deviation – Cross Plane Interaction

Impairments: increased hamstring tightness/spasticity

•

Compensation: increased pelvis transverse plane range of motion

•

Secondary deviation: increased hip abduction at initial contact

Primary Deviation: increased knee flexion at initial contact (bilateral)

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Secondary Deviation – Cross Plane Interaction •

•

Impairments: increased hamstring tightness/spasticity (bilateral)

Primary Deviation: increased knee flexion at initial contact (bilateral)

Compensation: increased pelvis transverse plane range of motion Secondary deviations: hip adduction in loading response

Official pediatric teaching hospital of

Secondary Deviation – Cross Plane Interaction •

•

Impairment: increased femoral anteversion (left – dashed)

Compensation: increased pelvic transverse plane rotation range of motion Secondary deviations: hip abduction at initial contact (right) and hip adduction at initial contact (left)

Primary Deviation: increased internal hip rotation (left – dashed)

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Case Study

Official pediatric teaching hospital of

Stance Phase Stability: Ankle

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Primary Deviation

Pla -40

Official pediatric teaching hospital of

Ext

25%

50%

75%

-40

25%

Gait Cycle

50%

75%

Gait Cycle

Clearance in Swing: Knee/Ankle

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Flx

Hip Rotation

40 Int

deg Ext Primary -20 Deviation

Abd -20

Knee Varus-Valgus

Var

Ext -40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Primary Deviation

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Official pediatric teaching hospital of

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

Swing Phase Clearance: Hip

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

Primary Deviation

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Secondary Deviation

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Official pediatric teaching hospital of

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

Compensation?

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Flx

Hip Rotation

40 Int

deg Ext Primary -20 Deviation

Abd -20

Knee Varus-Valgus

Var

Ext -40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Compensation

Plantar-Dorsiflexion

Dor

Primary Deviation Foot Progression

Int

deg Pla -40

Official pediatric teaching hospital of

Ext

25%

50%

75%

-40

Gait Cycle

25%

50%

75%

Gait Cycle

Pre Position at IC: Knee/Ankle

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Ext

deg Abd -20

-20

Primary Knee Varus-Valgus Deviation

Var

Primary Deviation

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

40 Dor

Primary Deviation Foot Progression

Int

deg

Primary Deviation

Pla -40

Official pediatric teaching hospital of

Ext

25%

50%

75%

-40

25%

Gait Cycle

Pelvic Obliquity

Pelvic Tilt

50%

75%

Gait Cycle

Pelvic Rotation

Ant

Int

deg Dn

Pos

-20

Hip Ab-Adduction

Add

Ext

Secondary Deviation

Compensation

-40

Hip Flexion-Extension

Flx

Hip Rotation

Primary Deviation

Int

deg Ext Primary -20 Deviation

Abd -20

Primary Knee Varus-Valgus Deviation

Var

Ext -40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Secondary Deviation

deg Val -30

25%

50%

75%

Primary -40 Deviation

-20

Gait Cycle

Compensation

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Primary Deviation

Pla -40

Official pediatric teaching hospital of

Ext

25%

50% Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

75%

-40

25%

50%

75%

Gait Cycle

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotation

Ant

Int

deg Dn

Pos

-20

Hip Ab-Adduction

Add

Ext

Secondary Deviation

Compensation

-40

Hip Flexion-Extension

Flx

Hip Rotation

Primary Deviation

Int

deg Ext Primary -20 Deviation

Abd -20

Primary Knee Varus-Valgus Deviation

Var

Ext -40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

Secondary Deviation

deg Val -30

25%

50%

75%

Primary -40 Deviation

-20

Gait Cycle

Compensation

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Primary Deviation

Pla -40

Official pediatric teaching hospital of

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

Post-op Evaluation

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Pelvic Obliquity

Pelvic Tilt

Pelvic Rotati on

Ant

Int

Pos

Ext

-20

-40

deg

Hip Ab-Adduction

Add

Hip Flexion-Extension

Flx

Int

Abd

Ext

-20

-40

• Pre (dashed) vs. Post (solid) Surgical Kinematics (left)

Hip Rotation

deg

Knee Varus-Valgus

Var

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

-20

-40

• Primary and secondary gait deviations improved. •

deg Val

-30

25%

50%

75%

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

40 Int

deg Pla

-40

Official pediatric teaching hospital of

Ext

25%

50%

75%

-40

25%

50%

Gait C ycle

Pelvic Obliqui ty

Pelvic Ti lt

75%

Gait C ycle

Pelvic Rotation

Ant

Int

Pos

Ext

-20

-40

deg

Hip Ab-Adducti on

Add

Hip Flexion-Extensi on

Flx

Int

Abd

Ext

-20

-40

• Pre (dashed) vs. Post (solid) Surgical Kinematics on noninvolved side (right)

Hip Rotation

deg

Knee Varus-Valgus

Var

Knee Flexion-Extension

Knee Rotation

Flx

Int

Val

Ext

-30

-20

-40

• Compensatory vault no longer needed!

deg

25%

50%

75%

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg

Official pediatric teaching hospital of

Pla

-40

Ext

25%

50%

75%

-40

Gait Cycle

Clinical Gait Analysis: A Focus on Interpretation

25%

50%

75%

Gait Cycle

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Summary • Gait in persons with CP can be complex • Separating primary from secondary from compensatory gait deviations across all planes of motion helps to direct treatment to allow the most informed treatment decisionmaking

Official pediatric teaching hospital of

How does one “differentiate” between primary, secondary deviations and compensations? • Measurement of the patient’s joint level impairments and gait oClinical exam (strength, ROM, torsions, etc.) oGait (kinematics, kinetics, EMG, etc.) • In the context of the phases of the gait cycle • With knowledge of typically developing reference data Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

Con’t • Development of a systematic approach to understanding and interpreting this information • We can also learn from objective documentation of oPre versus post surgical data comparisons oBarefoot versus orthosis data comparisons oLift versus no lift data comparisons oEtc…

Official pediatric teaching hospital of

Thank You

Official pediatric teaching hospital of

Clinical Gait Analysis: A Focus on Interpretation

Connecticut 2025

Cross Plane Interactions – Sylvia Õunpuu

KINEMATIC DATA JOINT ANGLES DURING MOTION INITIAL CONTACT 40

DORSIFLEXION 0 deg

Dor

INITIAL CONTACT

TOE OFF Plantar-Dorsiflexion

REFERENCE DATA (N=580)

SWING

STANCE

deg

PLANTAR FLEXION

Pla -40

* 25%

50%

75%

Ext

3 gait cycles right side

Gait Cycle

GAIT CYCLE

Clinical Gait Analysis: A Focus on Interpretation

Official pediatric teaching hospital of

Connecticut 2025

Trunk Motion – Sylvia Õunpuu

Objective Kinematic and Kinetic Relationships in Pathological Gait and the Influence of Trunk Motion on Gait

Understand the relationship between the trunk (upper body) motion and/or position and lower extremity kinematics and kinetics during gait.

Sylvia Õunpuu, MSc Center for Motion Analysis Division of Orthopaedics Connecticut Children’s Medical Center Farmington, Connecticut, USA 1

Topics

1. Typical (normal) Trunk Motion

1. Normal (typical) trunk motion 2. Purpose of trunk motion 3. Mechanism 4. Experimenting With Trunk Position 5. Case Examples

Know your angle definitions!

Findings depend on skeletal model used… 30

Trunk Obliquity

Trunk Tilt

Ant

Int

Pos

Ext

-30

-20

Up deg

-40

Trunk Rotation

Upper Trunk vs. Lab Coordinate system

Trunk vs. Pelvis

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Trunk Motion – Sylvia Õunpuu

Marker Placement

Sagittal and Coronal Motion

• Define segments • Many options! • Pros/Cons for each • Shoulders

Angle Definition: inclination of upper body relative to lab coordinate system

o Right and left ASIS o Mid right and left PSIS

Biclavicular Line

Upper Trunk Bi-clavicular line

Lab Coordinates

o Right and left clavicle o C7

• Pelvis

Upper Trunk

Pelvis

PSIS

PSIS PSIS

ASIS

Pelvis ASIS

Sagittal

ASIS

Coronal

2. Purpose of Trunk Motion

Trunk Transverse Plane Angle Definition: motion of the bi-clavicular line relative to lab coordinate system

Why does the trunk move during gait?

Direction of Progression

Bi-clavicular line

Lab Coordinates

Purpose Con’t

3. Mechanism

• To compensate for lower extremity weakness in individual muscles or muscle groups • To reduce joint or muscle pain • To compensate for contracture or deformity • A “motor” to allow advancement when there is lower extremity weakness

• Trunk motion changes the location of the center of mass • Alters the orientation of the ground reaction force with respect to the joint center and thus the external moments on the lower extremities • The resulting muscle response (internal moment) can be reduced or eliminated by changing trunk position

Clinical Gait Analysis: A Focus On Interpretation

Resultant GRF

Net Knee Extensor Moment

Connecticut 2025

Resultant GRF

Net Knee Extensor Moment

Trunk Motion – Sylvia Õunpuu

Mechanism con’t • During gait, muscle demands and body/segment orientation vary over the gait cycle • When one of the lower extremity muscles cannot meet typical demands, adaptations in trunk motion at a particular point of the gait cycle may allow ambulation

Muscle Activity During Gait • Therefore trunk motion that changes through out the gait cycle is likely related to the muscle weakness

(Orthopedic Management in Cerebral Palsy, E. Bleck, 1987) 16

Fixed Trunk Position Very subtle motions or change in position of the trunk can be adequate to compensate for lower extremity weakness.

• Spinal deformity • Increased unilateral muscle tone

Trunk Obliquity

Up deg Dn -30

Fixed Trunk Position

4. Experimenting With Trunk Position

• Walking Aids • Reduce quad demands 40

Trunk Tilt

Ant

Pos -20

Why? To help interpret data for patients with atypical trunk position!

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Trunk Motion – Sylvia Õunpuu

Forward Trunk Lean

Impact of Changing Trunk Position

Increased forward trunk lean = increased anterior pelvic tilt = increased hip flexion = increased hip extensor contraction = increased plantar flexor contraction = increased weight bearing over distal foot

Let’s Try!

Net Hip Extensor Moment

Resultant GRF

Net Knee Flexor Moment

Net Ankle Plantar Flexor Moment

Forward Trunk Lean – During Gait

Trunk Tilt

Ant

Pos

Net Hip Extensor Moment

-15

Pelvic Tilt

Resultant GRF

Net Knee Flexor Moment

-20

25%

50%

deg

Ext

-20

Hip Moment

-40

2.0

Ext

Nm/kg

Flx

-1.0

Knee Pow er

3.0

W/kg

Abs

-2.0

25%

50%

-2.0

75%

25%

Gait Cycle

50%

-2.0

75%

25%

Gait Cycle

50%

75%

Gait Cycle

Backward Trunk Lean – During Gait

Backward Trunk Lean Increased backward trunk lean = decreased anterior pelvic tilt = decreased hip flexion = increased hip flexor contraction = increased quadriceps contraction = increased weight bearing under heel

Ankle Pow er

3.0 Gen

Gen

W/kg

Ankle Moment

2.0

Ext

Hip Pow er

Plantar-Dorsiflexion

Pla

Knee Moment

Ext

3.0

75%

40 Dor

Gen

Gait Cycle

Knee Flexion-Extension

Flx

2.0

Ant

Pos

Hip Flexion-Extension

Flx

Trunk Tilt

45 Ant deg

Resultant GRF

Net Hip Flexor Moment

Pos -15

Resultant GRF

Pelvic Tilt

Net Knee Extensor Moment

Ant deg

Net Knee Extensor Moment

Pos -20

25%

50%

75%

Gait Cycle

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Trunk Motion – Sylvia Õunpuu

What have we just learned?

Backward Trunk Lean – During Gait 60

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

Ext

-20

Hip Moment

2.0

-40

Knee Moment

2.0 Ext

Ext

Nm/kg

Flx

-1.0

Hip Pow er

3.0

W/kg Abs -2.0

Knee Pow er

3.0

50%

75%

Gen

W/kg

-2.0

Gait Cycle

Ankle Pow er

3.0

Gen

Abs

25%

Ankle Moment

2.0

Ext

Gen

• Trunk position impacts lower extremity muscle demand • When there is lower extremity weakness, trunk movement can lesson the demand on weak muscles • Muscle demands vary through out the gait cycle so trunk motion to compensate for lower extremity weakness is dynamic

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

Gait Cycle

Not all about weakness… • Pain! - Muscle pain during contraction - Joint pain during muscle contraction - Trunk motion can reduce muscle contraction and therefore muscle and/or joint pain

Sagittal trunk Minimal forward trunk lean Sagittal knee

Net Knee Flexor Moment

Resultant GRF

5. Case Examples

Trunk Motion - Compensation for Weakness

Coronal Plane Lateral Trunk Lean

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Trunk Motion – Sylvia Õunpuu

Compensation for Weak Hip Abductors

Lateral Trunk Lean Gen Up

Net Hip Adductor Moment

deg Abs Dn -30

Var

deg

Val

Nm/kg

Add

Var

-1.0

Hip Power

3.0

25%

50%

75%

Resultant GRF

Knee Power

3.0

Gen

W/kg

-20

Knee Moment

2.0

Abd

Nm/kg

-1.0

Net Hip Adductor Moment

-30

Hip Moment

2.0

deg

Knee Varus-Valgus

Val

-20

Resultant GRF

Add

Abd

Pelvic Obliquity

Hip Ab-Adduction

Trunk Obliquity

W/kg

Abs

Gait Cycle -2.0

25%

50%

75%

-2.0

Gait Cycle

25%

50%

75%

Gait Cycle

Test Question

Trunk Motion - Compensation for Weakness

Where does the ground reaction force need to pass in single limb stance with respect to the knee when there is 2/5 quads strength?

Right knee extension strength 2/5 How can this patient support himself in stance?

A) Behind the knee B) In front of the knee C) Through the knee joint center

Mechanism

• Dynamic anterior trunk tilt during right lower extremity stance • Shifts center of gravity forward • Minimizes required extensor moment at the knee

Clinical Gait Analysis: A Focus On Interpretation

Knee Flexor Moment • Less than antigravity quads strength (2/5) • Knee flexion contracture • Knee flexor moment required

Connecticut 2025

Resultant GRF Net Knee Flexor Moment

Trunk Motion – Sylvia Õunpuu

Test Question

Trunk Motion as “Motor” 30

T runk Obliquity

Trunk T ilt

40 Ant

Int

Pos

Ext

-30

-20

Can a patient with L4 level myelomeningocele tolerate a forward trunk lean when walking barefoot?

Trunk Rotation

deg

Pelvic Obliquity

-40

Pelvic Tilt

Int

Pos

Ext

-20

-40

A) Yes B) No

Pelvic Rotation

Ant

Why?

deg

25%

50%

75%

Gait Cycl e

25%

50% Gait Cycl e

75%

25%

50%

75%

Gait Cycl e

Understanding Lower Extremity Moments - 0/5 strength plantar flexors - Resultant GRF and C of P path

? Sagittal Knee

Resultant GRF Net Knee Extensor Moment

Summary

Thank You!

• Make sure that you know the following: o Your angle definitions and skeletal model o “normal” trunk motion using same data collection methods

• Interpret trunk data in the context of o Lower extremity weakness and bony deformity o Joint kinetic data o EMG data

• Trunk motion o Serves multiple functions during gait o Variable depending on point in the gait cycle o Is directly connected to lower extremity function

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Pathologic Gait in Cerebral Palsy Andrew G. Georgiadis, MD June 4, 2025 Connecticut Gait Course

Necessary Knowledge Homework: 1. Draw normal sagittal plane kinematics 2. Draw each of the pathologic patterns in bilateral and unilateral cerebral palsy

Prelude • Plantarflexion-knee extension “coupling”

Point of contact

Ground reaction force in normal gait

Bilateral sagittal patterns • Rodda 2004 JBJSBr

What is the value of these terms Think of them as means of communication, not recipes. Try to understand, don’t memorize.

True equinus

True equinus (aka “only equinus”)

Distinguishing features: Ankle plantarflexion in stance Normal or hyperextended knee in midstance

True equinus (aka “only equinus”)

* Distinguishing features: Ankle plantarflexion in stance * Normal or hyperextended knee in midstance *

Jump Gait

Jump Gait (L - equinus plus knee flexion)

* Distinguishing features: Ankle plantarflexion in stance * Excessive knee flexion at terminal swing * Excessive knee flexion at IC/loading response *

Jump Gait (L - equinus plus knee flexion)

Distinguishing features: Ankle plantarflexion in stance Excessive knee flexion at terminal swing Excessive knee flexion at IC/loading response

Apparent equinus

(“Jump” at knee, no equinus)

Distinguishing features: Ankle plantarflexion normal in stance * Excessive knee flexion at terminal swing Excessive knee flexion at IC/loading response

Apparent equinus

(“Jump” at knee, no equinus)

Distinguishing features: Ankle plantarflexion normal in stance * Excessive knee flexion at terminal swing Excessive knee flexion at IC/loading response

Crouch gait

Distinguishing features: Ankle dorsiflexed in stance Excessive knee flexion throughout gait cycle Excessive hip flexion throughout gait cycle Pelvis – any

Crouch gait

Distinguishing features: Ankle dorsiflexed in stance Excessive knee flexion throughout gait cycle Excessive hip flexion throughout gait cycle Pelvis – any

Crouch gait – ground reaction force behind knee

Asymmetric gait • Combinations thereof

Unilateral (hemiplegic) sagittal patterns • Winters, Gage, Hicks 1987 JBJSAm

Type I hemiplegic pattern

Type I

Type II

Distinguishing features: Foot drop in swing Equinus in stance Knee normal or hyperextended Hip/pelvis normal

Type III

Distinguishing features: Foot drop in swing Equinus in stance Knee stiff (decreased overall motion) Hip/pelvis normal ROM

Type IV

Distinguishing features: Foot drop in swing Equinus in stance Knee stiff (decreased overall motion) Hip motion decreased Pelvis anterior in late stance

Stiff-knee gait

Fox Delp 2009 J Biomech

Stiff knee gait

Distinguishing features: Swing phase knee flexion: - diminished slope - late peak - diminished peak

Stiff knee gait – pre/post rectus surgery • Rectus femoris transfer • - Slope and timing of swing phase knee flexion improved • HSL • - improvement in KF in MSt and TSw, but diminished magnitude of peak KF in Sw

PRE POST

Pre-post unilateral RFT in patient with Winters Gage Hicks Type IV hemiplegia as part of SEMLS

“Scissoring” gait

Possible causes: Adduction contracture/spasticity Internal thigh rotation / internal femoral torsion (increased anteversion)

Thank You!

Indications for Soft Tissue Surgery:

Surgical Lengthening of the Muscle Tendon Unit to Improve Gait Children with Cerebral Palsy Jon R. Davids, MD Professor and Emeritus Ben Ali Chair in Pediatric Orthopaedics Department of Orthopaedic Surgery University of California Davis Medical School Sacramento, CA USA

Emeritus Assistant Chief of Orthopaedic Surgery Director, Motion Analysis Laboratory Shriners Hospital for Children

Disclosures Jon R. Davids, MD Indications for Soft Tissue Surgery: Surgical Lengthening of the Muscle Tendon Unit to Improve Gait Children with Cerebral Palsy

Disclosure Information The following relationships exist: • Armstrong Children’s Orthopaedic Alliance – Vice-President (no $$)

Identifying Contracture: CP Soft Tissue Surgery • The Muscle Tendon Unit (MTU)

– Orthopaedic Surgeon Perspective

• Assessment Tools • Clinical Decision Making • Surgical Decision Making • Soft Tissue Surgery – Indications / Techniques / Outcomes / Pitfalls

Identifying Contracture: CP Soft Tissue Surgery • Structure - Function Relationship • Anatomy, Physiology, Biomechanics –Complex Interaction • Optimal Function –Multiple Variables –Narrow Window

Identifying Contracture: CP Soft Tissue Surgery • Muscle / Skeletal Interaction

– Moment Generation •M=FxD

– Muscle

• Force Generation

– Skeletal Segment

• Distance / Moment Arm

Identifying Contracture: CP Soft Tissue Surgery • Muscle / Skeletal Interaction in CP

– Muscle: Force Generation • Spasticity • Weakness • Contracture • Selective Control

Identifying Contracture: CP Soft Tissue Surgery • Muscle/Tendon Unit In CP

– Pathophysiology

• Sequential, Progressive – Dynamic – Myostatic – Continuum

Identifying Contracture: CP Soft Tissue Surgery • Myostatic Deformity –MTU: Short –Tendon: Long –Muscle Belly: Short –Myofibrils: Long(!)

Identifying Contracture: CP Soft Tissue Surgery

• Myoarchitecture

• Design Characteristics –Distinct • Function –Distinct • Sensitivity To Lengthening –Distinct

Identifying Contracture: CP Soft Tissue Surgery

• Myoarchitecture

• Design Characteristics –Distinct • Function –Distinct – Sensitivity To Lengthening –Distinct

Semimembranosis

Gracilis, Semitendinosis

Identifying Contracture: CP Soft Tissue Surgery

• Muscle Strength • Children with CP

–Weaker than Age Matched Peers –Wiley and Damiano

Dev Med Child Neurol 40:100-107, 1998

Identifying Contracture: CP Soft Tissue Surgery • Strength to Weight Ratio – Less Favorable with Age ‒ STR-N / GMFCS Level

• Probability of Independent Ambulation • When STR-N is > 50 % Predicted

• Davids et al J Pediatr Orthop 35:523-9, 2015.

Identifying Contracture: CP Soft Tissue Surgery • Increased Muscle Weakness – After Surgical Lengthening

Eugene Bleck, MD

Mercer Rang, MD

Jim Gage, MD

Identifying Contracture: CP Soft Tissue Surgery • Surgery on the MTU

– Proceed with Caution!

• Is the MTU

– Short or Long?

• Short: Myostatic Deformity – Surgical Lengthening

– Fast or Slow?

• Slow: Spasticity

– Do Not Treat with Surgical Lengthening

Identifying Contracture: CP Soft Tissue Surgery • Assessment Tools

– Physical Examination – Kinematics

• Muscle Length / Velocity Calculation

– Kinetics – Dynamic EMG

Physical Exam

ROM, Strength, Motor Control

Exam Under Anesthesia

Identifying Contracture: CP Soft Tissue Surgery • Physical Examination

– Range of Motion – Strength – Selective Motor Control

• Normative Data

– Moon et al YMJ 2017

Identifying Contracture: CP Soft Tissue Surgery • Physical Examination – Many Co-variables

• Fear / Fatigue / Cold / Hungry / etc

• Standardized Techniques – Reliability

• Keenan et al JPOB 2004

– Intra-observer

• Correl Coefficient: 0.67-0.96

Identifying Contracture: CP Soft Tissue Surgery • Physical Examination – Many Co-variables

• Fear / Fatigue / Cold / Hungry / etc

• Standardized Techniques – Reliability

• Keenan et al JPOB 2004

– Inter-observer

• Correl Coefficient: 0.34-0.87 • Worst at the Hip

Identifying Contracture: CP Soft Tissue Surgery • Physical Examination

• Literature

• Quantitative Gait Analysis

• Kinematic / Kinetic Deviations • Poor Correlation with Physical Examination at the Hip / Pelvis • Lee et al JBJS 2011

Identifying Contracture: CP Soft Tissue Surgery • Physical Examination – Many Co-variables

• Fear / Fatigue / Cold / Hungry / etc

• Best Practice

– Repeat 3 Times for Decision Making – Examination Under Anaesthesia

• MCNee et al JPOB 2007

Identifying Contracture: CP Soft Tissue Surgery • Kinematics

– Describes Where

• Limb Segments are During Gait

– Does Not Identify Why

• Primary vs Compensatory Gait Deviations

– Difficult to Distinguish • Shortness versus – Weakness – Slowness • Of the MTU

Identifying Contracture: CP Soft Tissue Surgery • Muscle Length and Velocity Calculation – MSK Modeling

• Estimate MTU Origin and Insertion Sites • Track Through Gait Cycle

– Muscle Length

• Change in Distance Between Origin and Insertion • Short versus Long

– Muscle Velocity

• Rate of Change in Distance • Slow versus Fast

– Delp et al J Ortho Res 2006

Identifying Contracture: CP Soft Tissue Surgery • Muscle Length and Velocity Calculation – Biarticular Muscles (Cross 2 Joints) • Iliopsoas • Hamstrings • Rectus Femoris • Gastrocnemius

– Critical Analysis

• Origin / Insertion Accuracy • Muscle Path Assumptions

Identifying Contracture: CP Soft Tissue Surgery • Muscle Length and Velocity Calculation – Crouch Gait

• Hamstrings –Assumed Short in the Past –Frequently Long

Identifying Contracture: CP Soft Tissue Surgery • Muscle Length and Velocity Calculation – Crouch Gait

• Hamstrings –Assumed Short in the Past –Frequently Long • Lengthening a Long Muscle –Weakness –Increased Anterior Pelvic Tilt

Identifying Contracture: CP Soft Tissue Surgery • Muscle Length and Velocity Calculation – Crouch Gait

• Hamstrings –Assumed Short in the Past –Frequently Long • Lengthening a Short Muscle –Appropriate!

Identifying Contracture: CP Soft Tissue Surgery • Muscle Length and Velocity Calculation – Custom Software

• Not Commercially Available

– Alternative Technique for Hamstring Length

• Stewart et GaiPos 2004 • LEST = 3 (ΔHipIC) - ΔKneeIC

Identifying Contracture: CP Soft Tissue Surgery • Modern Approach

– Clinical Decision Making • Diagnostic Matrix

– Surgery

• Single Event, Multilevel (SEMLS)

– Anaesthesia

• Aggressive / Proactive

– Rehabilitation

• Multidisciplinary

DIAGNOSTIC MATRIX

DIAGNOSTIC MATRIX Clinical History

Individualized Treatment Plan

Quantitative Gait Physical Exam Diagnostic Imaging Clinical Decision Making

Exam Under

Anesthesia

Identifying Contracture: CP Soft Tissue Surgery • Clinical Decision Making

Birth to 4-6y

4 – 12y

7 – 12y

12 – adult

‒ Treatment of Contractures ‒ When is the Right Time? • Musculoskeletal Pathology in CP ‒ 4 Stages

Graham HK, et al. Child (2021)

Identifying Contracture: CP Soft Tissue Surgery • Clinical Decision Making ‒ Treatment of Contractures ‒ What are the Desired Outcomes? • Technical Domain

‒ Physical Examination ‒ Kinematics ‒ Xray ‒ Pedobarography

• Function / Satisfaction Domains

Identifying Contracture: CP Soft Tissue Surgery • Surgical Decision Making

– Treatment of Contractures – What is the Dose of Surgery?

Soft Tissue vs Skeletal

• How Much Should be Done?

– Surgical Dosing

• Linkage to Diagnostic Matrix

Slow vs Short

Swing vs Stance Phase

Identifying Contracture: CP Soft Tissue Surgery • SURGICAL TECHNIQUES – What is the Dose?

• RELEASE – Myotomy, Tenotomy • LENGTHEN – Recession, Z Lengthening • TRANSFER

MUSCLE BELLY

TENDON MUSCLE BELLY

MYOTENDINOUS JUNCTION

TENDON

Identifying Contracture: CP Soft Tissue Surgery • Surgical Zone: Muscle Belly – Contractile Components – Too Destructive

– Excessive Weakness

TENDON MUSCLE BELLY

MYOTENDINOUS JUNCTION

TENDON

Identifying Contracture: CP Soft Tissue Surgery • Surgical Zone: Aponeurosis (Myotendinous Junction) – Least Damaging to MTU

• Avoid Excessive Weakness

– Preferred Level – Limited Length Gain

TENDON MUSCLE BELLY

MYOTENDINOUS JUNCTION

TENDON

Identifying Contracture: CP Soft Tissue Surgery • Surgical Zone: Tendon – Structural Components • Too Destructive

• Excessive Stiffness

– Maximal Length Gain – Concerns For Weakness

TENDON MUSCLE BELLY

MYOTENDINOUS JUNCTION

TENDON

Identifying Contracture: CP Soft Tissue Surgery • Surgical Zone: Aponeurosis (Myotendinous Junction) – Preferred Level

• Jaspers et al J Orthop Res 2005 – Animal Model

• Anatomy • Physiology • Biomechanics

Identifying Contracture: CP Soft Tissue Surgery • Jaspers et al J Orthop Res 2005 – “New” Connective Tissue – Anatomy

• Histologically Similar to Aponeurosis

– Physiology

• More Compliant

– Biomechanics

• Myofibrils Shorter • Improved Length / Tension Relationship

Identifying Contracture: CP Soft Tissue Surgery • Soft Tissue Surgery

– For Myostatic Deformities • Contractures

– Indications / Techniques / Outcomes / Pitfalls – Sagittal Plane • Hip • Knee • Ankle

DIAGNOSTIC MATRIX Clinical History

Quantitative Gait Physical Exam Diagnostic Imaging Clinical Decision Making

Exam Under

Anesthesia

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Clinical History

• Inability To Stand Up Straight

• Physical Examination

• Hip Flexion Contracture (> 30 Degrees) • Thomas Test, Staheli Test • Frequently Overestimated • Stabilize The Pelvis

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession Pelvic Tilt 30 Ant • Diagnostic Imaging 20 • None 10 Pos • Quantitative Gait 0 Analysis Hip Angle 45 • Kinematics Flexion 25 • Multiple 5 Extension Possible Causes -15

50 75 % Gait Cycle

100

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Quantitative Gait Analysis • Kinetics • Increased EXT Moment • Delayed Cross Over • Multiple Possible Causes

Hip Moment (N-m/kg)

Extensor

Flexor

2 1 0 -1

50 75 % Gait Cycle

100

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Examination Under Anaesthesia

• Dynamic vs Myostatic

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Surgical Technique • At / Over the Brim • Between Nerve and Artery • San Diego

• Lateral to Femoral NV Bundle • Newington / Gillette

ASIS

FEMORAL NERVE PUBIS + ARTERY

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Surgical Technique • At / Over the Brim • Between Nerve and Artery • San Diego

• Lateral to Femoral NV Bundle • Newington / Gillette

SARTORIUS

ILIACUS

PSOAS

Identifying Contracture: CP Soft Tissue Surgery Pubic Courtesy of Tom Novacheck, MD and Symphysis Andrew Georgiadis, MD

ASIS Inguinal Ligament

Courtesy of Andrew Georgiadis and Tom Novacheck

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Literature Controversial • Always!

• Novacheck JPO 2002

• Never!

• DeLuca JPO 1998

• Based Upon GMFCS • Morais JPO 2006

• Based Upon Random Forest Algorithm • Schwartz GaiPos 2013

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Pitfalls and Pearls • Early Career / Personal Experience

• Mallet et al Orthopaedics & Traumatology: Surgery & Research 2016

• Physical Examination Improved When HFC >20 Degrees • No QGA Improvements

• Clinical Weakness Reported

Identifying Contracture: CP Soft Tissue Surgery • Iliopsoas Recession • Current Indications • High Knee Walk • Hip Flexion Contracture

• Myostatic Deformity • > 30 Degrees

Identifying Contracture: CP Soft Tissue Surgery • Tightness/Contracture • Trunk/Pelvis/Hip Alignment • Compensatory • High Kneel Walk • Hip Flexion Contracture • Myostatic Deformity • > 30 Degrees

• Surgery

• Iliopsoas Recession • Rarely Necessary

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Clinical History – Unable To Stand Straight – Walks With Knees Bent – Knee Pain And Fatigue With Distance

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Physical Examination – Straight Leg Raise • < 60 Degrees – Popliteal Angle • > 40 Degrees – Spasticity On Quick Stretch

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Physical Examination – Straight Leg Raise • < 60 Degrees • Popliteal Angle • > 40 Degrees • Spasticity On Quick Stretch

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Diagnostic Imaging – Lateral Knee Radiographs • Patella Alta • Fragmentation

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Quantitative Gait Analysis – Kinematics

• Increased Flexion at IC, TSw

Knee Angle Flexion

Extension

70 40 10 -20

50 75 % Gait Cycle

100

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Quantitative Gait Analysis – Kinetics

• Increased Internal Extension Moment in St

Knee Moment (N-m/kg)

2 Extensor 1 0 Flexor -1

50 75 % Gait Cycle

100

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Quantitative Gait Analysis – Dynamic EMG

• Prolonged Med Hamstrings In MSt Rectus Femoris Vastus Lateralis Medial Hamstring

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Examination Under Anaesthesia – Popliteal Angle – Palpate MED vs LAT Hamstrings

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening – Zone II Preferred

• Classic Surgical Technique – “Fast” Surgical Lengthening – Larger, Acute Corrections – Damage to Muscle Fibers – Neuropraxia – Weakness

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening • Dose – Slow Surgical Lengthening

• Precision – Open

• Davids et al JPO 39: e373-e379, 2019

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening (MHL) – “Slow” Surgical Lengthening (SSL) • Pathoanatomy, Pathophysiology

– Recession

• Myotendinous Junction • Minimal Acute Lengthening

– Δ Popliteal Angle 30 Degrees – No Disruption of Muscle Fibers

• Subsequent Gentle Stretching – Knee Immobilizer / Positional – Serial Stretch Casting

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening (MHL) – “Slow” Surgical Lengthening (SSL) • Pathoanatomy, Pathophysiology

– Recession

• Myotendinous Junction • Minimal Acute Lengthening

– Δ Popliteal Angle 30 Degrees – No Disruption of Muscle Fibers

• Subsequent Gentle Stretching – Knee Immobilizer / Positional – Serial Stretch Casting

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening – “Slow” Surgical Lengthening

• Strength

– Isometric: Maintained – Isokinetic: Improved

• Kinematics

– Desired Outcomes • Knee

– Extension @ IC/LR, TSw – Flexion @ MSw

• Pelvis

– Anterior Tilt Unchanged

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening – “Slow” Surgical Lengthening

• Strength

– Isometric: Maintained – Isokinetic: Improved

• Kinematics

– Desired Outcomes • Knee

– Extension @ IC/LR, TSw – Flexion @ MSw

• Pelvis

– Anterior Tilt Unchanged

Identifying Contracture: CP Soft Tissue Surgery • Medial Hamstring Lengthening – “Slow” Surgical Lengthening

• Strength

– Isometric: Maintained – Isokinetic: Improved

• Kinematics

– Desired Outcomes • Knee

– Extension @ IC/LR, TSw – Flexion @ MSw

• Pelvis

– Anterior Tilt Unchanged

Identifying Contracture: CP Soft Tissue Surgery • MHL: Specific Indications – GMFCS I, II – Kinematics

• Specific Surgical Technique – “Slow” Surgical Lengthening

• Specific Rehabilitation

– KI / SSC – Orthotics / Physical Therapy

• Improved Strength – Weakness Avoidable!

Identifying Contracture: CP Soft Tissue Surgery • Gastrocsoleus Lengthening – Clinical History

• Toe Walking • Dragging / Tripping • Foot Pain • Shoe Wear

Identifying Contracture: CP Soft Tissue Surgery • Gastrocsoleus Lengthening – Physical Examination

• Ankle/Foot Deformities are Supple / Correctible • Silverskiold Test – Gastroc versus Soleus

– Radiographs

• Foot Segmental Alignment • No Midfoot / Forefoot Deformities

Identifying Contracture: CP Soft Tissue Surgery • Gastrocsoleus Lengthening • Kinematics –Ankle

• Beware Midfoot Instability • Single vs Multi-segment Foot Model

Ankle Angle Dorsiflexion

Plantar Flexion

% Gait Cycle

Identifying Contracture: CP Soft Tissue Surgery • Gastrocsoleus Lengthening – Treatment: Lengthening – Surgical Anatomy Firth et al JBJS 2013

– Zone 1

• Selective: Gastroc Only • Baumann / Strayer

– Zone 2

• Selective: Gastro & Soleus (2:1) • Vulpius / Baker

Identifying Contracture: CP Soft Tissue Surgery • Gastrocsoleus Lengthening – Treatment: Lengthening – Surgical Anatomy Firth et al JBJS 2013

– Zone 3

• Not Selective: Gastroc & Soleus • White / Hoke

– Avoid if Possible

• Risk of Over lengthening / Weakness of Soleus

– Patient Selection / Surgical Dosing • Soufi et al JPO 2022

Identifying Contracture: CP Soft Tissue Surgery • Gastrocsoleus Lengthening – Treatment: Lengthening – Less is Safer

• Zone 1 or 2 (5-15 degrees correction) • Avoid Zone 3 (>15 degrees correction required)

– Zone 2

• Most Common

– Surgical Technique

• Identify Sural Nerve • Avoid Damage to Soleus

Foot

Knee

Identifying Contracture: CP Soft Tissue Surgery • Gastrocsoleus Lengthening – Treatment: Lengthening – Surgical Technique

• Don’t Over Lengthen! • 5 Degrees DF with Knee Extended

– DON’T OVER LENGTHEN! • Crouch Gait

Identifying Contracture: CP Soft Tissue Surgery • Take Home Message(s) • Myostatic Deformity –MTU: Short –Tendon: Long –Muscle Belly: Short –Myofibrils: Long(!)

Identifying Contracture: CP Soft Tissue Surgery • Surgical Soft Tissue Lengthening –Only for MTU That is Short

• Hip (IPS)

– Primary vs Compensatory Gait Deviations

• Knee (MHL)

– Difficult to Determine Short vs Long – Perform Slow Surgical Lengthening

• Ankle (GSR)

– Avoid Overlengthening the Soleus

Indications for Skeletal Surgery in Cerebral Palsy

Andrew G. Georgiadis, MD June 4, 2025 Connecticut Gait Course

When considering orthopaedic surgery for gait • What are you trying to accomplish for the patient? • What is your goal? • What is their goal/GOAL?

• The existence of a deformity / gait deviation may not be sufficient indication to operate. • A longitudinal assessment is often helpful.

• NB: Document why an operation was performed

What do experienced surgeons think?

Delphi consensus surgical indications • Available for:

• Femoral derotational osteotomy - McCarthy 2020 J Child Orthop • Gastrocseoleus lengthening – Rutz 2020 J Child Orthop • Rectus femoris surgery – Kay 2021 J Child Orthop • Anterior distal femur hemiepiphysiodesis - Shore 2021 J Child Orthop • Distal femoral extension osteotomy and patellar advancement/imbrication – Rutz 2022 J Child Orthop • Hamstring surgery – Kay 2022 J Child Orthop • Foot alignment assessment - Davids 2022 J Child Orthop

Femoral Derotational Osteotomy (FDO)

FDO

Courtesy: Kemble Wang, Kerr Graham

Femoral derotational osteotomy (FDO) Relative Indications for FDO INDICATION

ASSESSMENT OF OUTCOME

Hip subluxation (radiographic)

Radiographic indices related to hip subluxation • Reimer’s migration percentage • Femoral neck-shaft angle • Robin-Graham CP hip classification

Increased femoral anteversion by imaging (radiographic, >2SD of typical)

Quantitative assessment of femoral anatomy postsurgery (to within age-normal values)

Increased femoral anteversion by examination (exam, >2SD of typical – caveat emptor)

Improvement in static examination of hip rotation (best: arc midpoint)

Internal foot progression angle secondary to internal hip rotation (>2SD, kinematics)

Change in foot progression (internal to more external) Change in hip rotation on 3DGA (internal to more external)

Cosmesis

Patient/family satisfaction GOAL questionnaire domain score

Tripping

Frequency of tripping

Knee or hip pain

Pain frequency, PROs

Femoral derotational osteotomy (FDO) Relative Indications for FDO INDICATION

ASSESSMENT OF OUTCOME

Hip subluxation (radiographic)

Radiographic indices related to hip subluxation • Reimer’s migration percentage • Femoral neck-shaft angle • Robin-Graham CP hip classification

Increased femoral anteversion by imaging (radiographic, >2SD of typical)

Quantitative assessment of femoral anatomy postsurgery (to within age-normal values)

Increased femoral anteversion by examination (exam, >2SD of typical – caveat emptor)

Improvement in static examination of hip rotation (best: arc midpoint)

Internal foot progression angle secondary to internal hip rotation (>2SD, kinematics)

Change in foot progression (internal to more external) Change in hip rotation on 3DGA (internal to more external)

Cosmesis

Patient/family satisfaction GOAL questionnaire domain score

Tripping

Frequency of tripping

Knee or hip pain

Pain frequency, PROs

Femoral derotational osteotomy - indications • Hip subluxation • Non-gait indication with gait consequences

GMFCS III patient who underwent bilateral FDO for subluxation

Femoral derotational osteotomy (FDO) Relative Indications for FDO INDICATION

ASSESSMENT OF OUTCOME

Hip subluxation (radiographic)

Radiographic indices related to hip subluxation • Reimer’s migration percentage • Femoral neck-shaft angle • Robin-Graham CP hip classification

Increased femoral anteversion by imaging (radiographic, >2SD of typical)

Quantitative assessment of femoral anatomy postsurgery (to within age-normal values)

Increased femoral anteversion by examination (exam, >2SD of typical – caveat emptor)

Improvement in static examination of hip rotation (best: arc midpoint)

Internal foot progression angle secondary to internal hip rotation (>2SD, kinematics)

Change in foot progression (internal to more external) Change in hip rotation on 3DGA (internal to more external)

Cosmesis

Patient/family satisfaction GOAL questionnaire domain score

Tripping

Frequency of tripping

Knee or hip pain

Pain frequency, PROs

Femoral derotational osteotomy - indications • Increased femoral anteversion by imaging (>2SD of normal) • Medical imaging is gold standard • CT • MRI • BER (biplanar erect radiographs) • Specific technologies: EOS, RAX

Anteversion exam ≠ Anteversion by imaging ≠ dynamic hip rotation

• Sangeux Graham 2013 Gait Posture • Physical exam and CT assessments of anteversion = poorly correlated (R2=0.14)

Rue, Gage, DeLuca 1992 JBJSAm

Sangeux Graham 2014 GAIT POSTURE

Trochanteric Prominence Assessment – pitfalls

• Davids 2002 JPO • Errors >10° for 45% of femurs

Anatomy is more complicated than “I feel a bump therefore the femoral neck is horizontal” Many femora have complex multiplanar deformity.

Femoral Anteversion Mid-Arc of hip rotation L

LEFT 25°

23°

R 71°

Sangeux 2013 GP R2 = 0.39 11° adjustment

Arc midpoint + 11° = moderate correlation with imaging = 34 °

Assessing anatomy of the femur • Biplanar radiographs are accurate and reproducible, adults and children • Chaibi 2012 Comp Meth Biomed Eng • Gheno 2012 EJR • Assi 2012 EJR, ages • Rosskopf 2014 AJR, ages 4.7 – 14.5 • Meyrignac 2015 Eur Radiol, ages 8-18 • Pomerantz 2015 Skel Radiol (adult sawbones) • Rosskopf 2017 Skel Radiol, ages 6-16

• Transverse plane can be assessed with implants in situ • Femur • Tibia (largest errors)

What is normal femoral torsion for age? Robin Graham JBJS-Br 2008

What important piece of information is missing from this image?

What is normal femoral torsion for age?*

*How uncertain is the measurement, what is population variation?

https://wwrichard.net/2013/01/05/anteversion-a-natural-history/

Does femoral torsion in patients with CP remodel? CP

Fabry 1973 JBJSAm

A: not predictably

Femoral derotational osteotomy (FDO) Relative Indications for FDO INDICATION

ASSESSMENT OF OUTCOME

Hip subluxation (radiographic)

Radiographic indices related to hip subluxation • Reimer’s migration percentage • Femoral neck-shaft angle • Robin-Graham CP hip classification

Increased femoral anteversion by imaging (radiographic, >2SD of typical)

Quantitative assessment of femoral anatomy postsurgery (to within age-normal values)

Increased femoral anteversion by examination (exam, >2SD of typical – caveat emptor)

Improvement in static examination of hip rotation (best: arc midpoint)

Internal foot progression angle secondary to internal hip rotation (>2SD, kinematics)

Change in foot progression (internal to more external) Change in hip rotation on 3DGA (internal to more external)

Cosmesis

Patient/family satisfaction GOAL questionnaire domain score

Tripping

Frequency of tripping

Knee or hip pain

Pain frequency, PROs

FDO indications – internal foot progression Schwartz, Rozumalski, Novacheck 2014 Gait Posture

Unlikely to get a ”good outcome” if operate on anteversion only. Much more likely to get a “good outcome” if anteversion and internal rotation coexist.

Derotating anteversion without internal rotation risks an external foot progression angle (i.e. “bad outcome” or “overcorrection”)

FDO indications

TL;DR

Anteversion Internal Rotation

Femoral derotational osteotomy (FDO) Relative Indications for FDO INDICATION

ASSESSMENT OF OUTCOME

Hip subluxation (radiographic)

Radiographic indices related to hip subluxation • Reimer’s migration percentage • Femoral neck-shaft angle • Robin-Graham CP hip classification

Increased femoral anteversion by imaging (radiographic, >2SD of typical)

Quantitative assessment of femoral anatomy postsurgery (to within age-normal values)

Increased femoral anteversion by examination (exam, >2SD of typical – caveat emptor)

Improvement in static examination of hip rotation (best: arc midpoint)

Internal foot progression angle secondary to internal hip rotation (>2SD, kinematics)

Change in foot progression (internal to more external) Change in hip rotation on 3DGA (internal to more external)

Cosmesis

Patient/family satisfaction GOAL questionnaire domain score

Tripping

Frequency of tripping

Knee or hip pain

Pain frequency, PROs

FDO indications – cosmesis and foot progression

People happiest when foot progression is neutral to slightly external

(+)

Contribution to Body Image and Self Esteem domain of the GOAL questionnaire

(-) external

internal

Schwartz 2022 PLOS ONE

FDO outcomes – foot progression

Schwartz 2022 PLOS ONE

About 30% of FDO magnitude reflected in change in foot progression (@Gillette) Example: derotate 30°, mean change in foot progression is 10° with wide uncertainty

FDO - outcomes • Ounpuu DeLuca 2002 JPO • - Proximal FDO as part of SEMLS • - Static hip rotation (exam) and kinematic improvements endured at 5y

Time 0 (Solid), 1 year (large dash) , 5 years (small dash)

Effects of FDO • Change in static hip rotation

• Reported in most outcome studies of SEMLS with FDO

• Hip rotation in gait improves by 30-66% of magnitude of anteversion correction • Saraph 2002 JPO • Ounpuu 2002 JPO • Pirpiris Graham 2003 JBJSBr • Schwartz Nozumalski Novacheck 2013 Gait Posture • Kim 2015 JPO-B

• None of the above have pre-post quantitative CT assessment. • One study: Geisbusch Dreher JOR 2017 - EMG tracking

FDO - Recurrence • Recurrence of deformity • Ounpuu 2002 JPO – 0% • Boyer 2016 Gait Posture – 11% • Dreher 2012 Gait Posture – 15% • Kim Aiona 2005 – JPO – 30%

• Recurrence affected by: • Intraoperative goal (how much anteversion at the end of surgery) • Age at surgery (younger = more recurrence) • Definition of recurrence (Of dynamic internal hip rotation, the need for further surgery, etc. )

FDO – proximal or distal • Pirpiris Grahm 2003 JBJSBr *No difference in kinematic or exam outcomes - Distal FDO achieved independent ambulation earlier (7 wks vs. 10 wks)

• Nicklasch 2018 DMCN • - No difference in mean stance hip rotation or mid-point hip rotation (exam)

FDO • SUMMARY: • After FDO, magnitude of improvement in hip rotation is 30-66% magnitude of correction of anteversion • Physical examination of anteversion should be used for screening • True values via imaging, (CT, MRI, BERs) • Proximal or distal FDO – no difference in outcome • COMPLICATIONS: • Recurrence 0-30%, more likely in younger patients (<8 yoa) • If FDO undertaken with normal HR/FPA, risk of having external FPA.* •

*Schwartz 2013 Gait Posture

Tibial Derotational Osteotomy (TDO)

TDO • Selber Graham 2006 JBJSBr • External tibial torsion: TFA corrected from 37° to 8° • Internal tibial torsion: TFA corrected -22° to 7° • 5% complication rate

TDO – long term outcomes • Er Miller 2017 JPO • High rates of corrected limbs at short term follow up, but: • In treatment of ETT (internal producing TDO), 58% recurrence at >5 years → tibias became external • In treatment of ITT (external producing TDO), 56% overcorrected at >5 years → tibias became external

TDO

• Aiona 2012 JPO • 26 TDOs (all with fibular osteotomies) • Improved exam/kinematics • Improved knee varus moments • No change in ankle power

TDO – outcomes on foot progression

Schwartz 2022 PLOS ONE

About 70% of TDO magnitude reflected in change in foot progression Example: derotate 30°, mean change in foot progression is 20° with wide uncertainty

TDO • SUMMARY: - Distal (supramalleolar) osteotomy is neurologically safer - TDO to treat external torsion (produce internal) tend to recur back into external rotation - TDO to treat internal torsion (produce external) tend to continue to remodel into external rotation - Knee and ankle moments improved

• COMPLICATIONS: • Overcorrection – uncommon • Recurrence – higher with ETT

Distal femoral extension osteotomy and patellar tendon advancement (DFEO/PTA)

DFEO/PTA • Correction of knee flexion contracture by creating iatrogenic deformity in distal femur

More contracture (20-30 degs)

JBJS 2008

Adolescents & young adults with a diagnosis of cerebral palsy who had undergone the following procedures: 1. distal fem ext osteotomy with patellar tendon advancement (DFEO+PTA) 2. distal femoral extension osteotomy (DFEO only) 3. patellar tendon advancement alone (PTA only)

DFEO only

Crouch improved, but persistent Contracture improved, but persists

DFEO+PTA

Crouch ROM Contracture

corrected improved corrected

PTA only

Crouch corrected No contracture pre-op

DFEO/PTA • Boyer 2018 JBJS • Long term outcome of DFEO-PTA, average 13 years - Matched groups (DFEO/PTA versus other treatments) for comparable crouch and gait deviation - DFEO/PTA -

More likely out of crouch than controls, smaller magnitude of KFC No difference in pain, recreation, activity in early adulthood

Anterior Guided Growth (AGG) • Stevens JPO 2008 – original technique • Wang Georgiadis 2018 JPO • Anterior guided growth of distal femur can improve knee flexion contracture and sagittal plane knee kinematics • Best in younger, more functional patients with smaller contractures

Wang 2018 JPO

DFEO/PTA • SUMMARY: DFEO without PTA leads to persistent crouch gait at early follow-up • Enduring changes in knee kinematics/crouch • AGG may be an option for smaller contractures • COMPLICATIONS: • Neurovascular injury with acute straightening of knee

DFEO PTA

Foot reconstruction

Pes planovalgus reconstruction - osteotomy • Yoo 2005 JPO • 96 planovalgus feet in diplegic patients • Calcaneal neck lengthening* • 7.6% overcorrection

*Evans 1975 JBJS, Mosca 1995

Pes planovalgus reconstruction • Shore Graham 2013 JPO • -extra-articular subtalar fusion - 46 patients, bilateral surgery - Most GMFCS III and IV (79%)

Triple arthrodesis in cerebral palsy • Root 2015 JPO • Long term FU (11-38 yrs) on 21 patients with triple arthrodesis • Most GMFCS I or II (!) • Age at surgery: 19.4 years • 62% pain free • 95% satisfied

Single Event Multilevel Surgery (SEMLS)

SEMLS • Thomason Graham 2011 JBJS • Randomized clinical trial, diplegia, ages 6-12 years • Resistive strength training (8 pts) vs. • SEMLS (11 pts), 8±4 procedures per child • Improved gait quality (GPS and GGI) after 12 months with surgery • Deterioration in gait without surgery • Functional parameters (GMFM-66, FMS), time spent upright, and child quality of life improved at 24 months with surgery

• Gait and function are related, but not the same

• Thomason Graham 2013 GAIT POSTURE • 5 year FU on same patients - gait/function improvement endured

Multilevel Surgery (MLS) Outcomes • Dreher 2018 DMCN • Multicenter cohort of 231 patients with diplegia, 3 centers, evaluated at 1 and 9 years post MLS • Improvement in GPS (overall gait quality) at 1 year • Improvements sustained at 9 years in 77% of patients • 5% of patients had long-term deterioration of gait • 39% had more surgery

Thank You andrewgeorgiadis@gillettechildrens.com

Clinical gait analysis

A Focus on Interpretation

Understanding orthotic function using gait analysis Kaat Desloovere Clinical Motion Analysis Laboratory University Hospital Leuven Belgium

Overview of topics • General principles and types of AFOs • Selection of AFO based on gait pattern • SWOT analysis

General working mechanism of AFO System of external forces Working on the human body segments

Example of force application in an ankle foot orthosis: The three arrows in the figure represent the most important forces exerted by the orthosis in the sagittal plane.

Three-points-principle

System of three forces

Long lever-arm

• One primary force over the joint (F1) • Two opposite forces (F2 en F3) F1

AFO

Avoid pressure problems in orthesis: • Large surfaces • Low forces, by increasing lever-arms (= force application far away from ankle joint centre)

To avoid pressure problems Long lever-arms – large surfaces

‘Orthosis & shoe unit’ > orthosis + shoe

Optimal tuning of AFO + shoe is crucial Modified from slide of Engineer Andrew Rees, Gillette Children’s specialty healthcare, University of Minnesota

Ankle foot orthosis (AFO) General principles for patients with CP • Purpose • Compensation of primary problems – Weakness (for example dropvoet) – Spasticity (for example equinus) – Balance (AFO provides stability)

• Prevention (no correction!) of secondary problems (muscle contractures and bony deformities)

• Patient-specific => No ‘one size fits all’ • Individual indications • Match to the features and needs of patient – Just enough support to improve stability – Minimal limitation of ankle motion

• Balance between beneficial and negative effects • Benefits: improved biomechanics • Potential negative effects: for example functional loss

Types of AFO Two main categories • Static orthoses  Complete limitation of ankle motion  For example solid AFO

• Dynamic orthoses  Allows (part of) ankle motion  For example hinged AFO of posterior leafspring

Solid AFO

Innershoe with laces Anterior trimline Footplate

Bron: VIGO documentatie en internet

Features • Fixed ankle and foot (often in neutral position) • Anterior trimline close to ankle axis • Footplate often rigid and long • Often with integrated innersole for flexible foot deformities (varus/valgus) • Often with innershoe

Solid AFO Target group? (Risk of) crouch (flexion) Need for Grondreaction force effect (GRF-effect)

Gluteus and soleus weakness

Children with bilateral CP (diplegia) GRF Crouch (flexion): Weak glutei and soleus

Normal standing: Strong glutei and soleus

GRF AFO: Correction ankle

GRF behind knee

GRF in front of knee

GRF

Solid AFO Target group? (Risk of) crouch (flexion) Need for Grondreaction force effect (GRF-effect)

Gluteus and soleus weakness

Reaches proximal until the level of the knee joint GRF Crouch (flexion): Weak glutei and soleus

Normal standing: Strong glutei and soleus

GRF AFO: Correction ankle

GRF behind knee

GRF in front of knee

GRF

Anterior shell

GRF-orthosis

Stiff (long) footplate

Hinged AFO

Stop plantar flexion

Hinge with stop for plantar flexion

Features • Free dorsiflexion • Plantar flexion stop, usually at neutral ankle position • Often with integrated innersole for flexible foot deformities (varus/valgus)

Source: VIGO documentatie en internet

Posterior leafspring Features • No inner shoe • Combination with schoe is crucial (to fix orthosis) • Often flexible (allows dorsiflexion and some plantar flexion)

Source: internet search

Hinged AFO or flexible posterior leafspring Target group? • No risk for crouch (flexion) • Drop foot and premature heelrise or equinus • Premature knee (hyper) extension

Children with unilateral CP (hemiplegia)

From flexible to rigid leafspring

Very flexible, with short footplate

• • • •

Changing trimline Addition of carbon fibre Changing thickness of material Changing thickness and length of the footplate

Source: VIGO documentation and internet

Challenge Stiffness is partly defined by weight of patient Rigid, stiff long footplate

Overview of topics • General principles and types of AFOs • Selection of AFO based on gait pattern • SWOT analysis

Effect of AFO on gait, per gait pattern Illustrated by clinical cases • Dropfoot • Ankle deviation in stance (second rocker problems) – Increased plantar flexion or reduced dorsiflexion – Increased dorsiflexion

• Knee deviations in stance – Extension pattern – Flexion pattern

Drop foot Child with right unilateral CP (hemiplegia)

Pathology: First ankle rocker Foot clearance in swing Kinetics at LR

Knee Flexion/Extension

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

2.0

Knee Power

4.0

Gen

Abs

-2.0

Ankle Dorsi/Plantar

Kinematics - kinetics

Ankle Dors/Plan Moment

Ankle Power

Left good right barefoot (barefoot20020410 8.c3d) Right good right barefoot (barefoot20020410 8.c3d)

Left

Right

Flex

NORMAL

Knee Flexion/Extension

1° rocker

Plan

-15

-30

Knee Flex/Ext Moment

Ext

Kinematics - kinetics

Dors

Ext

2.0

Ankle Dorsi/Plantar

3.0

Ankle Dors/Plan Moment

Plan

PATIENT Flex

Dors

-1.0

2.0

Knee Power

4.0

Gen

Abs

-2.0

Ankle Power

Left good right barefoot (barefoot20020410 8.c3d) Right good right barefoot (barefoot20020410 8.c3d)

Left

Right

AFO for dropfoot

Flexible posterior leafspring (PLS) or hinged AFO

Knee Flexion/Extension

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

Ankle Dorsi/Plantar

Effect of PLS • Kinematics: Ankle Dors/Plan Moment

 Correct first ankle rocker  Allow second ankle rocker  Correct ankle in swing

• Kinetics: correction at LR  Decrease double bump in ankle moment

2.0

Knee Power

4.0

Gen

Abs

-2.0

R Barefoot

Ankle Power

R AFO

Right good right barefoot (barefoot20020410 8.c3d) Right Good Right withshoes (shoes20020410 6.c3d)

Knee Flexion/Extension

Ankle Dorsi/Plantar

Barefoot Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

2.0

Knee Power

4.0

Gen

Abs

-2.0

R Barefoot

Ankle Dors/Plan Moment

Posterior Leafspring Ankle Power

R AFO

Right good right barefoot (barefoot20020410 8.c3d) Right Good Right withshoes (shoes20020410 6.c3d)

AFO per gait pattern • Dropfoot • Ankle deviation in stance (second rocker problems) – Increased plantar flexion or reduced dorsiflexion – Increased dorsiflexion

• Knee deviations in stance – Extension pattern – Flexion pattern

AFO for pathological plantar flexion – knee extension couple with premature knee (hyper)extension Pathology: First ankle rocker Second ankle rocker Foot clearance in swing Premature knee extension Knee hyper extension

Knee Flexion/Extension

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

2.0

Knee Power

4.0

Gen

Abs

-2.0

Typical

Ankle Dorsi/Plantar

Bilateral CP (diplegia) Ankle Dors/Plan Moment

Ankle Power

Left good left barefoot (barefoot20030206 9.c3d) Right good right barefoot (barefoot20030206 6.c3d)

Left

Premature plantar flexion (heel rise) with premature knee (hyper)extension

Right

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

2.0

Gen

Typical

Knee Flexion/Extension

Knee Power

Ankle Dorsi/Plantar

Solid AFO Bilateral CP (diplegia) Ankle Dors/Plan Moment

Ankle Power

AFO modifies the the ankle and knee motion and joint moment 4.0

Gen

Abs

-2.0

R barefoot

R AFO

Right good right barefoot (barefoot20030206 6.c3d) Right GoodRight with shoes (shoes 20030206 7.c3d)

Correction of premature plantar flexion (heel rise) with premature knee (hyper)extension

Barefoot

AFO Solid AFO Optimally tuned

Knee Flexion/Extension

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

2.0

Knee Power

4.0

Gen

Abs

-2.0

R barefoot

Ankle Dorsi/Plantar

Solid AFO Bilateral CP (diplegia) Ankle Dors/Plan Moment

Ankle Power

R AFO

Right good right barefoot (barefoot20030206 6.c3d) Right GoodRight with shoes (shoes 20030206 7.c3d)

Ankle power generation during push-off Reduced power generation during push-off (Third ankle rocker)

Three ankle rockers

1° rocker 1° rocker

2° rocker rocker 2°

3°rocker rocker 3°

AFO per gait pattern • Dropfoot • Ankle deviation in stance (second rocker problems) – Increased plantar flexion or reduced dorsiflexion – Increased dorsiflexion

• Knee deviations in stance – Extension pattern – Flexion pattern

Pathological plantar flexion – knee extension couple with knee and hip flexion

Bilateral CP (diplegia)

Knee Flexion/Extension

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

2.0

Knee Power

4.0

Gen

Abs

-2.0

Ankle Dorsi/Plantar

Ankle Dors/Plan Moment

Ankle Power

Left good left barefoot (barefoot20040302 8.c3d) Right good right barefoot (barefoot20040302 9.c3d)

Left

Right

Pathological plantar flexion – knee extension couple with knee and hip flexion

Bilateral CP (diplegia)

Knee Flexion/Extension

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

3.0

Ext

Plan

Flex

Dors

-1.0

2.0

Knee Power

4.0

Gen

Abs

-2.0

Ankle Dorsi/Plantar

Ankle Dors/Plan Moment

Ankle Power

Right good right barefoot (barefoot20040302 9.c3d) Right GoodRight with shoes (shoes20040302 6.c3d)

R barefoot

R AFO

Effect of rigid posterior leafspring or solid AFO

Rigid posterior Leafspring or solid AFO Tuned to create GRF effect

Use of GRF effect in child with myelomeningocele (MMC)

GRF orthosis To overcome weakness

Effect of GRF orthosis in MMC Reaches proximal until the level of the knee joint Anterior shell

Flex

Dors

Ext

Plan

-15

-30

2.0

Knee Flex/Ext Moment

Dors

Ext

Plan

-1.0

Knee Power

Ankle Dorsi/Plantar

3.0Ankle Dors/Plan Moment

Flex

2.0

Stiff (long) footplate

Knee Flexion/Extension

4.0

Gen

Abs

-2.0

Ankle Power

Right right barefoot (barefoot20031212 15.c3d) Rgood barefoot R AFO Right Good Right with shoes (shoesleafsprings20031213 9.c3d)

Overview of topics • General principles and types of AFOs • Selection of AFO based on gait pattern • SWOT analysis

Strengths and weaknesses Effect of AFO on gait Laure Everaert (PhD student)

Evidence from literature Retrospective and prospective studies

Literature – effect on gait Gait speed ↑ Cadence ↓ Step length ↑ Stability of the distal joints ↑ Ankle dorsiflexion is swing First ankle rocker ↑ Ankle and knee motion in midstance Ankle power during push-off ↓ (Ries et al. 2015, Danino et al. 2016, Aboutorabi et al 2017, Lintanf et al 2018, Melanda et al. 2020)

Literature – effect on gait

AFOs improve step length and walking velocity AFOs do not improve overall gait deviation of children with CP

METHOLOGICAL ISSUES Overall gait deviation index (outcome) => not sensitive All gait patterns of heterogeneous group pooled in one cohort

Gait classification (N=170) (Gait classification according to Papageorgiou et al. 2019)

N=30

N=35

Hypotheses

E. Papageorgiou et al. (2019) Are spasticity, weakness, selectivity, and passive range of motion related to gait deviations in children with spastic cerebral palsy? A statistical parametric mapping study

• Specific effects in different regions of gait cycle (not measured by gait deviation indices) • Gait pattern-specific effect of AFO 42

Total group Specific effects in different regions of gait cycle Improved step length and walking velocity

Ankle angle

Knee angle

Ankle power

BAREFOOT Statistical parameter mapping

AFO

Gait pattern-specfic effect of AFO DROPFOOT

Solid AFO => 80.6% THREAT

CROUCH

Threats • AFO selection => patient tailored • Tuning of AFO • Use of AFO

Selection and tuning of AFO • Definition of optimum design for the AFO - shoe combination • Adjustments (to AFO and/or shoes) to optimize kinematics & kinetics  at midstance  at the ‘entrances’ and ‘exits’ of midstance • Patient-specific, each side separately

Source: Elaine Owen, AACPDM instructional course

Midstance Shank to vertical angle

Source: Elaine Owen, AACPDM instructional course

Midstance tuning • Shank insufficiently inclined in midstance • GRF excessively anteriorly aligned at knee and hip in midstance

• AFO+SHOE producing normal kinematics at midstance and terminal stance by increasing the inclination of the shank • Improvement of the GRF alignment at the knee and hip

Source: Elaine Owen, AACPDM instructional course

Midstance tuning • Shank excessively inclined in midstance • GRF posterior aligned at knee in midstance and terminal stance • GRF variable alignment at the hip

• AFO+SHOE producing normal kinematics at midstance and terminal stance by reducing the shank inclination • Improvement of the GRF alignment at the knee and hip

Source: Elaine Owen, AACPDM instructional course

Midstance Shank to vertical angle AFO shoe combination Adjusted following different approaches: in the solid AFO by modifying the heel sole difference by adjusting the ankle angle (for example in some degrees of dorsiflexion)

in a dynamic way by applying hinged AFOs

Tuning of ‘exits’ from midstance Application of special outer soles => rocker soles

Flexible sole - flat profile

Stiff sole – rocker profile

Stiff sole – point loading rocker profile

• Stiffness and profile of soles adjusted to optimise third ankle rocker • The stiff footplate brings GRF more anteriorly and prolonges the external knee extension moment in stance • In case of stiff sole, the sole should have a rocker sole profile (round or point loading rocker)

Tuning of ‘entrances’ to midstance Stiffness and profile of heels adjusted to optimise first ankle rocker

Negative heel

Plain heel

Positive heel

Improper selection or tuning of AFO Forward tilted shank in crouch

Crouch with proximal spasticity & contractures

Apparent equinus: proximal spasticity/ contractures

Apparent equinus with AFO True equinus with short gastrocnemius

More knee and hip flexion

Donning of AFO

Check heel position In AFO

• Flex the knee (to relax gastrocnemius) • Fit AFO with strap or inner shoe (carefully check heel position) • Heel should nicely fit in the AFO • Shoe should be strongly fit (avoid a shoe that is too large) • Be aware that heel heights may dramatically alter the biomechanical function of the orthosis (inform the family!) • Check for red skin when AFOs are taking out • Parents and child should be well instructed (and evaluated)

Opportunities • Smart hinges • Use of AFO during physiotherapy • Aim for symmetry

Smart hinges: Spring-like AFO Neuroswing

Tango Nexgear Modular design

Becker

Triple action ankle joint

Spring-like AFO • Pros – Very adjustable (is also a risk) – Less restrictive (stairs and chairs) – More muscle recruitment? (no scientific evidence) • Cons – Tuning is complex (due to many options) – Patient adjustment period – Need for more scientific studies

Use of AFOs in therapy • Therapy cannot be focused at all three levels (ankle, knee and hip/pelvis). • When using AFOs, motion is controlled at ankle, and physiotherapy can focus on knee, hip/pelvis and trunk

Source: documentation partly from internet

Use of AFOs in therapy • AFOs provide stability • Facilitates excercises at the level of the pelvis and trunk

Source: documentation partly from internet

Aim for symmetry Bilateral use of AFO in children with hemiplegia Reduce power on healthy side

Reduce power on healthy side Barefoot 50

Barefoot Pelvic Rotation

AFO 50

Int

deg

Ext

-50

5.0

Barefoot Ankle Power

5.0

AFO Pelvic Rotation

AFO Ankle Power

Gen

W/kg

Abs

-2.0

Left

Right

Thank you QUESTIONS?

Clinical gait analysis A Focus on Interpretation

Pathophysiology, assessment and treatment of spasticity Kaat Desloovere Clinical Motion Analysis Laboratory Department of Rehabilitation Sciences University of Leuven, University Hospitals Leuven Belgium

Outline Pathophysiology of ‘Spasticity’ Assessments of ‘Spasticity’ Impact of ‘Spasticity’ treatment

Clinical symptoms in patients with upper motor neuron syndrome Background 5/14

1º problems

2º problems

• • • • •

• Muscle contractures • Bony deformities

Weakness Muscle selectivity Balance Spasticity Hypertonia

Joint stiffness (hyper-resistance to passive movement)

(Rosenbaum et al. 2007)

Clinical spasticity scales Modified Ashworth scale

Scoring the resistance felt in a specific muscle group by passively moving a joint at one velocity Bohannon and Smith 1987

Background 14/14 Modified Tardieu scale -40°

-60°

Slow motion

High velocity

Angle at which reaction is felt Haugh et al. 2006

Two cases Case 1

Case 2

• 5 years old

• 8 years old

• Right Unilateral CP

• Left unilateral CP

(hemiplegia)

Ashworth

Tardieu

Ashworth

Tardieu

Gastrocnemius (GAS)

-15°

-5°

Medial hamstrings (MEH)

-50°

-60°

Spasticity ‘A velocity-dependent increase in tonic stretch-reflex due to hyper-excitability of the stretch-reflex’ (Lance 1980)

‘Spasticity’ in muscles at rest Conceptual Framework Clinical symptom: Increased resistance to muscle stretch Non-neural

Muscle tissue stiffness

elasticity viscosity shortage

Hyper-resistance Stretch hyperreflexia/ spasticity (velocity-dependent)

Neural

Involuntary background activation (non-velocity dependent)

postural reflexia non selective activation tonic reflexes fixed background activity

(Van den Noort et al. 2017 European consensus on the concepts and measurement of the pathophysiological neuromuscular responses to passive muscle stretch)

SYMPTOM

COMPONENTS (Muscle) tissue properties

Non neural

‘STIFFNESS’

• Elasticity • Viscosity • Shortening

SLOW

Hyperresistance FAST

Stretch hyper-reflexia (VELOCITY DEPENDENT) Lance 1980

Neural

Hyper-excitability of stretch reflex

‘SPASTICITY’

Instrumented assessment (Bar-On et al. 2013)

Slow stretch (5 secs)

Torque (Force sensor)

Muscle lengthening Muscle excitation (EMG) (IMU)

Fast stretch (1 sec)

ISA 20

Position (°) Angle (°)

0 -20 -40 150

-2 -1 FAST stretch

100

4 5 SLOW stretch

Time [s]

Velocity (°/s)

0 -2

-1

0,04

rms-EMG (mV)

Time [s]

0,02 0

-2

-1

-2

-1

Torque (Nm)

10 0

Time(s) [s] Time

Neural component ISA Stretch hyper-reflexia Typically developing (TD) child

EMG (mV)

SLOW stretch

Child with CP

SLOW stretch

Time(s)

FAST stretch

0.4

0.3

EMG (mV)

0.2

0.1

-0.1

-0.2 -7

-6

-5

-4

-3

-2

Time (s)

-1

Time (s)

Neural component Stretch hyper-reflexia

SLOW stretch

EMG (mV)

Child with CP

EMG (mV)

Typically developing child

EMG response

Time(s)

FAST stretch

0.4

EMG (mV)

0.3

0.2

0.1

-0.1

-0.2 -7

-6

-5

-4

-3

-2

Time (s)

(Bar-On et al. 2013)

-1

Stretch reflex

Time (s)

EMG difference between fast and slow stretch

Neural component ISA Stretch hyper-reflexia Root Mean Square EMG

Change between Low and High Amount of EMG in zone of interest

Max. velocity

Neural component ISA Stretch hyper-reflexia Root Mean Square EMG (%) Child with CP

Average RMS-EMG (%)

Typically developing child

Stretch velocities

Neural component - Stretch hyper-reflexia Cases Case 1

Case 2

• 5 years old

• 8 years old

• Right unilateral CP (hemiplegia)

• Left unilateral CP (hemiplegia

Cases: Gastrocnemius RMS-EMG

Cases

Case 2

RMS-EMG (mV)

0.1

High – Low: 0.007 mV

0.05

0 -10

-5 0 Time (s)

High – Low: 9.32%

RMS-EMG (mV)

Case 1 0.1 0.08 0.06 0.04 0.02 0

Low

Medium

High

High – Low: 0.004 mV

-5

0 Time (s)

High – Low: 11.50%

Low

Medium

High

Joint hyper-resistanceISA Neural + non neural components

Torque (Nm)

SLOW stretch

Joint angle (°)

Joint hyper-resistanceISA Neural + non neural components Work

Torque (Nm)

SLOW stretch

Joint angle (°)

Joint hyper-resistanceISA Neural + non neural components Work

Torque (Nm)

FAST stretch

Change between Low and High

Joint angle (°)

Joint hyper-resistance Neural + non neural components Torque needs to be decomposed in neural and non-neural components

Fast Slow

Joint Torque (Nm)

𝜃

(Bar-On et al. 2014)

Joint angle (°)

𝜃

Joint hyper-resistance Non-neural component NON-NEURAL

Related to passive structures Anthropometric parameters measured and estimated

Stiffness Viscosity

(Drillis 1964 and Jensen 1986)

𝑇 = 1+𝑏

)+ 𝑇

(De Vlugt et al. 2010)

Inertia

Joint Torque (Nm)

Slow

𝜃

(Bar-On et al. 2014)

𝑑𝜃 𝑒 ( 𝑑𝑡

Joint angle (°)

𝜃

Joint hyper-resistance Non-neural component NEURAL Related to muscle activity

Average model deviation %

∫

∣ 𝑇 − 𝑇 ∣ 𝑑𝜃

Fast Slow

Joint Torque (Nm)

𝜃

(Bar-On et al. 2014)

Joint angle (°)

𝜃

ISA Torque CP

Typical child 14

Torque (Nm) Moment [Nm]

Moment [Nm]

Torque (Nm)

10 8 6 4 2

0 -60

-50

-40

-30 -20 Pos [deg]

Position (º)

-10

-10 -20 Pos [deg]

-30

Position (º)

-40

-50

-60

ISA Case 2: GAS MAS-score 1+

Case 1: GAS MAS-score 1+

-5

0 Time (s)

0.08 0.06 0.04 0.02 0

High – Low: 9.32%

High – Low: 0.004 mV

0.1 RMS-EMG (mV)

0.05

0 -10

-5

5 Time (s)

High – Low: 11.50%

10 5 0

Low

Medium

Norm. RMS-EMG (%)

High – Low: 0.007 mV

Norm. RMS-EMG (%)

RMS-EMG (mV)

0.1

10 5

0 High Low Stretch velocities

Medium

High

ISA Case 2: GAS MAS-score 1+

Case 1: GAS MAS-score 1+ 15

High – Low: 3.40 Nm

Torque (Nm)

High – Low: 5.25 Nm

Torque (Nm)

0 -40

-20

Position (º)

-40

-20

Position (º)

Modified Ashworth Score does not distinguish between subjects

Joint hyper-resistance neural non-neural

100 80

Contribution to 60 ankle torque (%) 40 20 0

Case Yana1

Case Eline2

Modified Ashworth Score

Psychometric properties Reliability and validity

Sensitivity

Predictive ability

Sensitivity to improve BoNT treatment

Stretch reflex phenotypes Adductors

Gastrocnemius

Medial Hamstrings Rectus Femoris

(Bar-On et al. 2015)

Stretch reflex phenotypes (Bar-On et al. 2015)

RMS-EMG (mV)

SLOW stretch

RMS-EMG (mV)

Velocity Dependent (VD) phenotypes FAST stretch

Time (s)

SLOW stretch

Time (s)

RMS-EMG (mV)

Length Dependent (LD) phenotypes FAST stretch

Time (s)

(Tuzson et al. ’03, Damiano et al. ’06, Maholtra et al. 2008, Lebiedowska & Fisk 2009, Wu et al. 2010)

Spasticity patterns

Stretch reflex phenotypes P1

90% ROM

Position [deg]

63.33% ROM

0 -10

36.66% ROM

-20

10% ROM

-30 -40 -4

-2

2 4 Time [s]

Spasticity patterns

More muscle activation

Average normalized RMS-EMG (%)

Stretch reflex phenotypes

5 3 0

3 2 1

Position zones

More muscle length

Bar-On et. al. PlosOne 2014

Fast stretch

Medium stretch

Slow stretch

More muscle lengthening velocity

Spasticity patterns

5 4 3 2 3

1 0

3 2 1

20 15 10 5

3 2 zones

velocity categories

80 60 40 20

3 2

zones

Respond to low and high velocity

Respond to high velocity

Avg. norm. rms emg med. ham. [%]

Stretch reflex phenotypes

velocity categories

Respond to low velocity

5 3 0

3 2 1

Respond mostly to high velocity

Respond mostly to low velocity

Stretch reflex phenotypes are muscle-specific LENGTH-DEPENDENT Adductors 71% LD 29% VD

VELOCITY-DEPENDENT Gastrocnemius 30-45% LD 55-70% VD

Medial Hamstrings 78% LD 22% VD

(Bar-On et al. 2015)

Rectus Femoris 21% LD 79% VD

COMPONENTS

SYMPTOM

(Muscle) tissue properties Non neural

OUTCOMES Slow movement

‘STIFFNESS’

• Joint torque (decomposed) • Joint angle (ROM) • …

• Elasticity • Viscosity • Shortening

SLOW

Hyperresistance FAST

Stretch hyper-reflexia (VELOCITY DEPENDENT)

‘SPASTICITY’

Lance 1980

Neural

Hyper-excitability of stretch reflex

Involuntary background activation (NON-VELOCITY DEPENDENT) • • • •

Postural reflexes Non-selective activation Tonic reflexes Fixed background

• • • •

Phenotyping

Non-neural Neural velocity dependent Neural length dependent …

Fast movement

EMG Joint angle at EMG (catch) Joint torque (decomposed?) …

No (very slow) movement • • • •

EMG without stretch EMG at different angles Type of brain lesion …

Outline Pathophysiology of ‘Spasticity’ Assessments of ‘Spasticity’ Impact of ‘Spasticity’ treatment

Spasticity treatment options General Oral medication

Stretching in PT

R e DBS v e r s orthoses i b l e Phenol

SDR ITB

BoNT-A

Orthopedic Surgery

Stretching casts

P e r m a n e n t

• Pediatrician/Neurologist • Rehabilitation specialist • Neurosurgeon • Orthopaedic surgeon • Physiotherapist • Occupational therapist • Nurse • Patient and caregivers

Focal

(Graham 2016)

Multidisciplinary approach

Botulinum toxin (BoNT) Regular treatment in children with CP • Prevention of acetylcholine release from the presynaptic terminal at the neuromuscular junction (NMJ) • Reduction of spasticity • Reduction of pain • Reversible (NMJ recovery after 2 to 3 months)

(Desloovere et al. 2006; Molenaers et al. 2006)

BoNT-A: multidisciplinary integrated treatment • Fundamentals of a successful treatment with BoNT-A • Patient selection, timing and goal setting • Muscle selection • Correct dosage and injection technique

=> Instrumented assessments => Multilevel treatment in needed => According to muscle volume => Interval of 1 year between injections

• Integration: Combination of the injections with: • Orthotic management • Casting • Intensive physiotherapy

• Outcome assessment Evaluation of function/gait pre AND post

Molenaers et al, 2010; Molenaers et al, 2013

BoNT-A: multidisciplinary integrated treatment BoNTBTX A

Functional benefits

• Delayed and reduced need for orthopedic surgery • Functional => improved gait Repeated BoNT-A-injections (Interval between repeated sessions = 1 year)

Functional outcome Pre BoNT-A

Pre BTX

(8 years)

2 months Post BTX Post BoNT-A

(Molenaers et al. 2006, 2009, 2010, 2013; Desloovere et al. 2007; Nieuwenhuys et al. 2016)

Instrumented assessment (Bar-On et al. 2013)

Slow stretch (5 secs)

Torque (Force sensor)

Fast stretch (1 sec)

Muscle lengthening Muscle excitation (EMG) (IMU)

(Bar-On et al. 2014)

Neural component Stretch hyper-reflexia

SLOW stretch

EMG (mV)

Child with CP

EMG (mV)

Typically developing child

EMG response

Time(s)

FAST stretch

0.4

EMG (mV)

0.3

0.2

0.1

-0.1

-0.2 -7

-6

-5

-4

-3

-2

Time (s)

(Bar-On et al. 2013)

-1

Stretch reflex

Time (s)

EMG difference between fast and slow stretch

Effect of BoNT on spasticity

EMG response during slow and fast stretch (medial gastrocnemius ) Pre-BoNT

RMS EMG

2 months postBoNT

Time

Effect of BoNT on spasticity (N=14) spasticity

EMG response during fast stretch (medial gastrocnemius ) EMG during Fast stretch

Milli volt

EMG during Fast stretch

Pre BoNT

2 months Post BoNT

Pre BoNT

2 months Post BoNT (Peeters et al. 2022)

Effect of BoNT on spasticity

•

Quantitative spasticity parameters are sensitive for BoNT in the hamstrings

•

Instrumented spasticity is more responsive to BoNT than clinical scales

•

Torque is less sensitive to BoNT than EMG

Spasticity phenotypes

FAST stretch

Time (s)

RMS-EMG (mV)

Length Dependent (LD) SLOW stretch

Reduction in EMG at high stretch velocity between pre- and post BoNT-A

FAST stretch

EMG differences between pre and post BoNT-A (µV)

SLOW stretch

RMS-EMG (mV)

Velocity Dependent (VD)

P<0,002

25 20 15 10 5 0

VELOCITY

LENGTH

Time (s)

(Bar-On 2020)

Selective Dorsal Rhizotomy (SDR) General Stretching in PT

R e v e r s i b l e

Oral medication

SDR DBS

ITB

orthoses

BoNT-A

Orthopedic Surgery

Phenol Stretching casts

Focal

P e r m a n e n t

Effect of SDR on spasticity (N=15) One year post SDR

spasticity

Milli volt

EMG response during fast stretch (medial gastrocnemius )

Significant reduction in muscle activity during fast stretch (p<0,05)

(Verreydt et al. 2023)

Acknowledgments

Thank you Questions?

More info: kaat.desloovere@uzleuven.be

Funding

TBM IPSA & TAMTA

La Fondation Motrice

KU Leuven Internal funding

Flemish Research Foundation

Avoidable Iatrogenic Complications What not to do in Cerebral Palsy? The Importance of Motion Analysis (with special thanks to Dr. James R. Gage) Tom F Novacheck, MD Medical Director, Integrated Care Services Chair Cerebral Palsy Institute Gillette Children’s St Paul, MN, USA Professor of Orthopedics University of MN

Mistakes Happen! • They can be costly to all concerned… • And, in retrospect, most could have been avoided • more forethought • better insight into the elements of the problem • a well thought out plan

Why do iatrogenic problems occur ? • Inadequate understanding of normal gait • Inadequate concept of the pathology &/or its effect on function • Unrealistic expectations/goals • Surgical technical problems • Some problem with rehabilitation

What information do we need?

Make the right decision Avoid the wrong decision More often

1980’s single level, soft tissue only aka. “Birthday Syndrome”

This is the patient who got Jim Gage into gait analysis… A photo for UCP Connecticut before treatment … (surgeons operating)

This is her when he met her at 18, after 8 “staged-surgeries” throughout her childhood…  Unable to walk  Unable to bend her knees  Unable to get up out of a chair  requiring assistance with ADL’s

New(ish) developments • new methods for physical therapy • new orthosis fabrication and design • development and incorporation of computerized threedimensional motion analysis • the concept of single event multilevel surgery (SEMLS) • Tone management • repopularization of selective dorsal rhizotomy (1980’s) • advent of botulinum toxin (early 1990’s) • Intrathecal baclofen pump (late 1990’s)

• switching the orthopedic SEMLS focus

• from muscle tendon lengthening to lever arm deformity correction

• Multidisciplinary care • Better classification of function

Iatrogenic Problems •Two types • Problems of not doing something (omission) • Problems of doing something (co-mission)

Errors of Omission

Errors of Omission • Failure to understand the role of spasticity • Failure to correct lever arm dysfunction • Pes valgus/varus • External tibial torsion • Femoral anteversion • Hip subluxation • Abductor moment-arm insufficiency

Spasticity Control + Bone Deformity Correction •

Primary (From Injury to CNS)

•

Secondary (From Growth)

•

Tertiary (“Coping Responses”)

Omission Failure to correct lever-arm dysfunction • Pes valgus/varus • External tibial torsion • Femoral anteversion • Hip subluxation • Abductor moment-arm insufficiency

CD – Spastic Diplegia An ideal candidate for Selective Dorsal Rhizotomy • History • Born prematurely • Periventricular Leukomalacia • Good selective motor control & balance • No prior surgery

• Pre-Rhizotomy • March 1991

CD – Post Rhizotomy • March 1992

• Roughly one year post rhizotomy

CD -- The Beginning of Crouch • 1996

• Five years post SDR

• 1997

• At 1st visit to Gillette • Six years post SDR • Bilateral patellar stress fractures and pain

CD – Post SEMLS & PTA 

Post SEMLS walking with floor reaction AFO’s

• 6 months post PTA

Walking with shoes

Errors of Co-mission

Errors of Co-mission Severeid’s Law:

“ Most problems are caused by solutions.”

Why?

• Poor understanding of the problem • Unrealistic expectations • “Cook-booking” rather than applying logic to solving the problem • Blind acceptance of teaching

Errors of Co-mission • Unbalancing muscles • “Staged surgery”

• Inappropriate lengthening of power generators • Lengthening muscles that aren’t short • Neurectomies • Most complete tendon transfers

Dr. Rang’s “Birthday Syndrome” •

“Staged Surgery”

A. Prior to surgery B. Post “TAL” C. Post hamstring lengthening D. Post psoas lengthening

Usually not smiling (or walking) by this time

Percutaneous Tenotomies “If It’s Tight, Cut It !” • Attractive as “benign” surgery

• Multiple tiny incisions with minimal scarring • Short hospital stay

• Perc releases are like cutting spark plug wires to improve engine performance

The effect of inappropriate lengthening of the power generators • "Look, no scars!", but no muscles or power left either. • There are lots of ways to maintain muscle length and strength: • • • •

Spasticity reduction Night splints Stretching casts Botox

• Muscle lengthening = Weakening • It should be done as a last resort. • “Tenotomies” are rarely, if ever indicated

TendoAchilles Lengthening  Results in Crouch Gait: Pre • Triceps surae is “overweakened” • Soleus can no longer restrain tibia during second rocker

Post

TendoAchilles Lengthening in Individuals with Mixed-Tone • Soleus lengthening in a spastic child is a bad idea, but … • Soleus lengthening in a mixed-tone child can be disastrous! • May appear to have contractures while awake • But, not under anesthesia • With mixed-tone, weakening of an antagonist often results in dominance of the agonist and results in deformities such as: • Fixed calcaneus • Fixed abduction

Tendon Transfers in the Foot • Complete muscle transfers in the foot in CP are dangerous

• Peroneus brevis transfer produces hindfoot varus • Posterior tibial transfer produces hindfoot valgus • Peroneus longus transfer produces dorsal bunion &/or forefoot supination/varus

• Split transfers (e.g., SPOTT or SPLATT)

• work well (efficacy) & • are unlikely to produce iatrogenic problems (safety)

Posterior Tibialis Transfer through the interosseous membrane to dorsum of foot • This procedure has been tried in spastic hemiplegia • Leon Root • initially advocate • but later retracted

• Phase-shift noted by Perry and Hoffer is not reliable to insure that overcorrection into calcaneus will not occur • Polio ≠ Cerebral Palsy • polio = paralysis • CP = weakness, spastic/dystonic

Posterior Tibialis Transfer  • Transfer through the interosseous membrane produces Calcaneal-Valgus Deformity • Po lio ≠ Cerebral Palsy • In polio, the antagonist is paralyzed; in CP, it is alive-and-well

• Split tendon transfers are better • to peroneus brevis, the antagonist of the tibialis posterior • Appropriate lengthening of the triceps surae and shortening of the tibialis anterior is a safer way to deal with foot drop

Over-lengthened Hamstrings  Produces lordosis, stiff-knee, recurvatum • Loss of posterior pelvic support • Permanent loss of hip extensor strength in first half of stance • Marked dominance of the rectus femoris

Remedy for Over-Lengthened Hamstrings  No real solution exists

• May need crutches because COM cannot be brought back over base of support • Intractable lordosis • spondylolysis • low back pain

• Treatment options

• abdominal strengthening &/or a lumbar brace? • weaken the antagonists • intramuscular psoas lengthening • distal rectus femoris transfer

Excessive Weakening She had 8 “staged-surgeries” throughout her childhood •

an Egger’s procedure

•

hip flexor tenotomy at the lesser trochanter

•

no rectus femoris transfer

•

no tone control

What Gait Pattern is this? Adductors? Genu valgum?

Quantitative Gait Analysis

Kinematics of the “scissoring gait and valgus knee” in CP Knee Motion

Patient

70 Flex

Normal

40 10 Ext -20

50 % Gait Cycle

Foot Progression

Hip Rotation 30

30 Int

-10

-10 Ext -30

-30 25

50 75 % Gait Cycle

-50

25 50 75 % Gait Cycle

Excessive Weakening of Hip Adductors  Results in an externally rotated, wide-based gait

• Usual outcome of obturator neurectomy • Internal femoral rotation 2° to anteversion is often mistaken for adductor over-pull • In GMFCS I/II/II, simple proximal adductor longus tenotomy with distal intramuscular gracilis tenotomy is sufficient

Solution for Weakened Hip Adductors • If semitendinosis is available, transfer to adductor magnus insertion • distal rectus femoris transfer to biceps femoris • If true retroversion is present, consider subtrochanteric osteotomy to correct external femoral rotation

Prolonged or Excessive Immobilization • Disuse = weakness, scarring, and fibrosis • Functionally there is stiffness, weakness, and loss of functional range-of-motion

Formulate Realistic Goals... • Many of the gait problems in a child with cerebral palsy are not remediable • Selective motor control • Balance

• Be sure your treatment goals match those of the patient and family

Thank you!

Pierz

Gait Analysis and Treatment Decision-making in Charcot-Marie-Tooth Disease Kristan A. Pierz, MD Medical Director, Center for Motion Analysis Connecticut Children’s Medical Center Associate Professor, UCONN Gait Course 2025 Official pediatric teaching hospital of

Objectives 1.

Describe common gait features in Charcot-Marie-Tooth Disease

Utilize gait analysis to guide treatment decisions

Highlight knowledge gaps and opportunities for collaboration when studying rare diseases

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 20241

Pos

Ext

-20

-40

Pierz Hip Ab-Adduction

20 Add

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

-40

deg

Gait Analysis Is…

• The systematic and objective documentation of gait function • Integrates gait findings 30

Knee Varus-Valgus

Var

Knee Flexion-Extension

Flx

Knee Rotation

Int

deg

o Joint angles (joint kinematics) Val Ext o Joint moments and powers (joint kinetics) -20 o Muscle activity -30 25%

50%

Ext

with the impairments o Weakness o Limited range of motion o Bony deformity

Plantar flexor weakness

-40

75%

Gait Cycle

Plantar-Dorsiflexion

Dor

40 Int

deg Pla

Foot Progression

Dorsiflexor weakness

Ext Official pediatric teaching hospital of

-40

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

377823 2 Right (5/24/2004) 377823 4 Right (5/24/2004) 377823 6 Right (5/24/2004)

Gait Analysis Is…con’t • The development of a list of oprimary gait problems and their causes (that should be treated) and oassociated gait compensations (that should not be treated) oproposed treatments including specific indications and the proposed gait outcomes

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 20242

Pierz

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Gait Analysis Is Also…con’t Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

• Objective evaluation of treatment outcomes using the same treatment decision-making methods • A systematic approach to treatment decision-making and evaluation 60

Flx

Dor

Deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Pfl

Nm/kg

Flx

Dfl

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W /kg

Abs

-2.0

Plantar-Dorsiflexion

Ankle Moment

Pre = dashed Post = solid

Ankle Power

Official pediatric teaching hospital of

390428 12 Right (5/3/2006) 390428 3 Right (12/10/2004)

Sources of This Knowledge • Our experience of examining 1000’s of individual patients with neuromuscular disorders o Pre and post treatment

• Knowledge of pathology being analyzed • Research findings o Slowly building o Multi-center needed for rare disease

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 20243

Pierz

Official pediatric teaching hospital of

Charcot-Marie-Tooth disease (CMT) Jean-Martin Charcot 1825-1893

Pierre Marie 1853-1940

Howard Henry Tooth 1856-1925

Hereditary Motor and Sensory Neuropathy (HMSN)

Gait Disorders in Neuromuscular Diseases

Official pediatric teaching hospital of

Leuven 20244

Pierz

Charcot-Marie-Tooth (CMT) (Hereditary Motor and Sensory Neuropathy) • Most commonly inherited neurological disorder • 1-19 per 100,000; >100 genes

• de-myelination of large peripheral nerves • myelin & axonal subtypes (CMT 1, 2, X, 4-7)

• many more subtypes (CMT1a, 2N, etc, etc..)

• Onset during childhood (with exceptions) • Characterized by: • distal muscle weakness and imbalance • foot and ankle deformities • associated gait implications • disease progression at varying rates

Official pediatric teaching hospital of

Textbook Gait Description • Single Gait Pattern • Foot drop (excessive equinus) in swing • Steppage (hyperflexion of knee and hip in swing) • Circumduction and pelvic hiking in swing (Fenton, JOPA 1984)

Official pediatric teaching hospital of

(Morrisy, Pediatric Orthopedics) (Vinci, Archives of Physical Medicine & Rehab 2002)

Gait Disorders in Neuromuscular Diseases

Leuven 20245

Pierz

Textbook Clinical Description • Forefoot equinus and adductus • Hindfoot varus • Pes cavus Center for Motion Analysis Mat • ToePEDOBAROGRAPH deformities 213971 8/03/04 o clawBarefoot toesWalking

(Guyton; Foot and Ankle 2000)

Official pediatric teaching hospital of

PSI

Gait Patterns in CMT Normal

• Clinical experience – persons with CMT have varying: oClinical presentation (joint level impairments) oGait patterns that require different treatment plans to improve gait function

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 20246

Pierz

Gait Implications

Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

• Decreased walking velocity oImpacts activities of dailyPelvic Obliquity Trunk Tilt living Trunk Obliquity oKeeping up with peers 20

Up40

Ant40

Ant deg

Int

• Tripping and falling

Pos

deg

oInjury oImpacts activities of dailyHip Ab-Adduction living Pelvic Obliquity Pelvic Tilt Dn

Pos -20

-30

-20

-40

Add40

Flx 40

Ant deg

Int

deg

Abd

Ext

Pos -20

Ext -20

-20

30 20

Hip Ab-Adduction

60 Var

deg

Abd

Flx

Int

Val

Ext

Ext -30

Ext -20

25%

50%

75%

Gait Cycle

Int

Ext -40

Hip Flexion-Extension Pelvic Rotation

Hip Rotation

40 Int

Official pediatric teaching hospital of

Ext -40

Knee Flexion-Extension

Knee Rotation

Hip Rotation Int

Ext -40

-40

Knee Flexion-Extension

Flx

Plantar-Dorsiflexion

Foot Progression

Knee Rotation

40 Dor

Int

Int deg

Pla

• Variety of Gait Outcomes Val

Trunk Rotation

Flx deg

-20

Knee Varus-Valgus o Weakness 30 o Contracture Var o Bony deformity deg

Hip Flexion-Extension

• Ankle/Foot Impairments -20

Pelvic Rotation

-40

Knee Varus-Valgus

Ankle/Foot Function the Most Common Gait Issue Add

Pelvic Tilt

Ext -20

-20

-40

Ext

Ext -40

Ext

25%

50%

75%

-40

25%

o Delayed and increased peak dorsiflexion in -30 -20 -40 377823 2 Right (5/24/2004) 377823 4 Right (5/24/2004) 377823 6 Right (5/24/2004) terminal stance Plantar-Dorsiflexion Foot Progression 40 40 o Increased internal or external foot progression Dor Int o Increased equinus in stance and swing deg o Medial/lateral ankle instability Pla Ext Gait Cycle

25%

50%

75%

Gait Cycle

75%

Gait Cycle

Official pediatric teaching hospital of

-40

25%

50%

75%

-40

25%

Gait Cycle

50%

75%

Gait Cycle

377823 9 Left (5/24/2004) 377823 10 Left (5/24/2004) 377823 11 Left (5/24/2004)

Gait Disorders in Neuromuscular Diseases

Leuven 20247

Pierz

Kinematics to Evaluate? • Peak ankle dorsiflexion in terminal stance has a clinically relevant gait impact • Three patterns in CMT related to the ankle dorsiflexion o greater than typical (flail foot) o within typical range (cavovarus foot) o less than typical (equinus ankle/cavus foot)

Official pediatric teaching hospital of

Ankle Sagittal Plane Kinematics

Treatment Strategies are Based Upon Ankle Function

• Flail foot: greater than typical (solid) • Cavovarus foot: typical (large dash)

Official pediatric teaching hospital of

• Equinus ankle/cavus foot: less than typical (dash-dot)

Gait Disorders in Neuromuscular Diseases

Leuven 20248

Pierz

The Flail Foot

Official pediatric teaching hospital of

The Flail Foot – Compromised Prerequisites of Gait • Stance phase stability • Swing phase clearance • Appropriate prepositioning at initial contact • Adequate step lengths Treatment Goals: Address these compromised prerequisites of gait

Gait Disorders in Neuromuscular Diseases

Official pediatric teaching hospital of

Leuven 20249

Pierz

The Flail Foot • Clinical Examination Findings (group*) o Limited passive dorsiflexion range of motion – Knee extended (1 ± 7 degrees) – Knee flexed (8 ± 7 degrees) o Full plantar flexion & forefoot inversion/eversion o Strength: (median/maximum/minimum) – Plantar Flexors (2/5/2) – Dorsiflexors (4/5/0) – Forefoot Invertors (5/5/0) – Forefoot Evertors (4/5/2) Official pediatric teaching hospital of

*Õunpuu et al., Gait and Posture, 2013

The Flail Foot • Gait Pattern oIncreased and delayed peak dorsiflexion in terminal stance oIncreased equinus in swing and at initial contact oReduced peak plantar flexor moment and power generation in terminal stance

Gait Disorders in Neuromuscular Diseases

Official pediatric teaching hospital of

Leuven 202410

Pierz

Flail Foot • Functional outcome of ankle weakness includes instability in standing and during gait due to limited ability to bear weight over the forefoot

Official pediatric teaching hospital of

Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Compensation Up

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

• Increased hip flexion in swing • Common textbook descriptor of gait in CMT • Compensation for clearance • Found only in persons with increased equinus in swing 20

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Val

Ext

-30

-20

deg

25%

50%

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Official pediatric teaching hospital of

Ext

25%

50% Gait Cycle

75%

-40

25%

50%

75%

Gait Cycle

377823 2 Right (5/24/2004) 377823 4 Right (5/24/2004) 377823 6 Right (5/24/2004)

Gait Disorders in Neuromuscular Diseases

Leuven 202411

Pierz

The Flail Foot • Treatment Options oBrace oSurgery to maintain a “braceable position” of foot and ankle if needed

Official pediatric teaching hospital of

Ankle-foot Orthoses (AFO’s) • limit excessive dorsiflexion and allow weight bearing on the distal portion of the foot • will provide more stability for the patient in standing and during gait • limit excessive equinus and associated clearance problems in swing Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202412

Pierz

Barefoot vs. Hinged AFO • Reduced excessive plantar flexion in swing • No change in peak ankle dorsiflexion timing in terminal stance • No improvement in peak ankle plantar flexor moment in terminal stance

Official pediatric teaching hospital of

Hinged AFO

Barefoot Trunk Obliquity

Trunk Tilt

With AFO

Pos

-30

-20

-30

Pelvic Obliquity

Int

Ext

Pos

Ext

-20

-40

Pelvic Rotation

Pelvic Obliquity

Ant

deg

Pelvic Tilt

• Compensation no longer needed • Peak hip flexion in swing now normal -20

Hip Ab-Adduction

Ant

Int

Pos

-20

Ext

Pos

Ext

-40

-20

Hip Flexion-ExtensionHip Ab-Adduction

Hip Rotation

-40

Hip Flexion-Extension

Flx

Add

Int

Flx

Int

Abd

Ext

Abd

Ext

-20

Add

deg

Knee Varus-Valgus

Var

Hip Rotation

deg

-40

-20

Knee Flexion-Extension Knee Varus-Valgus 30

Flx

Var

Int

Ext

Val

-20

-30

deg

-40

Knee Rotation Knee Flexion-Extension 80

Knee Rotation

Flx

Int

Ext

deg

Val -30

Pelvic Rotation

Int

deg

Trunk Rotation

Ant

-40

Pelvic Tilt

Trunk Tilt

Int

deg

Trunk Rotation

Trunk Obliquity

Ant

25%

50%

75%

Ext

25%

Gait Cycle

50% -40

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression Plantar-Dorsiflexion

Int

deg

Dor

Int

Foot Progression

deg

Pla -40

Ext

25%

50% Gait Cycle

75%

-40

Pla

25%

-40 50% Gait Cycle

Official pediatric teaching hospital of

Ext

75% 25%

50%

75%

-40

25%

Gait Cycle

50%

75%

Gait Cycle

377823 2 Right (5/24/2004) 377823 4 Right (5/24/2004) 377823 6 Right (5/24/2004) 377823 9 Left (5/24/2004) 377823 10 Left (5/24/2004) 377823 11 Left (5/24/2004)

Gait Disorders in Neuromuscular Diseases

Leuven 202413

Pierz

Ant

Int

Pos

Ext

deg deg

Pos

Ext

-20

Hip Ab-Adduction

Add

60 Flx

Barefoot vs. Solid AFO deg

Ext

-20

Var

-20

Hip Flexion-Extension Hip Ab-Adduction

40 Int

Add

-20

-40

Hip Rotation Hip Flexion-Extension

80 Flx

deg

Flx

Int

Ext

-20

-40 -20

-40

Knee Flexion-Extension Knee Varus-Valgus

Ext

Abd

30 Var

Knee Rotation Knee Flexion-Extension

Int

deg

Ext

Val

Ext Ext

Ext

-30

-20

-30

-40 -20

-40

50%

75%

Knee Rotation

Int Flx

Val

25%

Hip Rotation

deg

Abd

Knee Varus-Valgus • Reduced excessive plantar flexion in swing • Reduced excessive dorsiflexion in terminal stance • Associated reduced excessive knee flexion in stance

-40

25%

Gait Cycle

50%

75%

Gait Cycle

Plantar-Dorsiflexion

Dor

40 40 Int Dor

deg

Pla

Ext Pla

-40

Foot Progression Plantar-Dorsiflexion

25%

50%

75%

-40 -40

Foot Progression

Int

Ext

25%25%

50% 50%

75% 75%

Gait Cycle Gait Cycle

Gait Cycle

-40

25%

50%

75%

Gait Cycle

538652 15 Left (11/4/2013) 538652 15 Left (11/4/2013) 538652 15 Left (11/4/2013) 538652 12 Left (11/4/2013) 538652 12 Left (11/4/2013) 538652 12 Left (11/4/2013)

Barefoot

Solid AFO

Official pediatric teaching hospital of

Flail Foot TX: Surgery may be needed if foot “unbraceable”

Tendon transfers won’t work if no strength

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202414

Pierz

The Cavovarus Foot

Official pediatric teaching hospital of

The Cavovarus Foot Compromised Prerequisites of Gait • Stance phase stability • Appropriate prepositioning at initial contact • (Pain)

Treatment Goals: Position foot to improve stability and reduce pain

Gait Disorders in Neuromuscular Diseases

Official pediatric teaching hospital of

Leuven 202415

Pierz

The Cavovarus Foot • Clinical Examination Findings (group*) oLimited passive dorsiflexion range of motion – Knee extended (2 ± 6 degrees) – Knee flexed (9 ± 7 degrees)

oFull plantar flexion oVariable forefoot inversion/eversion oStrength: (median/maximum/minimum) – Plantar Flexors (4/5/2) – Dorsiflexors (5/5/4) – Forefoot Invertors (5/5/3) – Forefoot Evertors (5/5/3)

Official pediatric teaching hospital of

*Õunpuu et al., Gait and Posture, 2013

The Cavovarus Foot • Clinical findings: • Bilateral plantar flexor weakness • Bilateral claw toes • Bilateral cavus • Bilateral normal passive ROM

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202416

Pierz

The Cavovarus Foot • Gait Characteristics oDelayed peak dorsiflexion in terminal stance oReduced peak plantar flexor moment and power generation in terminal stance

Official pediatric teaching hospital of

Center for Motion Analysis PEDOBAROGRAPH Mat 213971 8/03/04 Foot Pressures Barefoot Walking

• Increased lateral weight bearing • Reduced toe contact

Typically Developing Left

Right Official pediatric teaching hospital of

PSI

Gait Disorders in Neuromuscular Diseases

Leuven 202417

Pierz

Cavovarus Foot Treatment Considerations • Cavus: Imbalance between peroneus longus (plantarflexes 1st ray) & anterior tibialis (dorsiflexes 1st ray) • Varus: Imbalance between posterior tibialis (inverts hindfoot) & peroneus brevis (everts hindfoot)

Official pediatric teaching hospital of

Cavovarus Treatment: Non-Op • Plantar fascia stretch • Strengthening exercises: dorsiflexors & evertors • Bracing

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202418

Pierz

Barefoot vs. Solid AFO • Reduced excessive peak dorsiflexion in terminal stance • Reduced plantar flexion range of motion • Maintained peak plantar flexor moment in terminal stance • Reduced peak power generation in terminal stance Barefoot

Solid AFO

Official pediatric teaching hospital of

Cavovarus Treatment: Surgical • Soft tissue release o Plantar fascia

• Soft tissue lengthening o Posterior tibialis

• Tendon transfers – to balance/delay recurrence o Peroneus longus to brevis o EHL to neck of 1st MT o Anterior tibialis laterally

• Osteotomy – if fixed o Dorsiflexing 1st ray osteotomy o Calcaneal osteotomy o cuboid osteotomy

• Arthrodesis – if severe/recurred

Gait Disorders in Neuromuscular Diseases

Official pediatric teaching hospital of

Leuven 202419

Pierz

Cavus Component – TX Note • The implications of plantar fascia release on “available” plantar flexor length in combination with weakness need to be considered to prevent excessive peak dorsiflexion post treatment • Consider peak dorsiflexion in terminal stance pre tx to predict outcome

Official pediatric teaching hospital of

Equinus and Cavus Foot/Toe walker

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202420

Pierz

The Toe Walker Compromised Prerequisites of Gait • Stance phase stability • Appropriate prepositioning at initial contact • Swing phase clearance

Treatment Goals: Plantigrade foot

Official pediatric teaching hospital of

Toe Walker • Clinical Examination Findings (group*) oLimited passive dorsiflexion range of motion –Knee extended (-2 ± 9 degrees) –Knee flexed (-2 ± 13 degrees) oFull plantar flexion and forefoot inversion/eversion oStrength: (median/maximum/minimum) –Plantar flexors (5/5/2) –Dorsiflexors (5/5/2) –Forefoot Invertors (5/5/3) –Forefoot Evertors (5/5/4) Official pediatric teaching hospital of

*Õunpuu et al., Gait and Posture, 2013

Gait Disorders in Neuromuscular Diseases

Leuven 202421

Ant

Pierz

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

The Toe Walker Flx

Dor

deg

Ext

Pla

-20

-40

-20

2.0

Ext

m/kg

Flx

-1.0

3.0

Gen

• Gait Characteristics oIncreased equinus in stance and wing oAbsence of dorsiflexior moment in loading oReduced power generation in terminal stance

Hip Moment

Hip Power

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

W/kg

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

Official pediatric teaching hospital of

129704 2 Right (7/24/2002) 129704 3 Right (7/24/2002) 129704 4 Right (7/24/2002)

Toe Walker - TX • implications of “toe walking” include instability in stance and standing due to the limited base of support under the foot

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202422

Pierz

The Toe Walker • Treatment Options o Leave alone – increased body weight and weakness o Stretching casts/night bracing/day bracing o Soft tissue: plantar fascia vs. plantar flexor lengthening o Dorsiflexing osteotomy

• Clinicians must consider implications of o reducing plantar flexor contracture by lengthening a weak muscle which is likely to weaken more over time o reducing cavus deformity with implications on “available” plantar flexor length

Official pediatric teaching hospital of

Tx Outcomes • Bilateral plantar fascia release • Relaxed standing

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202423

Pierz

Pre vs. Post

Pre Surgery - 2000

Post Surgery - 2014 Official pediatric teaching hospital of

Trunk Tilt

deg

Pos

-20

Trunk Tilt

Ant

Pelvic Tilt

Gait Findings – Pre vs. Post Ant

Ant

deg

Pos

-20

Flx

deg

Ext

-20

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Gen

W/kg

Abs

-2.0

• Increased dorsiflexion in stance and swing • Addition of dorsiflexor moment in loading response • Maintained power generation terminal stance Hip Flexion-Extension

Hip Moment

Knee Hip Flexion-Extension Flexion-Extension

Flx

Dor

Flx

Dor

deg

Ext

Pla

Ext

Pla

-20

-40

-20

-40

2.0

Ext

Knee Moment Hip Moment

Nm/kg Nm/kg

Hip Power

Plantar-Dorsiflexion Knee Flexion-Extension

Flx

AnkleKnee Moment Moment

2.0

Ext

Nm/kg Nm/kg

Nm/kg

2.0

Flx

-1.0

Knee Hip Power Pow er

3.0

Gen

W/kg

Abs

-2.0

AnkleKnee Power Pow er

3.0

Plantar-Dorsiflexion

Ankle Moment

Ankle Pow er

W/kg

-2.0

Official pediatric teaching hospital of

129704 2 Right (7/24/2002) 129704 3 Right (7/24/2002) 129704 4 Right (7/24/2002) 129704 11 Right (2/5/2014) 129704 12 Right (2/5/2014) 129704 13 Right (2/5/2014)

Right-Pre

Gait Disorders in Neuromuscular Diseases

Right-Post

Leuven 202424

Ant

Pierz

deg

Pos

-20

Pelvic Tilt

Ant

deg

Three Sagittal Plane Ankle Patterns in CMT Pos

-20

Flail Foot

Hip Flexion-Extension

Flx

deg

Ext

-20

Hip Moment

2.0

Cavovarus Foot

Pla

-40

Knee Moment

Ext

Nm/kg

Flx

-1.0

3.0

W/kg

Knee Power

Ankle Moment

2.0

Nm/kg

Hip Power

Equinus Ankle/ Cavus Foot

deg

Ext

3.0

Plantar-Dorsiflexion

Dor

Nm/kg

Gen

Ankle Power

3.0

Gen

W/kg

Abs

-2.0

Trunk Tilt

40 Abs Ant -2.0

Knee Flexion-Extension

Official pediatric teaching hospital of

deg

129704 2 Right (7/24/2002) 129704 3 Right (7/24/2002) 129704 4 Right (7/24/2002) Pos

-20

Pelvic Tilt

Ant

deg

Variation in Treatment Goals Pos

-20

Flx

Tx Goaldeg

* *

Hip Flexion-Extension

Ext

Reduce -20 excessive and/or delayed2.0 ankle Ext dorsiflexion Nm/kg TST and Flx excessive plantar-1.0 flexion SW 3.0

Knee Flexion-Extension

Flx

deg

Dor

Tx Goal

Ext

-20

Hip Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

3.0

Plantar-Dorsiflexion

Tx Goal

deg

Pla

Position foot to Kneeimprove Moment stance phase stability and reduce pain Knee Power

-40

Ankle Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Gen

W/kg

Abs

-2.0

Plantigrade foot in stance phase and increased dorsiflexion in SW

Ankle Power

* Official pediatric teaching hospital of

60 129704 2 Right (7/24/2002) 129704 3 Right (7/24/2002) 129704 4 Right (7/24/2002)

Gait Disorders in Neuromuscular Diseases

Leuven 202425

Ant

Pierz

deg

Pos

-20

Pelvic Tilt

Ant

deg

Treatment Should Impact Prerequisites of Gait Pos

-20

Hip Flexion-Extension

Tx GoalFlx

Flx

deg

Ext

Stance Stability -20 & Swing 2.0 Clearance Ext & Nm/kg Preposition at Initial Flx Contact-1.0 3.0

Solid AFO

-20

Hip Moment

2.0

Knee Flexion-Extension

Tx Goal

Flx

-1.0

Hip Power

3.0

Tx Goal

Pla

Stance Stability Knee Moment

-40

2.0

Ankle Moment

Ext

Plantar fascia release and/or bony Knee Power surgery

Nm/kg

Flx

-1.0

3.0

Gen

W/kg

Abs

-2.0

Plantar-Dorsiflexion

deg

Ext

Nm/kg

Dor

Stance Stability & Swing Clearance & Preposition at Initial Contact

Ankle Power

PF/Heel cord lengthening Official pediatric teaching hospital of

61 129704 2 Right (7/24/2002) 129704 3 Right (7/24/2002) 129704 4 Right (7/24/2002)

Variation in Gait Patterns in CMT1? • Multiple combinations of ankle kinematics for stance and swing in CMT1 • Abnormalities include dorsi/plantarflexor weakness and/or plantarflexor contracture

• Specific gait patterns require different treatment approaches (even in same patient) • Comprehensive gait analysis can distinguish between multiple ankle phenotypes (patterns) to determine the most appropriate treatment to improve gait for individual patients

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202426

Pierz

CMT Type – CMT1 vs. CMT2 • Are gait patterns impacted by CMT Type? • At a given age, CMT2 > CMT1 disease severity & gait difficulties • CMT2 > CMT1 weakness and associated ankle abnormalities in stance and swing

Official pediatric teaching hospital of

63 40

Trunk Tilt

Ant deg Pos -20

Pelvic Tilt

Comparison CMT1 vs. CMT2

Ant deg

(sagittal plane ankle kinematic, moment, power)

Pos -20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

2.0

Patient 1 CMT1 -20

Hip Moment

2.0

Knee Moment

-40

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Pow er

3.0

Gen

W/kg

Abs

-2.0

Knee Pow er

Plantar-Dorsiflexion

3.0

Ankle Moment

Patient 2 CMT2

Ankle Pow er

W/kg

-2.0

129704 11 Right (2/5/2014) 129704 12 Right (2/5/2014) 129704 13 Right (2/5/2014)

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202427

Pierz

Disease Progression – Gait Patterns Change? • In CMT1, peak dorsiflexion in TST increased with age through 13 years • In CMT2, no significant association between age and ankle function (cross-sectional model) • No consistent trends with age for individual patients with repeat tests • More research is needed

Official pediatric teaching hospital of

Take Home Points • Progressive disorders are challenging

• Genetic evaluations/treatment options continue to evolve • Motion analysis allows objective assessment • More research is needed to better understand natural history and treatment outcomes

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202428

Pierz

Thank You

Official pediatric teaching hospital of

Gait Disorders in Neuromuscular Diseases

Leuven 202429

Case Studies

Case Study #2

Connecticut Children’s Medical Center Center for Motion Analysis

CASE STUDY #2 -- PRE-OPERATIVE GAIT ANALYSIS AGE: 8 +11 years

DX: Toe walking

GMFCS: NA

HISTORY: • •

Born full term with a birth weight of 7 lbs. 12 oz. Began walking at 1 year of age with toe walking.

TREATMENT: • • •

No previous lower extremity surgeries. Prescribed day time and night time AFO’s, but not currently fitting. Has pending physical therapy evaluation for stretching and gait training.

PATIENT AND FAMILY CONCERNS: • • •

Her mother would like her to be able to stand and walk flat footed. Difficulty standing still. Patient does not complain of any pain with daily activities.

FUNCTIONAL ABILITIES/PARTICIPATION: • • •

Patient denies tripping and falling with typical activities. Functional Assessment Questionnaire: Parent reported patient is a 10/10 on the Functional Walking Score and is able to complete 21/22 advanced gross motor skills. PODCI scores (out of 100): Global Function: 96; Transfers and Basic mobility: 100, Sports and Physical Function: 85, Pain: 100

GAIT BY OBSERVATION: • • • •

Best walk: Bilateral flat foot contact with early heel rise. Typical walk: Toe-toe gait pattern bilaterally with absent heel contact. Standing: Prefers to stand up on toes, but can stand plantigrade. Standing: When standing with bilateral feet plantigrade, foot progression is external.

Barefoot pre-op Page 1

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 2 Pre-Operation

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

Ankle Dorsiflex. Knee @ 0

-5

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

-5

Plantar Flexion

Hip Extension Knee @ 90

-15

4+W

-10

4+W

Toe Flexor

Toe Extensor

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Knee Extension Hips @ 0

Knee Extension Hips @ 90

-30

-20

Hamstring Tightness

Knee Flexion Total

Knee Q Angle @ 0 (deg)

(+var, -val)

Knee Q Angle @ 20 (deg)

(+var, -val)

Knee Coronal Movement

(1=mild, 3=severe)

Knee Int. Rotation (@ 90)

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Anterior Tibialis Clonus

Confusion w/o Resistance

Confusion w/ Resistance

Leg Length (to heel, mm) Galeazzi

(-)

Reverse Galeazzi

(-)

Leg Length (mm)

Foot/Thigh Angle

(+ ext, - int)

Heel/Thigh Angle

(+ ext, - int)

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

Heel Bisector

2-3

Plantar Fascia Tightness

(Y=yes, N=no)

Knee Extensor Lag (active)

(to available range)

Abdominal Strength

(+ hyperextension)

770

775

Calluses

B forefoot heels soft

MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Hip Extensors (gluts)

Hip Adductors

(-,M=mid,S=sup,

Hip Internal Rotators

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Knee Extensors (quads/rectus)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

(C=continuous)

(at max bulk)

Foot Length (mm)

MMT Strength R

Straight Leg Raise

Calf Girth (mm)

Comments

KEY: ROM (Range of Motion), F (Full), L (Limited), WFL/WNL (Within Functional/Normal Limit); MIN (Minimum/Minimal); '-' (None), UA (Unable to Assess Accurately), U (Unable to Isolate), N (Not Fully Isolated), W (Within Available Range); MMT (Manual Muscle Test) Grading: All out of 5: 1 (trace), 2 (poor), 3 (fair), 4 (good), 5 (normal); MOD ASHWORTH Grading: 0 or '-' (No increase in muscle tone), 1 (Slight increase in muscle tone, manifested by a catch and release or by min resistance at the end ROM when the affected part/s is/are moved in flex or ext), 1+ (Slight increase in muscle tone, manifested by a catch, followed by min resistance throughout the remainder - less than half – of the ROM), 2 (More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved), 3 (Considerable increase in muscle tone, passive movement is difficult), 4 (Affected part(s) rigid in flex or ext)

Barefoot pre-op page 2

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Pre-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE2 1 Left (3/21/2016) CASE2 1 Right (3/21/2016)

Barefoot pre-op Page 3

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Pre-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE2 2 Right (3/21/2016) CASE2 3 Right (3/21/2016) CASE2 3 Right (3/21/2016)

Barefoot pre-op Page 4

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE2 2 Left (3/21/2016) CASE2 2 Left (3/21/2016) CASE2 3 Left (3/21/2016)

Barefoot pre-op Page 5

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE2 2 Left (3/21/2016) CASE2 2 Right (3/21/2016)

Barefoot pre-op Page 6

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait Cycle

CASE2 2 Right (3/21/2016) CASE2 3 Right (3/21/2016) CASE2 3 Right (3/21/2016)

Barefoot pre-op Page 7

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait Cycle

CASE2 2 Left (3/21/2016) CASE2 2 Left (3/21/2016) CASE2 3 Left (3/21/2016)

Barefoot pre-op Page 8

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait Cycle

CASE2 2 Right (3/21/2016) CASE2 3 Right (3/21/2016) CASE2 3 Right (3/21/2016)

Barefoot pre-op Page 9

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

Gait Cycle

CASE2 2 Left (3/21/2016) CASE2 2 Left (3/21/2016) CASE2 3 Left (3/21/2016)

Barefoot pre-op Page 10

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE2 3 Left (3/21/2016) CASE2 3 Right (3/21/2016)

Barefoot pre-op Page 11

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

deg

-30

25%

50%

75%

Gait Cycle

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE2 3 Left (3/21/2016) CASE2 3 Right (3/21/2016)

Barefoot pre-op Page 12

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right Side EMG 5

Right Gastrocnemius

Right Gastrocnemius*

-5

% Gait Cycle

Right Anterior Tibialis

% Gait Cycle

Right Anterior Tibialis*

-5

% Gait Cycle

Right Hamstrings

V % Gait Cycle

Right Vastus Medialis

-5 5

% Gait Cycle

Right Vastus Lateralis

-5 5

Right Vastus Medialis*

-5 5

% Gait Cycle

Right Vastus Lateralis*

-5 5

-5

% Gait Cycle

Right Rectus Femoris

% Gait Cycle

Right Rectus Femoris*

-5

% Gait Cycle

-5

% Gait Cycle

Right Hamstrings**

% Gait Cycle

Right Vastus Medialis**

-5 5

% Gait Cycle

Right Anterior Tibialis**

V % Gait Cycle

-5 5

% Gait Cycle

Right Hamstrings*

-5 5

Right Gastrocnemius**

% Gait Cycle

Right Vastus Lateralis**

% Gait Cycle

Right Rectus Femoris**

V % Gait Cycle

-5

% Gait Cycle

Left Side EMG 5

Left Gastrocnemius

Left Gastrocnemius*

-5

% Gait Cycle

Left Anterior Tibialis

V % Gait Cycle

Left Hamstrings

-5 5

% Gait Cycle

Left Vastus Medialis

-5 5

Left Hamstrings*

-5 5

% Gait Cycle

Left Vastus Medialis*

-5 5

-5

% Gait Cycle

Left Vastus Lateralis*

-5 5

% Gait Cycle

Left Rectus Femoris

V -5

-5 5

-5

% Gait Cycle

Left Rectus Femoris*

% Gait Cycle

Left Vastus Lateralis**

-5 5

% Gait Cycle

Left Rectus Femoris**

V % Gait Cycle

CASE2 5 - Barefoot - 3-21-16 Barefoot pre-op Page 13

% Gait Cycle

Left Vastus Medialis**

V % Gait Cycle

% Gait Cycle

Left Hamstrings**

-5

Left Vastus Lateralis

% Gait Cycle

Left Anterior Tibialis**

V % Gait Cycle

-5 5

% Gait Cycle

Left Anterior Tibialis*

-5 5

Left Gastrocnemius**

-5

% Gait Cycle

(shaded bar = normal reference)

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT PRE-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE2 2.c3d 0.57 m 1.11 m 57.8 % 0.91 s 132 steps/min 1.22 m/s

CASE2 3.c3d 0.50 m 0.98 m 58.9 % 0.89 s 135 steps/min 1.10 m/s

CASE2 3.c3d 0.49 m 0.96 m 58.9 % 0.89 s 135 steps/min 1.07 m/s

CASE2 2.c3d 0.53 m 1.08 m 58.7 % 0.91 s 132 steps/min 1.19 m/s

CASE2 2.c3d 0.53 m 1.08 m 58.0 % 0.93 s 129 steps/min 1.19 m/s

CASE2 3.c3d 0.46 m 0.96 m 60.4 % 0.88 s 136 steps/min 1.09 m/s

Barefoot pre-op Page 14

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #2 -- POST-OPERATIVE GAIT ANALYSIS AGE: 11 + 10 years

DX: Toe walking

GMFCS: NA

TREATMENT: • • • •

Bilateral tendo-Achilles lengthening (Hoke) – Age 9 + 8 years Day and night time bracing for the first 2 months. Day time bracing continued for additional 4 months. Outpatient physical therapy 2 times per week for the first 6 months, then decreased to 1 time per week.

PATIENT AND FAMILY RESPONSE TO SURGERY AND CURRENT CONCERNS: • • •

Improved ability to walk flat footed. Reports of her feet feeling “fatigued” after running. Reports left foot is more outward when walking.

FUNCTIONAL ABILITIES/PARTICIPATION: • • •

Patient denies tripping and falling with typical activities. Functional Assessment Questionnaire: Parent reported patient is a 10/10 on Functional Walking Scale without significant changes to her ability to complete 22/22 advanced gross motor skills. PODCI scores (out of 100): Global Function: 97; Transfers and Basic mobility: 100, Sports and Physical Function: 88, Pain: 100

GAIT BY OBSERVATION: • • •

Bilateral heel contact at initial contact. Bilateral appropriate timing of heel rise. Able to stand plantigrade with improved stability.

Barefoot post-op Page 15

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 2 Post-Operation

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

Ankle Dorsiflex. Knee @ 0

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

Plantar Flexion

Hip Extension Knee @ 90

Toe Flexor

Toe Extensor

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Knee Extension Hips @ 0

Knee Extension Hips @ 90

-50

-45

Hamstring Tightness

Knee Flexion Total

Knee Q Angle @ 0 (deg)

(+var, -val)

Knee Q Angle @ 20 (deg)

(+var, -val)

Knee Coronal Movement

(1=mild, 3=severe)

Knee Int. Rotation (@ 90)

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Anterior Tibialis Clonus

Confusion w/o Resistance

Confusion w/ Resistance

Leg Length (to heel, mm) Galeazzi

Reverse Galeazzi

Leg Length (mm)

Foot/Thigh Angle

(+ ext, - int)

Heel/Thigh Angle

(+ ext, - int)

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

Heel Bisector

2-3

Plantar Fascia Tightness

(Y=yes, N=no)

Knee Extensor Lag (active)

(to available range)

Abdominal Strength

(+ hyperextension)

880

885

Calluses MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Hip Extensors (gluts)

Hip Adductors

(-,M=mid,S=sup,

Hip Internal Rotators

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Knee Extensors (quads/rectus)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

(C=continuous)

(at max bulk)

Foot Length (mm)

MMT Strength R

Straight Leg Raise

Calf Girth (mm)

Comments

Barefoot post-op Page 16

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Post-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE2 10 Left (2/1/2019) CASE2 10 Right (2/1/2019)

Barefoot post-op Page 17

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE2 11 Right (2/1/2019) CASE2 14 Right (2/1/2019) CASE2 16 Right (2/1/2019)

Barefoot post-op Page 18

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Post-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE2 11 Left (2/1/2019) CASE2 14 Left (2/1/2019) CASE2 16 Left (2/1/2019)

Barefoot post-op Page 19

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Post-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE2 11 Left (2/1/2019) CASE2 11 Right (2/1/2019)

Barefoot post-op Page 20

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait Cycle

CASE2 11 Right (2/1/2019) CASE2 14 Right (2/1/2019) CASE2 16 Right (2/1/2019)

Barefoot post-op Page 21

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait Cycle

CASE2 11 Left (2/1/2019) CASE2 14 Left (2/1/2019) CASE2 16 Left (2/1/2019)

Barefoot post-op Page 22

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait Cycle

CASE2 11 Right (2/1/2019) CASE2 14 Right (2/1/2019) CASE2 16 Right (2/1/2019)

Barefoot post-op Page 23

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

Gait Cycle

CASE2 11 Left (2/1/2019) CASE2 14 Left (2/1/2019) CASE2 16 Left (2/1/2019)

Barefoot post-op Page 24

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE2 16 Left (2/1/2019) CASE2 16 Right (2/1/2019)

Barefoot post-op Page 25

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE2 16 Left (2/1/2019) CASE2 16 Right (2/1/2019)

Barefoot post-op Page 26

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT POST-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE2 11.c3d 0.67 m 1.30 m 56.7 % 1.06 s 113 steps/min 1.23 m/s

CASE2 14.c3d 0.72 m 1.44 m 59.0 % 0.98 s 123 steps/min 1.48 m/s

CASE2 16.c3d 0.69 m 1.41 m 59.8 % 0.93 s 129 steps/min 1.51 m/s

CASE2 11.c3d 0.64 m 1.30 m 59.0 % 1.02 s 118 steps/min 1.28 m/s

CASE2 14.c3d 0.67 m 1.38 m 61.1 % 0.94 s 127 steps/min 1.47 m/s

CASE2 16.c3d 0.73 m 1.47 m 58.1 % 0.97 s 123 steps/min 1.51 m/s

Barefoot post-op Page 27

Connecticut Children’s Medical Center Center for Motion Analysis Right side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE2 11 Right (2/1/2019) CASE2 2 Right (3/21/2016)

Barefoot (kinematics) Page 28

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE2 11 Left (2/1/2019) CASE2 2 Left (3/21/2016)

Barefoot (kinematics) Page 29

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (BAREFOOT Post Op vs Pre Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

W /kg

-2.0

25%

50%

Knee Power

3.0

Gen

W /kg

Abs

25%

50%

75%

-2.0

Gait Cycle

CASE2 11 Right (2/1/2019) CASE2 2 Right (3/21/2016)

Barefoot (sagittal kinetics) Page 30

Ankle Power

3.0

Gen

-2.0

75%

Gait Cycle

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (BAREFOOT Post Op vs Pre Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power*

Knee Power*

3.0

Gen

W/kg

Abs

25%

50%

-2.0

75%

Gait Cycle

25%

50%

75%

-2.0

Gait Cycle

CASE2 11 Left (2/1/2019) CASE2 2 Left (3/21/2016)

Barefoot (sagittal kinetics) Page 31

Ankle Power*

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Case Study #3

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #3 -- PRE-OPERATIVE GAIT ANALYSIS AGE: 9 + 11 years

DX: Cerebral Palsy, diplegia

GMFCS: Level II

HISTORY: • Born at 37 weeks via Cesarean section with a birth weight of 5 lbs, 5 oz. • Second born of twins. • Began walking at 20 months of age. TREATMENT: • • •

No previous lower extremity surgeries. No bracing currently. She had them in the past, but did not like to wear them. School based physical therapy one time per week.

PATIENT AND FAMILY CONCERNS: • •

Her mother is concerned that she easily fatigues with activity. Patient has right sided abdominal/rib pain after walking long distances.

FUNCTIONAL ABILITIES/PARTICIPATION: • • • •

Plays at recess and enjoys biking riding. Functional Mobility Scale: Household: Level 5; School: Level 5; Community: Level 5. Functional Assessment Questionnaire: Parent reported patient is a 8/10 on the Functional Walking Scale and is able to complete 21/22 advanced gross motor skills. PODCI scores (out of 100): Global Function: 83; Transfers and Basic mobility: 100, Sports and Physical Function: 69, Pain: 67

GAIT BY OBSERVATION: • • • • •

Right internal foot progression with right > left inward pointing knees. Right toe toe gait pattern with no heel contact in stance Left forefoot initial contact gait pattern with minimal heel contact in stance Stiff knee gait. Visual valgus knee.

SELECTIVE MOTOR CONTROL: SCALE: Selective Control Assessment of the Lower Extremity

Total limb score: Range 0-10; Right: 9 Left: 10 (10= typical isolated control each joint) Joint Score: Normal: 2 Hip Knee Ankle STJ Toes Hip Knee Ankle STJ Toes Impaired:1; Unable: 0 2 2 2 2 1 2 2 2 2 2 Comments: (+) confusion test (flexor synergy) with forefoot in supination position with resistance bilaterally, without resistance right side only. Bilateral adductor spasticity or contracture. Bilateral plantar flexion contracture and spasticity. Movement in other joints noted with left toes motion. STJ= Subtalar joint Barefoot pre-op Page 1

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 3 Pre-Operation

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

110

115

Ankle Dorsiflex. Knee @ 0

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

Plantar Flexion

4-W

Hip Extension Knee @ 90

MMT Strength

Toe Flexor

Toe Extensor

Straight Leg Raise

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Knee Extension Hips @ 0

Knee Extension Hips @ 90

-40

-50

Foot/Thigh Angle

(+ ext, - int)

Heel/Thigh Angle

(+ ext, - int)

Hamstring Tightness

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

Knee Flexion Total

Knee Q Angle @ 0 (deg)

(+var, -val)

Heel Bisector

2-3

Plantar Fascia Tightness

(Y=yes, N=no)

Knee Q Angle @ 20 (deg)

(+var, -val)

Knee Coronal Movement

(1=mild, 3=severe)

Knee Extensor Lag (active)

(to available range)

Abdominal Strength

Knee Int. Rotation (@ 90)

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Anterior Tibialis Clonus

Confusion w/o Resistance

Confusion w/ Resistance

(+ hyperextension)

Calluses MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Hip Extensors (gluts)

Hip Adductors

(-,M=mid,S=sup,

Hip Internal Rotators

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Foot Length (mm)

Knee Extensors (quads/rectus)

Leg Length (to heel, mm)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Galeazzi

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

Calf Girth (mm)

(at max bulk)

Reverse Galeazzi Leg Length (mm)

(C=continuous)

765

775

Comments

Barefoot pre-op Page 2

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Pre-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE3 10 Left (1/13/2017) CASE3 10 Right (1/13/2017)

Barefoot pre-op Page3

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Pre-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE3 11 Right (1/13/2017) CASE3 11 Right (1/13/2017) CASE3 12 Right (1/13/2017)

Barefoot pre-op Page 4

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE3 11 Left (1/13/2017) CASE3 12 Left (1/13/2017) CASE3 12 Left (1/13/2017)

Barefoot pre-op Page 5

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE3 11 Left (1/13/2017) CASE3 11 Right (1/13/2017)

Barefoot pre-op Page 6

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait Cycle

CASE3 11 Right (1/13/2017) CASE3 11 Right (1/13/2017) CASE3 12 Right (1/13/2017)

Barefoot pre-op Page 7

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait Cycle

CASE3 11 Left (1/13/2017) CASE3 12 Left (1/13/2017) CASE3 12 Left (1/13/2017)

Barefoot pre-op Page 8

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait Cycle

CASE3 11 Right (1/13/2017) CASE3 11 Right (1/13/2017) CASE3 12 Right (1/13/2017)

Barefoot pre-op Page 9

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

Gait Cycle

CASE3 11 Left (1/13/2017) CASE3 12 Left (1/13/2017) CASE3 12 Left (1/13/2017)

Barefoot pre-op Page 10

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE3 11 Left (1/13/2017) CASE3 11 Right (1/13/2017)

Barefoot pre-op Page 11

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

deg

-30

25%

50%

75%

Gait Cycle

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE3 11 Left (1/13/2017) CASE3 11 Right (1/13/2017)

Barefoot pre-op Page 12

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right Side EMG 5

Right Gastrocnemius

Right Gastrocnemius*

-5

% Gait Cycle

Right Anterior Tibialis

% Gait Cycle

Right Anterior Tibialis*

-5

% Gait Cycle

Right Hamstrings

% Gait Cycle

Right Hamstrings*

-5

% Gait Cycle

Right Vastus Medialis

V -5 5

% Gait Cycle

Right Vastus Medialis*

V % Gait Cycle

Right Vastus Lateralis

-5 5

% Gait Cycle

Right Vastus Lateralis*

-5 5

-5

% Gait Cycle

Right Rectus Femoris

% Gait Cycle

Right Rectus Femoris*

-5

% Gait Cycle

Right Anterior Tibialis**

% Gait Cycle

Right Hamstrings**

% Gait Cycle

Right Vastus Medialis**

-5 5

Right Gastrocnemius**

% Gait Cycle

Right Vastus Lateralis**

% Gait Cycle

Right Rectus Femoris**

% Gait Cycle

Left Side EMG 5

Left Gastrocnemius

Left Gastrocnemius*

-5

% Gait Cycle

Left Anterior Tibialis

% Gait Cycle

Left Anterior Tibialis*

-5

% Gait Cycle

Left Hamstrings

V -5 5

% Gait Cycle

Left Hamstrings*

V % Gait Cycle

Left Vastus Medialis

-5 5

% Gait Cycle

Left Vastus Medialis*

-5 5

-5

% Gait Cycle

Left Vastus Lateralis

V -5 5

% Gait Cycle

Left Vastus Lateralis*

V % Gait Cycle

Left Rectus Femoris

V -5

-5 5

-5

% Gait Cycle

Left Rectus Femoris*

% Gait Cycle

Left Vastus Medialis**

% Gait Cycle

Left Vastus Lateralis**

-5 5

% Gait Cycle

Left Rectus Femoris**

V % Gait Cycle

CASE3 13 - Barefoot - 1-13-17

Barefoot pre-op Page 13

% Gait Cycle

Left Hamstrings**

V % Gait Cycle

% Gait Cycle

Left Anterior Tibialis**

-5 5

Left Gastrocnemius**

-5

% Gait Cycle

(shaded bar = normal reference)

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT Pre-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE3 11.c3d 0.64 m 1.21 m 58.9 % 0.89 s 135 steps/min 1.35 m/s

CASE3 12.c3d 0.59 m 1.14 m 58.2 % 0.92 s 131 steps/min 1.25 m/s

CASE3 11.c3d 0.64 m 1.21 m 57.9 % 0.89 s 135 steps/min 1.35 m/s

CASE3 11.c3d 0.58 m 1.22 m 62.3 % 0.88 s 136 steps/min 1.38 m/s

CASE3 12.c3d 0.55 m 1.18 m 61.7 % 0.89 s 135 steps/min 1.32 m/s

CASE3 12.c3d 0.55 m 1.18 m 62.3 % 0.88 s 136 steps/min 1.32 m/s

GDI Side

Trial name

GDI value

Right 1

CASE3 11.c3d

Right 2

CASE3 12.c3d

Right 3

CASE3 11.c3d

Left 1

CASE3 11.c3d

Left 2

CASE3 12.c3d

Left 3

CASE3 12.c3d

Barefoot pre-op Page 14

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #3 -- POST-OPERATIVE GAIT ANALYSIS AGE: 11 + 4 years

DX: Cerebral Palsy, diplegia

GMFCS: Level II

TREATMENT: •

Surgery at 10 + 2 years: Right femoral derotation osteotomy, rectus femoris lengthening, gastrocnemius lengthening; bilateral percutaneous medial hamstring lengthening. • Post operatively, had short leg cast for 1 month. Knee immobilizer in place as well. • Outpatient physical therapy for 6 months at outside facility. • Wore AFO about 5 months post operatively. Discontinued by patient. PATIENT AND FAMILY RESPONSE TO SURGERY AND CURRENT CONCERNS:

• Parent reported improved foot position, better endurance and no longer wears out toes on shoes • Her mother is concerned about residual leg length discrepancy. • Patient would like to dance without pain but no pain on daily activities

FUNCTIONAL ABILITIES/PARTICIPATION: • • • • •

Independent community ambulatory without orthosis or aids. Occasional right ankle pain reported with some activities. No concerns with tripping and falling. Functional Mobility Scale: Household: Level 5; School: Level 5; Community: Level 5 Functional Assessment Questionnaire: Parent reported patient is a 10/10 on the Functional Walking Scale and is able to complete 21/22 advanced gross motor skills. Post- surgery, she noted an improvement in the ability to hop on either foot. • PODCI scores (out of 100): Global Function: 92; Transfers and Basic mobility: 100, Sports and Physical Function: 86, Pain: 82 GAIT BY OBSERVATION: • • • •

Bilateral knee mild flexion at initial contact. Bilateral flat foot contact. Bilateral forward pointing knees. Bilateral neutral foot progression

SELECTIVE MOTOR CONTROL:

SCALE: Selective Control Assessment of the Lower Extremity Total limb score: Range 0-10;

Right: 9

Left: 10

(10= typical isolated control each joint)

Joint Score: Normal: 2 Impaired:1; Unable: 0

Hip Knee Ankle STJ Toes 2 2 2 2 1

Hip Knee Ankle 2 2 2

STJ 2

Comments: (+) confusion test (flexor synergy) with forefoot in midline, with and without resistance on the right only. Sustained clonus right plantar flexors. STJ= Subtalar joint Barefoot post-op Page 15

Toes 2

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 3 Post-Operation

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

115

120

Ankle Dorsiflex. Knee @ 0

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

Plantar Flexion

Toe Flexor

Toe Extensor

Hip Extension Knee @ 90

Straight Leg Raise

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Knee Extension Hips @ 0

Knee Extension Hips @ 90

-40

Hamstring Tightness

Knee Flexion Total Knee Q Angle @ 0 (deg)

MMT Strength R

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Foot/Thigh Angle

(+ ext, - int)

Heel/Thigh Angle

(+ ext, - int)

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

Heel Bisector

2-3

(+var, -val)

Plantar Fascia Tightness

(Y=yes, N=no)

Knee Q Angle @ 20 (deg)

(+var, -val)

Knee Extensor Lag (active)

(to available range)

Knee Coronal Movement

(1=mild, 3=severe)

Abdominal Strength

Knee Int. Rotation (@ 90)

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Anterior Tibialis Clonus

Confusion w/o Resistance

Confusion w/ Resistance

Calf Girth (mm) 840

Galeazzi

POS R>L

Reverse Galeazzi

POS R>L

Leg Length (mm)

780

Comments

860

810

Calluses MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Hip Extensors (gluts)

Hip Adductors

(-,M=mid,S=sup,

Hip Internal Rotators

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Knee Extensors (quads/rectus)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

(C=continuous)

(at max bulk)

Foot Length (mm) Leg Length (to heel, mm)

(+ hyperextension)

Hyperflexible at left elbow and bilateral fingers but not at wrist

Barefoot post-op Page 16

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Post-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE3 20 Left (5/4/2018) CASE3 20 Right (5/4/2018)

Barefoot post-op Page 17

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE3 22 Right (5/4/2018) CASE3 24 Right (5/4/2018) CASE3 25 Right (5/4/2018)

Barefoot post-op Page 18

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Post-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE3 22 Left (5/4/2018) CASE3 24 Left (5/4/2018) CASE3 25 Left (5/4/2018)

Barefoot post-op Page 19

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Post-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE3 22 Left (5/4/2018) CASE3 22 Right (5/4/2018)

Barefoot post-op Page 20

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait Cycle

CASE3 22 Right (5/4/2018) CASE3 24 Right (5/4/2018) CASE3 25 Right (5/4/2018)

Barefoot post-op Page 21

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait Cycle

CASE3 22 Left (5/4/2018) CASE3 24 Left (5/4/2018) CASE3 25 Left (5/4/2018)

Barefoot post-op Page 22

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50% Gait Cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait Cycle

CASE3 22 Right (5/4/2018) CASE3 24 Right (5/4/2018) CASE3 25 Right (5/4/2018)

Barefoot post-op Page 23

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

Gait Cycle

CASE3 22 Left (5/4/2018) CASE3 24 Left (5/4/2018) CASE3 25 Left (5/4/2018)

Barefoot post-op Page 24

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE3 25 Left (5/4/2018) CASE3 25 Right (5/4/2018)

Barefoot post-op Page 25

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE3 25 Left (5/4/2018) CASE3 25 Right (5/4/2018)

Barefoot post-op Page 26

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT POST-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE3 22.c3d 0.60 m 1.16 m 59.8 % 0.97 s 123 steps/min 1.18 m/s

CASE3 24.c3d 0.59 m 1.22 m 62.6 % 0.89 s 135 steps/min 1.37 m/s

CASE3 25.c3d 0.58 m 1.16 m 61.5 % 0.91 s 132 steps/min 1.28 m/s

CASE3 22.c3d 0.56 m 1.13 m 65.2 % 0.96 s 125 steps/min 1.18 m/s

CASE3 24.c3d 0.57 m 1.15 m 65.7 % 0.88 s 137 steps/min 1.32 m/s

CASE3 25.c3d 0.57 m 1.19 m 63.4 % 0.93 s 129 steps/min 1.27 m/s

GDI Side

Trial name

GDI value

Right 1

CASE3 22.c3d

Right 2

CASE3 24.c3d

Right 3

CASE3 25.c3d

Left 1

CASE3 22.c3d

Left 2

CASE3 24.c3d

Left 3

CASE3 25.c3d

Barefoot post-op Page 27

Connecticut Children’s Medical Center Center for Motion Analysis Right side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE3 22 Right (5/4/2018) CASE3 11 Right (1/13/2017)

Barefoot (kinematics) Page 28

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE3 22 Left (5/4/2018) CASE3 11 Left (1/13/2017)

Barefoot (kinematics) Page 29

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (BAREFOOT Post Op vs Pre Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

W /kg

-2.0

25%

50%

Knee Power

3.0

Gen

W /kg

Abs

25%

50%

75%

-2.0

Gait Cycle

CASE3 22 Right (5/4/2018) CASE3 11 Right (1/13/2017)

Barefoot (sagittal kinetics) Page 30

Ankle Power

3.0

Gen

-2.0

75%

Gait Cycle

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (BAREFOOT Post Op vs Pre Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power*

Knee Power*

3.0

Gen

W/kg

Abs

25%

50%

-2.0

75%

Gait Cycle

25%

50%

75%

-2.0

Gait Cycle

CASE3 22 Left (5/4/2018) CASE3 11 Left (1/13/2017)

Barefoot (sagittal kinetics) Page 31

Ankle Power*

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait Cycle

75%

GAIT ANALYSIS REPORT IMPRESSION Patient Name: XXX DOB: XX/XX/XXXX Date of Last Analysis: 7/15/20XX Diagnosis: Gait Abnormality, Diplegia of both lower extremities Walking Aids: independent Orthoses: None Testing Conditions: 1.Barefoot and independent (2. Bilateral solid AFO’s/SMOs etc. and independent /walker/hand held etc)

Age: 9 y.o. 11 m.o. Date of Analysis: 1/13/20XX

HISTORY: PCP: Dr. Pediatrician Birth History : Born at 37 weeks gestation, second of twins, c-section delivery at 5 lbs 5 oz. Development: Delayed milestones including sitting and walking at about 20 months of age. Past Medical History Diagnosis • Cerebral palsy

Date

No previous orthopedic surgery. (xx/xx/xxxx: Bilateral hamstring lengthenings, gastrocnemius lengthenings, etc Xx/xx/xxxx: B Dysport injections to XX muscles (dosage), etc.) Therapies (PT and OT): Physical Therapy in school 1x/week Pain: Pain in the ride side of torso after extending walking. Rests for relief. Patient/Family goals: Mother is worried about fatigue and the pain that XX feels in her muscles on the right side of her torso. Mother feels that gait has not really changed over time. Would like for XX to walk better. Proposed Treatment: Orthopaedic surgical intervention is being considered at this time. Specific procedures were not specified. Functional Scores GMFCS - Gross Motor Function Classification System

Level II: Walks without restrictions on level surface, uses rail for stairs; limitations walking on uneven surface or long distances. FMS - Functional Mobility Scale (Level 6 most independent) House hold (5m) Level 5: Independent walking on level surfaces without walking aids; requires rail for stair negotiation. School (50m) Level 5: Independent walking on level surfaces without walking aids; requires rail for stair negotiation. Community (500m) Level 5: Independent walking on level surfaces without walking aids; requires rail for stair negotiation.

PODCI - Pediatric Outcomes Data Collection Instrument - Max score out of 100 (Previous PODCI measures from 07/15/20xx are in (parentheses)). Transfers & Basic Mobility 100 (100) Sports & Physical Function 69 (66) Pain & Comfort Global Function

67 (74) 83 (83)

Summary of Function • XX is a community ambulator without orthoses or aids. • She has had orthoses in the past, but does not like to wear them. • She is very physically active but does not participate in organized sport. • She does trip and fall in all environments but this is rare and she has never been injured. • XX has more involvement on the right vs left lower extremity. Both upper extremities appear to have normal control. • Mother graded a 8/10 on the FAQ. SUMMARY OF PHYSICIAN RECOMMENDATIONS: Please see attached physician letter.

• Data Collected: Video analysis, Clinical examination, Kinematics, Kinetics and Surface Electromyography • Kinetics discussed refer to net internal moments and powers. (If not obtained: Kinetics were not obtained secondary to small steps lengths/walker use, etc.)

• Gait kinematics and kinetics were consistent (or inconsistent) from stride to stride. • Available Xrays were reviewed. 1. Physician Recommendation:

Bilateral medial hamstring lengthenings and a right rectus femoris lengthening and gastrocnemius lengthening

Gait Feature: (Kinematics and kinetics evidence)

• • • • • •

Physical Exam: (Clinical exam evidence)

(Video, EMG, pedobarograph evidence)

Bilateral increased knee flexion at initial contact Bilateral increased knee flexion in stance Right reduced peak knee flexion in swing Right increased equinus in swing and at initial contact Right premature plantar flexion in mid stance with associated double bump ankle kinetic pattern

• Ankle dorsiflexion (knee flexed/extended): R: 10/5, L: 20/5

• • • • Supplemental Data:

Double bump pelvic tilt

Popliteal angle R: -40 deg, L -50 deg. Ely: R: 1, L: 2 MAS: Knee extensors: R: 2, L: 1 MAS: Ankle plantarflexors: B: 1+

• EMG: Right rectus femoris activity mid swing and right rectus femoris activity in passive stretch. Left rectus femoris activity in swing and not on passive stretch on table. Bilateral hamstring activity in passive stretch in sitting position.

• Video: bilateral knee flexion at initial contact and toe initial contact in stance on right. Left possible vault in mid stance with foot flat initial contact. Other: (Xrays, patient comments/concerns)

• XX has more involvement on the right vs left side.

• Left ankle function is more likely a vault for the following reasons: Normal ankle angle at IC, premature plantar flexion in mid stance, ability to isolate plantar flexion strength on clinical exam (5/5)

2. Physician Recommendation: Gait Feature:

Right Proximal Femoral Derotation Osteotomy

• Right increased internal hip rotation in stance • Right increased internal foot progression stance (secondary to above deviation)

Physical Exam:

• Right passive hip ROM: internal 85 deg, external 5 deg and femoral anteversion 55 deg.

Supplemental Data:

• Video: right internal foot progression and right inpointing knee

Other:

• Recent hip x-ray shows bilateral seated hips.

SUMMARY OF ADDITIONAL GAIT FEATURES AND SIGNIFICANT FINDINGS Gait Changes over Time (7/20xx - 1/20xx). No surgical or orthopedic invention in the interim. Gait Feature: • Bilateral increased equinus with a double bump ankle kinematic and kinetic pattern

• • • • •

Physical Exam:

Right ankle increased equinus in swing and at IC Bilateral knee flexion at initial contact increased Right knee flexion in swing (peak) is less Right hip rotation and foot progression shows increased internal position Bilateral increased anterior pelvic tilt and double bump pattern

• Bilateral ankle increased tightness with knee extended

• Right hip passive ROM reduction in external rotation range from 35 to 5 degrees Supplemental Data:

• VIDEO - increased equinus on the right and possible vault on the left and internal rotation of the right foot

Other:

• none

(Barefoot to braced comparison: (if data collected while braced, changes noted with bracing would be documented here) • Kinematic and kinetic changes when braced. Gait Feature: Physical Exam: • NA Supplemental Data:

• VIDEO – any observations noted on visual exam while braced.

Other:

• XX

(Additional boxes may be used to discuss other deviations that might be important to note, but may not require intervention.)

Scale: Selective Control Assessment of the Lower Extremity Total Limb Left: 10 Score: Range 0-10; (10 = typical isolated control each joint) Joint Score: Hip Knee Normal: 2 2 2 Impaired: 1 Unable: 0 Comments: none

Right: 9

Ankle 2

STJ 2

Toe 2

Hip 2

Knee 2

Ankle 2

STJ 2

Toe 1

If applicable: Foot posture index may be included:

Foot Posture Index (FPI) 0=neutral; -2 = supination; +2 = pronation Right Left Talar head palpation {Score:21031414} {Score:21031414} Curves above/below lateral malleolus {Score:21031414} {Score:21031414} Inversion/eversion of the calcaneous {Score:21031414} {Score:21031414} Bulge in talonavicular joint region {Score:21031414} {Score:21031414} Congruence of medial longitudinal arch {Score:21031414} {Score:21031414} Abd/Adduction of forefoot on rearfoot {Score:21031414} {Score:21031414} Total (-12 to +12) *** *** Total scores range: -12 (extremely supinated/cavus) to +12 (extremely pronated/planus) SUMMARY OF TEMPORAL AND STRIDE PARAMETERS: During barefoot ambulation: Step Lengths Stride Lengths Walking Velocity

R=98-107% of normal 94-101% of normal 99-110% of normal

L=92-97% of normal

Referenced to typical ranges of matched leg lengths

(Temporal and stride parameters while braced would also be included if data collected)

Clinician completing test Center for Motion Analysis

MD reviewing data and making recommendations Center for Motion Analysis cc: Referring MD (Documents included for a full test: Gait Analysis Report Impression, Physical Therapy Evaluation, Physician letter of recommendations to referring physician. Full clinical exam, Kinematic/Kinetic data, Electromyography, Pedobarograph)

Age: 9 y.o. 11 m.o. Date of Analysis: 1/13/20XX

Date

67 (74) 83 (83)

• Gait kinematics and kinetics were consistent (or inconsistent) from stride to stride. • Available Xrays were reviewed. 1. Physician Recommendation:

Bilateral medial hamstring lengthenings and a right rectus femoris lengthening and gastrocnemius lengthening

Gait Feature: (Kinematics and kinetics evidence)

• • • • • •

Physical Exam: (Clinical exam evidence)

(Video, EMG, pedobarograph evidence)

• Ankle dorsiflexion (knee flexed/extended): R: 10/5, L: 20/5

• • • • Supplemental Data:

Double bump pelvic tilt

Popliteal angle R: -40 deg, L -50 deg. Ely: R: 1, L: 2 MAS: Knee extensors: R: 2, L: 1 MAS: Ankle plantarflexors: B: 1+

• XX has more involvement on the right vs left side.

2. Physician Recommendation: Gait Feature:

Right Proximal Femoral Derotation Osteotomy

• Right increased internal hip rotation in stance • Right increased internal foot progression stance (secondary to above deviation)

Physical Exam:

• Right passive hip ROM: internal 85 deg, external 5 deg and femoral anteversion 55 deg.

Supplemental Data:

• Video: right internal foot progression and right inpointing knee

Other:

• Recent hip x-ray shows bilateral seated hips.

• • • • •

Physical Exam:

• Bilateral ankle increased tightness with knee extended

• Right hip passive ROM reduction in external rotation range from 35 to 5 degrees Supplemental Data:

• VIDEO - increased equinus on the right and possible vault on the left and internal rotation of the right foot

Other:

• none

• VIDEO – any observations noted on visual exam while braced.

Other:

• XX

(Additional boxes may be used to discuss other deviations that might be important to note, but may not require intervention.)

Right: 9

Ankle 2

STJ 2

Toe 2

Hip 2

Knee 2

Ankle 2

STJ 2

Toe 1

If applicable: Foot posture index may be included:

R=98-107% of normal 94-101% of normal 99-110% of normal

L=92-97% of normal

Referenced to typical ranges of matched leg lengths

(Temporal and stride parameters while braced would also be included if data collected)

Clinician completing test Center for Motion Analysis

Case Study #4

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #4 -- PRE-OPERATIVE GAIT ANALYSIS AGE: 6 + 11 years

DX: Acute Atrophic Spinal Paralysis

GMFCS: NA

HISTORY: • • • • • • •

Born full term with a birth weight of 6 lbs. 3 oz. Caesarian section delivery with APGARS 8, 8 Required 3 day NICU stay due to respiratory distress Perinatal insult to thoracic cord (T3-T7 atrophy to spinal cord) Delayed developmental milestones with onset of walking between 2.5-3 years of age Bilateral hip dysplasia Associated spastic diplegia

TREATMENT: • • • • •

Bilateral proximal femoral varus derotation osteotomies – 4 + 0 years Bilateral pelvic osteotomy – 4 + 0 years Bilateral hardware removal from femur – 5 + 1 years Bilateral BOTOX gastrocnemius - 6 + 5 years Participating in outpatient PT 2 times per week

PATIENT AND FAMILY CONCERNS: • • •

The patient’s mother and father are concerned about increased incidence of falling which occurs in all environments (home, school and community) multiple times a day They are also concerned about increase inward position of the right foot which is getting worse after BOTOX injection. Patient does not complain of any pain with daily activities.

FUNCTIONAL ABILITIES/PARTICIPATION: • • • • •

Community ambulator with bilateral AFO’s and no assistive devices, however, she uses a wheelchair for longer distance walking Parent reports that she is very active and “always on the move”, however, also reported that she gets tired very quickly. Functional Mobility Scale: Household: Level 5; School: Level 5; Community: Level 5 Functional Assessment Questionnaire: Parent reports patient is a 5/10 on the Functional Walking Scale and is able to complete 11/22 advanced gross motor skills. PODCI scores (out of 100): Global Function: 79; Transfers and Basic mobility: 89, Sports and Physical Function: 39, Pain: 100

GAIT BY OBSERVATION:

• • • • • •

Right internal foot progression with forward pointing knee in mid stance Bilateral toe initial contact with no heel contact in stance and premature plantar flexion mid stance Bilateral increased knee flexion at initial contact with “Jump Knee” pattern Bilateral clearance problems with foot drag in initial swing Increased issues with running With bilateral AFO’s, increased gait asymmetry with ongoing toe walking on the right and heel contact left

Barefoot pre-op Page 1

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 4 Pre-Operation

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

120

Ankle Dorsiflex. Knee @ 0

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

Plantar Flexion

Hip Extension Knee @ 90

MMT Strength R

Toe Flexor

Toe Extensor

Straight Leg Raise

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Knee Extension Hips @ 0

Foot/Thigh Angle

-10

(+ ext, - int)

Knee Extension Hips @ 90

-40

-45

Heel/Thigh Angle

-5

(+ ext, - int)

Hamstring Tightness

M>L

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

Knee Flexion Total

Heel Bisector

2-3

Knee Q Angle @ 0 (deg)

(+var, -val)

Plantar Fascia Tightness

(Y=yes, N=no)

Knee Q Angle @ 20 (deg)

(+var, -val)

Knee Extensor Lag (active)

-30

-15

(to available range)

Knee Coronal Movement

(1=mild, 3=severe)

Abdominal Strength

Knee Int. Rotation (@ 90)

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Anterior Tibialis Clonus

Confusion w/o Resistance

Confusion w/ Resistance

(+ hyperextension)

Calluses MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Hip Extensors (gluts)

Hip Adductors

(-,M=mid,S=sup,

Hip Internal Rotators

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Foot Length (mm)

Knee Extensors (quads/rectus)

Leg Length (to heel, mm)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Galeazzi

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

Calf Girth (mm)

(at max bulk)

Reverse Galeazzi Leg Length (mm)

(C=continuous)

540

Comments

Barefoot pre-op Page 2

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Pre-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE4 30 Left (2/6/2017) CASE4 30 Right (2/6/2017)

Barefoot pre-op Page 3

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Pre-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE4 31 Right (2/6/2017) CASE4 34 Right (2/6/2017) CASE4 35 Right (2/6/2017)

Barefoot pre-op Page 4

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE4 31 Left (2/6/2017) CASE4 34 Left (2/6/2017) CASE4 35 Left (2/6/2017)

Barefoot pre-op Page 5

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE4 31 Left (2/6/2017) CASE4 31 Right (2/6/2017)

Barefoot pre-op Page 6

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait cycle

CASE4 31 Right (2/6/2017) CASE4 34 Right (2/6/2017) CASE4 35 Right (2/6/2017)

Barefoot pre-op Page 7

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait cycle

CASE4 31 Left (2/6/2017) CASE4 34 Left (2/6/2017) CASE4 35 Left (2/6/2017)

Barefoot pre-op Page 8

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

Gait cycle

CASE4 31 Right (2/6/2017) CASE4 34 Right (2/6/2017) CASE4 35 Right (2/6/2017)

Barefoot pre-op Page 9

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

W /kg

-2.0

Knee Power

3.0

50% Gait cycle

75%

-2.0

Ankle Power

3.0

W /kg

25%

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

W /kg

25%

50%

75%

-2.0

25%

Gait cycle

CASE4 31 Left (2/6/2017) CASE4 34 Left (2/6/2017) CASE4 35 Left (2/6/2017)

Barefoot pre-op Page 10

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Pre-Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE4 31 Left (2/6/2017) CASE4 31 Right (2/6/2017)

Barefoot pre-op Page 11

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Pre-Op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE4 31 Left (2/6/2017) CASE4 31 Right (2/6/2017)

Barefoot pre-op Page 12

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right Side EMG 5

Right Gastrocnemius

Right Gastrocnemius*

-5

% Gait Cycle

Right Anterior Tibialis

% Gait Cycle

Right Anterior Tibialis*

-5

% Gait Cycle

Right Hamstrings

V -5 5

% Gait Cycle

Right Hamstrings*

V % Gait Cycle

Right Vastus Medialis

V -5

-5 5

% Gait Cycle

-5 5

Right Vastus Medialis*

-5 5

% Gait Cycle

Right Vastus Lateralis*

-5 5

-5

% Gait Cycle

Right Rectus Femoris

V -5

% Gait Cycle

Right Rectus Femoris*

V % Gait Cycle

-5

% Gait Cycle

Right Hamstrings**

% Gait Cycle

Right Vastus Medialis**

-5 5

% Gait Cycle

Right Anterior Tibialis**

V % Gait Cycle

Right Vastus Lateralis

Right Gastrocnemius**

% Gait Cycle

Right Vastus Lateralis**

% Gait Cycle

Right Rectus Femoris**

V % Gait Cycle

-5

% Gait Cycle

Left Side EMG 5

Left Gastrocnemius

Left Gastrocnemius*

-5

% Gait Cycle

Left Anterior Tibialis

V -5 5

% Gait Cycle

Left Anterior Tibialis*

V % Gait Cycle

Left Hamstrings

V -5

-5 5

% Gait Cycle

-5 5

Left Hamstrings*

-5 5

% Gait Cycle

Left Vastus Medialis*

-5 5

-5

% Gait Cycle

V -5 5

% Gait Cycle

Left Vastus Lateralis*

V % Gait Cycle

Left Rectus Femoris

V -5

-5 5

-5

% Gait Cycle

Left Rectus Femoris*

% Gait Cycle

Left Vastus Lateralis**

-5 5

% Gait Cycle

Left Rectus Femoris**

V % Gait Cycle

CASE4 41 - Barefoot - 2-6-17

Barefoot pre-op Page 13

% Gait Cycle

Left Vastus Medialis**

V % Gait Cycle

% Gait Cycle

Left Hamstrings**

-5

Left Vastus Lateralis

% Gait Cycle

Left Anterior Tibialis**

V % Gait Cycle

Left Vastus Medialis

Left Gastrocnemius**

-5

% Gait Cycle

(shaded bar = normal reference)

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT PRE-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE4 31.c3d 0.45 m 0.89 m 59.3 % 0.90 s 133 steps/min 0.99 m/s

CASE4 34.c3d 0.47 m 0.92 m 59.6 % 0.91 s 132 steps/min 1.01 m/s

CASE4 35.c3d 0.41 m 0.86 m 60.4 % 0.93 s 130 steps/min 0.92 m/s

CASE4 31.c3d 0.46 m 0.91 m 62.0 % 0.90 s 133 steps/min 1.02 m/s

CASE4 34.c3d 0.43 m 0.92 m 59.3 % 0.98 s 122 steps/min 0.93 m/s

CASE4 35.c3d 0.42 m 0.85 m 62.8 % 0.94 s 127 steps/min 0.90 m/s

GDI Side

Trial name

Right 1

CASE 4 31.c3d

Right 2

CASE 4 34.c3d

Right 3

CASE 4 35.c3d

Left 1

CASE 4 31.c3d

Left 2

CASE 4 34.c3d

Left 3

CASE 4 35.c3d

Barefoot pre-op Page 14

GDI value

Connecticut Children’s Medical Center Center for Motion Analysis

Standing (Braces Pre-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE4 36 Left (2/6/2017) CASE4 36 Right (2/6/2017)

Braces pre-op Page 15

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE4 37 Right (2/6/2017) CASE4 37 Right (2/6/2017) CASE4 37 Right (2/6/2017)

Braces pre-op Page 16

75%

Connecticut Children’s Medical Center Center for Motion Analysis L side consistency kinematics (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE4 37 Left (2/6/2017) CASE4 37 Left (2/6/2017) CASE4 37 Left (2/6/2017)

Braces pre-op Page 17

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs Left representative trial (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

CASE4 37 Left (2/6/2017) CASE4 37 Right (2/6/2017)

Braces pre-op Page 18

Foot Progression

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

B S AFO PRE-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE4 37.c3d 0.35 m 0.76 m 52.1 % 0.99 s 121 steps/min 0.77 m/s

CASE4 37.c3d 0.51 m 0.97 m 53 % 0.96 s 125 steps/min 1.02 m/s

CASE4 37.c3d 0.44 m 0.94 m 53.4 % 0.98 s 122 steps/min 0.96 m/s

CASE4 37.c3d 0.43 m 0.86 m 60.2 % 1.03 s 117 steps/min 0.84 m/s

CASE4 37.c3d 0.46 m 0.83 m 64.7 % 0.97 s 124 steps/min 0.86 m/s

CASE4 37.c3d 0.43 m 0.86 m 60.9 % 0.96 s 125 steps/min 0.84 m/s

GDI Side

Trial name

Right 1

CASE 4 37.c3d

Right 2

CASE 4 37.c3d

Right 3

CASE 4 37.c3d

Left 1

CASE 4 37.c3d

Left 2

CASE 4 37.c3d

Left 3

CASE 4 37.c3d

Braces pre-op Page 19

GDI value

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #4 -- POST-OPERATIVE GAIT ANALYSIS AGE: 8 + 4 years

DX: Acute Atrophic Spinal Paralysis

GMFCS: NA

TREATMENT: • Right tibial external rotation osteotomy – 7 + 7 years • Bilateral intramuscular lengthening of the rectus femoris – 7 + 7 years • Bilateral percutaneous lengthening of the medial hamstrings - 7 + 7 years • Bilateral gastrocnemius lengthening - 7 + 7 years • Bilateral solid AFO’s most of the day every day, no night time bracing • PT once per week PATIENT AND FAMILY RESPONSE TO SURGERY AND CURRENT CONCERNS: • Mother reports that surgical outcomes have resulted in improved mobility, functional independence, and no more falling. She feels her daughter walks much better. • Patient would like to be able to ride a bike. FUNCTIONAL ABILITIES/PARTICIPATION: • Independent community ambulatory without orthosis or aids. • No reports of pain with typical daily activities. • No concerns with tripping and falling. • Functional Mobility Scale: Household: Level 5; School: Level 5; Community: Level 5 • Functional Assessment Questionnaire: Parent report patient is a 6/10 on the Functional Walking Scale and is able to complete 9/22 advanced gross motor skills. • PODCI scores (out of 100): Global Function: 76; Transfers and Basic mobility: 89, Sports and Physical Function: 36, Pain: 100 GAIT BY OBSERVATION: • Right foot progression neutral. • Increased full knee extension in stance. • Bilateral flat foot initial contact • Bilateral foot plantigrade in mid-stance with early heel rise • Bilateral increased knee flexion at initial contact • Bilateral foot clearance in initial swing

Barefoot post-op Page 20

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 4 Post-Operation

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

Ankle Dorsiflex. Knee @ 0

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

Plantar Flexion

Hip Extension Knee @ 90

MMT Strength R

Toe Flexor

Toe Extensor

Straight Leg Raise

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Knee Extension Hips @ 0

Foot/Thigh Angle

(+ ext, - int)

Knee Extension Hips @ 90

-40

Heel/Thigh Angle

(+ ext, - int)

Hamstring Tightness

M>L

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

Knee Flexion Total

Heel Bisector

2-3

Knee Q Angle @ 0 (deg)

(+var, -val)

Plantar Fascia Tightness

(Y=yes, N=no)

Knee Q Angle @ 20 (deg)

(+var, -val)

Knee Extensor Lag (active)

-20

-15

(to available range)

Knee Coronal Movement

(1=mild, 3=severe)

Abdominal Strength

Knee Int. Rotation (@ 90)

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Anterior Tibialis Clonus

Confusion w/o Resistance

Confusion w/ Resistance

(+ hyperextension)

Calluses MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Hip Extensors (gluts)

Hip Adductors

(-,M=mid,S=sup,

Hip Internal Rotators

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Knee Extensors (quads/rectus)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Ankle Plantar Flexors Knee @ 90 (soleus)

Reverse Galeazzi

Ankle Invertors (post tib)

Leg Length (mm)

Ankle Evertors (peroneals)

Calf Girth (mm)

(at max bulk)

Foot Length (mm) Leg Length (to heel, mm) Galeazzi

(C=continuous)

(-)

Comments

Barefoot post-op Page 21

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Post-op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE4 55 Left ( 7/26/18) CASE4 55 Right ( 7/26/18)

Barefoot post-op Page 22

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE4 51 Right (7/26/2018) CASE4 52 Right (7/26/2018) CASE4 53 Right (7/26/2018)

Barefoot post-op Page 23

75%

Connecticut Children’s Medical Center Center for Motion Analysis L side consistency kinematics (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE4 51 Left (7/26/2018) CASE4 52 Left (7/26/2018) CASE4 53 Left (7/26/2018)

Barefoot post-op Page 24

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs Left representative trial (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

CASE4 52 Left (7/26/2018) CASE4 52 Right (7/26/2018)

Barefoot post-op Page 25

Foot Progression

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait cycle

CASE4 51 Right (7/26/2018) CASE4 52 Right (7/26/2018) CASE4 53 Right (7/26/2018)

Barefoot post-op Page 26

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait cycle

CASE4 53 Left (7/26/2018) CASE4 52 Left (7/26/2018) CASE4 51 Left (7/26/2018)

Barefoot post-op Page 27

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait cycle

CASE4 51 Right (7/26/2018) CASE4 52 Right (7/26/2018) CASE4 53 Right (7/26/2018)

Barefoot post-op Page 28

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

Gait cycle

CASE4 51 Left (7/26/2018) CASE4 52 Left (7/26/2018) CASE4 53 Left (7/26/2018)

Barefoot post-op Page 29

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE4 53 Left (7/26/2018) CASE4 53 Right (7/26/2018)

Barefoot post-op Page 30

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE4 53 Left (7/26/2018) CASE4 53 Right (7/26/2018)

Barefoot post-op Page 31

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT POST-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE4 51.c3d 0.48 m 0.98 m 58.6 % 0.82 s 145 steps/min 1.19 m/s

CASE4 52.c3d 0.53 m 0.98 m 59.2 % 0.86 s 140 steps/min 1.15 m/s

CASE4 53.c3d 0.48 m 0.95 m 58.8 % 0.85 s 141 steps/min 1.12 m/s

CASE4 51.c3d 0.56 m 1.04 m 61.3 % 0.88 s 136 steps/min 1.18 m/s

CASE4 52.c3d 0.42 m 0.95 m 64.7 % 0.85 s 141 steps/min 1.12 m/s

CASE4 53.c3d 0.51 m 0.97 m 64.8 % 0.88 s 137 steps/min 1.11 m/s

GDI Side

Trial name

Right 1

CASE 4 51.c3d

Right 2

CASE 4 52.c3d

Right 3

CASE 4 53.c3d

Left 1

CASE 4 51.c3d

Left 2

CASE 4 53.c3d

Left 3

CASE 4 54.c3d

Barefoot post-op Page 32

GDI value

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Braces Post-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE4 56 Left (7/26/2018) CASE4 56 Right (7/26/2018)

Brace post-op Page 33

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Braces Post-Op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50% Gait Cycle

75%

-40

Foot Progression

25%

50% Gait Cycle

CASE4 58 Right (7/26/2018) CASE4 60 Right (7/26/2018) CASE4 61 Right (7/26/2018)

Brace post-op Page 34

75%

Connecticut Children’s Medical Center Center for Motion Analysis L side consistency kinematics (Braces Post-Op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Foot Progression

25%

Gait Cycle

CASE4 58 Left (7/26/2018) CASE4 60 Left (7/26/2018) CASE4 61 Left (7/26/2018)

Brace post-op Page 35

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs Left (Braces Post-op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

CASE4 58 Left (7/26/2018) CASE4 58 Right (7/26/2018)

Brace post-op Page 36

Foot Progression

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Braces post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

W/kg

-2.0

25%

50% Gait cycle

Knee Power

3.0

75%

Gen

W/kg

Abs

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait cycle

CASE4 58 Right (7/26/2018) CASE4 60 Right (7/26/2018) CASE4 61 Right (7/26/2018)

Brace post-op Page 37

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Braces post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power*

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait cycle

CASE4 58 Left (7/26/2018) CASE4 60 Left (7/26/2018) CASE4 61 Left (7/26/2018)

Brace post-op Page 38

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Braces post op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power*

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait cycle

CASE4 58 Right (7/26/2018) CASE4 60 Right (7/26/2018) CASE4 61 Right (7/26/2018)

Brace post-op Page 39

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Braces post-op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

W/kg

-2.0

Knee Power

3.0

50% Gait cycle

75%

-2.0

Ankle Power

3.0

W/kg

25%

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

W/kg

25%

50%

75%

-2.0

25%

Gait cycle

CASE4 58 Left (7/26/2018) CASE4 60 Left (7/26/2018) CASE4 61 Left (7/26/2018)

Brace post-op Page 40

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Brace Post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE4 58 Left (7/26/2018) CASE4 58 Right (7/26/2018)

Brace post-op Page 41

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Brace post-op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

50 Gait cycle

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE4 58 Left (7/26/2018) CASE4 58 Right (7/26/2018)

Brace post-op Page 42

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

B S AFO POST-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE4 58.c3d 0.58 m 1.10 m 55.2 % 0.80 s 150 steps/min 1.37 m/s

CASE4 60.c3d 0.54 m 1.12 m 54.1 % 0.82 s 147 steps/min 1.38 m/s

CASE4 61.c3d 0.57 m 1.11 m 57.7 % 0.81 s 148 steps/min 1.37 m/s

CASE4 58.c3d 0.52 m 1.06 m 61.1 % 0.79 s 152 steps/min 1.31 m/s

CASE4 60.c3d 0.57 m 1.11 m 59.6 % 0.83 s 145 steps/min 1.50 m/s

CASE4 61.c3d 0.55 m 1.13 m 59.2 % 0.82 s 147 steps/min 1.39 m/s

GDI Side

Trial name

Right 1

CASE 4 58.c3d

Right 2

CASE 4 60.c3d

Right 3

CASE 4 61.c3d

Left 1

CASE 4 58.c3d

Left 2

CASE 4 60.c3d

Left 3

CASE 4 61.c3d

Brace post-op Page 43

GDI value

Connecticut Children’s Medical Center Center for Motion Analysis Right side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE4 53 Right (7/26/2018) CASE4 31 Right (2/6/2017)

(kinematics) Page 44

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE4 53 Left (7/26/2018) CASE4 31 Left (2/6/2017)

(kinematics) Page 45

25%

50% Gait Cycle

75%

Case Study #5

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (BAREFOOT Post Op vs Pre Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE4 53 Right (7/26/2018) CASE4 34 Right (2/6/2017)

(sagittal kinetics) Page 46

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (BAREFOOT Post Op vs Pre Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE4 53 Left (7/26/2018) CASE4 31 Left (2/6/2017)

(sagittal kinetics) Page 47

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #5 -- PRE-OPERATIVE GAIT ANALYSIS AGE: 6 + 0 years

DX: Cerebral Palsy Spastic Diplegia

GMFCS: III

HISTORY: • • •

Born 28 weeks gestation with a birth weight of 2 lbs. 8 oz. Required 8 weeks NICU stay Began walking at 3 years of age with a walker

TREATMENT: • BOTOX to bilateral gastrocnemius and hamstrings 4 times between ages 2.5 to 3.5 years • Physical and Occupational Therapy 1 time per week outpatient and school • Bilateral solid AFO’s are “too tight” PATIENT AND FAMILY CONCERNS: • • •

The patient’s parents are concerned about increased tightness. Patient does not complain of any pain, but has leg cramps after extended walking. Mother would like him to walk without a walker. Child would like to play baseball.

FUNCTIONAL ABILITIES/PARTICIPATION: • • • • • •

Uses bilateral solid AFO’s, rollator walker (primary) and wheel chair for long distances. No issues with tripping and falling Parent reports that he is very active and participates in swimming, hiking, wheelchair basketball, baseball and soccer. Functional Mobility Scale: Household: Crawls or holds onto furniture. School: Level 2; Community: Level 2 Functional Assessment Questionnaire: Parent reports patient is an 8/10 on the Functional Walking Scale and is able to complete 6/22 advanced gross motor activities. PODCI scores (out of 100): Global Function: 72; Transfers and Basic mobility: 70, Sports and Physical Function: 74, Pain: 80

GAIT BY OBSERVATION: • • • •

Bilateral toe initial contact with no heel contact in stance Bilateral increased knee flexion at initial contact and in stance Bilateral clearance problems with foot drag in initial swing With bilateral AFO’s: similar gait pattern with ongoing toe contact and increased knee flexion in stance and clearance issues in swing, bilaterally

Barefoot pre-op Page 1

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 5 Pre-Operation

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

110

120

3min

Ankle Dorsiflex. Knee @ 0

Hip Extension Knee @ 0

-5

Ankle Dorsiflex. Knee @ 90

Plantar Flexion

Hip Extension Knee @ 90

MMT Strength R

-10

-5

Toe Flexor

Toe Extensor

Straight Leg Raise

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

L=0

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Knee Extension Hips @ 0

(+ hyperextension)

Foot/Thigh Angle

(+ ext, - int)

Knee Extension Hips @ 90

-35

-40

Heel/Thigh Angle

(+ ext, - int)

Hamstring Tightness

M>L

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

Knee Flexion Total

Knee Q Angle @ 0 (deg)

Knee Q Angle @ 20 (deg)

Knee Coronal Movement

Knee Int. Rotation (@ 90)

Heel Bisector

2-3

3-4

(+var, -val)

Plantar Fascia Tightness

(Y=yes, N=no)

(+var, -val)

Knee Extensor Lag (active)

(to available range)

(1=mild, 3=severe)

Abdominal Strength

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Hip Extensors (gluts)

Anterior Tibialis Clonus

Hip Adductors

Confusion w/o Resistance

(-,M=mid,S=sup,

Hip Internal Rotators

Confusion w/ Resistance

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Foot Length (mm)

Knee Extensors (quads/rectus)

Leg Length (to heel, mm)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Galeazzi

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

Calf Girth (mm)

(C=continuous)

(at max bulk)

Reverse Galeazzi Leg Length (mm)

530

Calluses MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Comments

Barefoot pre-op Page 2

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Pre-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE5 1 Left (7/2/2015) CASE5 1 Right (7/2/2015)

Barefoot pre-op Page 3

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Pre-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE5 3 Right (7/2/2015) CASE5 3 Right (7/2/2015) CASE5 3 Right (7/2/2015)

Barefoot pre-op Page 4

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side consistency kinematics (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE5 3 Left (7/2/2015) CASE5 3 Left (7/2/2015) CASE5 3 Left (7/2/2015)

Barefoot pre-op Page 5

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE5 3 Left (7/2/2015) CASE5 3 Right (7/2/2015)

Barefoot pre-op Page 6

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right Side EMG 5

Right Gastrocnemius

Right Gastrocnemius*

-5

% Gait Cycle

Right Anterior Tibialis

V -5 5

V % Gait Cycle

Right Hamstrings

V -5 5

-5 5

% Gait Cycle

Right Vastus Medialis

-5 5

-5

% Gait Cycle

Right Hamstrings*

Right Vastus Lateralis

-5 5

-5

% Gait Cycle

Right Vastus Medialis*

-5

% Gait Cycle

Right Vastus Lateralis*

-5

% Gait Cycle

V -5

% Gait Cycle

Right Rectus Femoris*

V % Gait Cycle

-5

% Gait Cycle

Right Vastus Medialis**

-5

Right Rectus Femoris

% Gait Cycle

Right Hamstrings**

V % Gait Cycle

% Gait Cycle

Right Anterior Tibialis**

V -5

% Gait Cycle

Right Anterior Tibialis*

Right Gastrocnemius**

% Gait Cycle

Right Vastus Lateralis**

% Gait Cycle

Right Rectus Femoris**

V -5

% Gait Cycle

Left Side EMG 5

Left Gastrocnemius

Left Gastrocnemius*

-5

% Gait Cycle

Left Anterior Tibialis

V -5 5

% Gait Cycle

Left Anterior Tibialis*

V % Gait Cycle

Left Hamstrings

-5 5

-5

% Gait Cycle

Left Hamstrings*

-5

% Gait Cycle

V -5 5

% Gait Cycle

Left Vastus Medialis*

V % Gait Cycle

Left Vastus Lateralis

-5 5

-5

% Gait Cycle

Left Vastus Lateralis*

-5

% Gait Cycle

V -5

% Gait Cycle

Left Rectus Femoris*

V % Gait Cycle

-5

% Gait Cycle

Left Vastus Medialis**

% Gait Cycle

Left Vastus Lateralis**

% Gait Cycle

Left Rectus Femoris**

V % Gait Cycle

CASE5 7 - Barefoot - 7-2-15 Barefoot pre-op Page 7

% Gait Cycle

Left Hamstrings**

-5

Left Rectus Femoris

% Gait Cycle

Left Anterior Tibialis**

-5

Left Vastus Medialis

Left Gastrocnemius**

-5

% Gait Cycle

(shaded bar = normal reference)

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT PRE-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE5 3.c3d 0.31 m 0.68 m 56.6 % 0.82 s 145 steps/min 0.83 m/s

CASE5 3.c3d 0.33 m 0.68 m 55.3 % 0.86 s 140 steps/min 0.79 m/s

CASE5 3.c3d 0.34 m 0.69 m 56.0 % 0.83 s 144 steps/min 0.82 m/s

CASE5 3.c3d 0.35 m 0.66 m 60.8 % 0.85 s 141 steps/min 0.78 m/s

CASE5 3.c3d 0.35 m 0.66 m 58.1 % 0.88 s 137 steps/min 0.78 m/s

GDI Side

Trial name

GDI value

Right 1

CASE5 3.c3d

Right 2

CASE5 3.c3d

Right 3

CASE5 3.c3d

Left 1

CASE5 3.c3d

Left 2

CASE5 3.c3d

Left 3

CASE5 3.c3d

Barefoot pre-op Page 8

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Braces Pre-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE5 4 Left (7/2/2015) CASE5 4 Right (7/2/2015)

Braces pre-op Page 9

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE5 6 Right (7/2/2015) CASE5 6 Right (7/2/2015) CASE5 6 Right (7/2/2015)

Braces pre-op Page 10

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis L side consistency kinematics (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE5 6 Left (7/2/2015) CASE5 6 Left (7/2/2015) CASE5 6 Left (7/2/2015)

Braces pre-op Page 11

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs Left representative trial (Braces Pre-Op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

CASE5 6 Left (7/2/2015) CASE5 6 Right (7/2/2015)

Braces pre-op Page 12

Foot Progression

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

Bilateral solid AFO PRE-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE5 6.c3d 0.35 m 0.78 m 55.6 % 0.90 s 133 steps/min 0.86 m/s

CASE5 6.c3d 0.36 m 0.71 m 54.3 % 0.97 s 124 steps/min 0.73 m/s

CASE5 6.c3d 0.35 m 0.70 m 52.4 % 1.03 s 116 steps/min 0.67 m/s

CASE5 6.c3d 0.35 m 0.79 m 42.7 % 0.92 s 131 steps/min 0.87 m/s

CASE5 6.c3d 0.35 m 0.70 m 59.5 % 0.97 s 124 steps/min 0.67 m/s

GDI Side

Trial name

GDI value

Right 1

CASE5 6.c3d

Right 2

CASE5 6.c3d

Right 3

CASE5 6.c3d

Left 1

CASE5 6.c3d

Left 2

CASE5 6.c3d

Left 3

CASE5 6.c3d

Braces pre-op Page 13

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #5 – FIRST POST-OPERATIVE GAIT ANALYSIS AGE: 7+ 6 years

DX: Cerebral Palsy Spastic Diplegia

GMFCS: II

TREATMENT: • • • • • •

Bilateral intramuscular lengthening of the rectus femoris – 6 + 6 years Bilateral percutaneous lengthening of the medial hamstrings - 6 + 6 years Bilateral gastrocnemius lengthening - 6 + 6 years Bilateral solid AFO’s at school only and not in summer time Physical therapy three times per week (2 times at school and 1 time outpatient) Occupational therapy two times per week (1 time at school and 1 time outpatient)

PATIENT AND FAMILY RESPONSE TO SURGERY AND CURRENT CONCERNS: • • • • •

Mother reports that surgical outcomes have resulted in improved walking ability including independent ambulation, ability to get on and off school bus, learning to run, ability to walk everywhere and willingness to try everything. Other skills where improvement noted on FAQ: walking up and down stairs (with and without railing), step over objects with both feet, kick a ball with both feet, ride a 3 wheeled bike and ride an escalator. Parent also noted following benefits on FAQ: improved self-esteem, mobility and independence and that she was extremely satisfied with the surgery Patient is extremely satisfied with the surgery Mother is concerned with increasing incidence of falls over the past few months in all environments (home, school and community)

FUNCTIONAL ABILITIES/PARTICIPATION: • • • • •

Independent community ambulatory with bilateral solid AFO’s without aids. He uses the walker only at recess at school. No reports of pain with activities. Functional Mobility Scale: Household: Level 5; School: Level 5 (mandated walker at recess); Community: Level 5 Functional Abilities Questionnaire: Parent reported patient is an 8/10 on the Functional Walking Scale and is able to complete 15/22 activities on advanced skills list PODCI scores (out of 100): Global Function: 77; Transfers and Basic mobility: 85, Sports and Physical Function: 70, Pain: 89

GAIT BY OBSERVATION: • • • • •

Bilateral foot progression within typical range during stance. Bilateral increased knee flexion at initial contact. Bilateral flat foot initial contact Bilateral foot plantigrade in mid-stance Bilateral ongoing periodic foot drag in initial swing (AFO’s>barefoot)

SCALE: Selective Control Assessment of the Lower Extremity Total limb score: Range 0-10; Right: 3

Left: 2 (10= typical isolated control each joint) Hip Knee Ankle STJ Toes Hip Knee Ankle STJ Joint Score: Normal: 2 1 1 1 0 0 1 1 0 0 Impaired:1; Unable: 0 Comments: (+) confusion test (flexor synergy) with forefoot in midline position with and without resistance bilaterally. STJ : Subtalar joint Barefoot post-op Page 14

Toes 0

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 5 Post-Operation 1

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

115

Ankle Dorsiflex. Knee @ 0

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

Plantar Flexion

Toe Flexor

Toe Extensor

Hip Extension Knee @ 90

Straight Leg Raise

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Knee Extension Hips @ 0

Knee Extension Hips @ 90

-45

Hamstring Tightness

Knee Flexion Total

120

125

Knee Q Angle @ 0 (deg)

Knee Q Angle @ 20 (deg)

Knee Coronal Movement

Knee Int. Rotation (@ 90)

MMT Strength R

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Foot/Thigh Angle

-5

(+ ext, - int)

Heel/Thigh Angle

(+ ext, - int)

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

(+ hyperextension)

Heel Bisector

2-3

(+var, -val)

Plantar Fascia Tightness

(Y=yes, N=no)

(+var, -val)

Knee Extensor Lag (active)

(to available range)

(1=mild, 3=severe)

Abdominal Strength

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Hip Extensors (gluts)

Anterior Tibialis Clonus

Hip Adductors

Confusion w/o Resistance

(-,M=mid,S=sup,

Hip Internal Rotators

Confusion w/ Resistance

P=pro)

Hip External Rotators

Knee Flexors (hamstrings)

Foot Length (mm)

Knee Extensors (quads/rectus)

Leg Length (to heel, mm)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Galeazzi

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

Calf Girth (mm)

(C=continuous)

(at max bulk)

Reverse Galeazzi Leg Length (mm)

590

Calluses MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Comments

Barefoot post-op Page 15

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Barefoot Post-op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE5 10 Left (1/23/17) CASE5 10 Right (1/23/17)

Barefoot post-op Page 16

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis R side consistency kinematics (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50% Gait Cycle

75%

-40

25%

50% Gait Cycle

CASE5 11 Right (1/23/2017) CASE5 12 Right (1/23/2017) CASE5 13 Right (1/23/2017)

Barefoot post-op Page 17

75%

Connecticut Children’s Medical Center Center for Motion Analysis L side consistency kinematics (Barefoot Post-op) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

CASE5 12 Left (1/23/2017) CASE5 15 Left (1/23/2017) CASE5 16 Left (1/23/2017)

Barefoot post-op Page 18

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs. Left representative trial (Barefoot Post-Op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion*

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

CASE5 12 Left (1/23/2017) CASE5 12 Right (1/23/2017)

Barefoot post-op Page 19

Foot Progression

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait cycle

CASE5 11 Right (1/23/2017) CASE5 12 Right (1/23/2017) CASE5 13 Right (1/23/2017)

Barefoot post-op Page 20

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

Deg

Pos

-20

Pelvic Tilt

Ant

Deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

Deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait cycle

CASE5 12 Left (1/23/2017) CASE5 15 Left (1/23/2017) CASE5 16 Left (1/23/2017)

Barefoot post-op Page 21

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait cycle

CASE5 11 Right (1/23/2017) CASE5 12 Right (1/23/2017) CASE5 13 Right (1/23/2017)

Barefoot post-op Page 22

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

Deg

-30

Pelvic Obliquity

Deg

-20

Hip Ab-Adduction

Add

Knee Varus-Valgus

Var

Deg

Abd

Val

-20

-30

Deg

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W /kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

Gait cycle

CASE5 12 Left (1/23/2017) CASE5 15 Left (1/23/2017) CASE5 16 Left (1/23/2017)

Barefoot post-op Page 23

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Barefoot Post-Op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE5 12 Left (1/23/2017) CASE5 12 Right (1/23/2017)

Barefoot post-op Page 24

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Barefoot Post-Op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

CASE5 12 Left (1/23/2017) CASE5 12 Right (1/23/2017)

Barefoot post-op Page 25

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT POST-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE5 11.c3d 0.38 m 0.78 m 60.2 % 1.03 s 117 steps/min 0.76 m/s

CASE5 12.c3d 0.44 m 0.89 m 62.2 % 0.82 s 147 steps/min 1.08 m/s

CASE5 13.c3d 0.44 m 0.92 m 63.0 % 0.90 s 133 steps/min 1.02 m/s

CASE5 12.c3d 0.46 m 0.93 m 59.8 % 0.85 s 141 steps/min 1.10 m/s

CASE5 15.c3d 0.36 m 0.76 m 62.7 % 0.92 s 131 steps/min 0.83 m/s

CASE5 16.c3d 0.50 m 0.89 m 59.8 % 0.85 s 141 steps/min 1.04 m/s

GDI Side

Trial name

GDI value

Right 1

CASE5 11.c3d

Right 2

CASE5 12.c3d

Right 3

CASE5 13.c3d

Left 1

CASE5 12.c3d

Left 2

CASE5 15.c3d

Left 3

CASE5 16.c3d

Barefoot post-op Page 26

Connecticut Children’s Medical Center Center for Motion Analysis Standing (Braces Post-Op) 30

Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Add

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Var

Flx

Int

deg

Val

Ext

-30

-20

-40

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

CASE5 25 Left (1/23/2017) CASE5 25 Right (1/23/2017)

Brace post-op Page 27

Trunk Rotation

Pelvic Rotation

Hip Rotation

Knee Rotation

Foot Progression

Connecticut Children’s Medical Center Center for Motion Analysis Right Side Consistency Kinematics (Braces Post-Op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50% Gait Cycle

75%

-40

Foot Progression

25%

50% Gait Cycle

CASE5 20 Right (1/23/2017) CASE5 22 Right (1/23/2017) CASE5 23 Right (1/23/2017)

Brace post-op Page 28

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left Side Consistency Kinematics (Braces Post-Op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Foot Progression

25%

Gait Cycle

CASE5 20 Left (1/23/2017) CASE5 22 Left (1/23/2017) CASE5 23 Left (1/23/2017)

Brace post-op Page 29

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right vs Left (Braces Post-op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

CASE5 22 Left (1/23/2017) CASE5 22 Right (1/23/2017)

Brace post-op Page 30

Foot Progression

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Braces post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

W/kg

-2.0

25%

50% Gait cycle

Knee Power

3.0

75%

Gen

W/kg

Abs

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait cycle

CASE5 20 Right (1/23/2017) CASE5 22 Right (1/23/2017) CASE5 23 Right (1/23/2017)

Brace post-op Page 31

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Braces post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power*

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait cycle

CASE5 20 Left (1/23/2017) CASE5 22 Left (1/23/2017) CASE5 23 Left (1/23/2017)

Brace post-op Page 32

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side coronal plane kinetics (Braces post op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power*

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

75%

-2.0

25%

50% Gait cycle

CASE5 20 Right (1/23/2017) CASE5 22 Right (1/23/2017) CASE5 23 Right (1/23/2017)

Brace post-op Page 33

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side coronal plane kinetics (Braces post-op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

W/kg

-2.0

Knee Power

3.0

50% Gait cycle

75%

-2.0

Ankle Power

3.0

W/kg

25%

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

W/kg

25%

50%

75%

-2.0

25%

Gait cycle

CASE5 20 Left (1/23/2017) CASE5 22 Left (1/23/2017) CASE5 23 Left (1/23/2017)

Brace post-op Page 34

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L sagittal plane kinetics (Brace Post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

75%

-2.0

Gait cycle

CASE5 22 Left (1/23/2017) CASE5 22 Right (1/23/2017)

Brace post-op Page 35

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis R vs L coronal plane kinetics (Brace post-op) Trunk Obliquity

deg

-30

Pelvic Obliquity

deg

-20

Hip Ab-Adduction

Knee Varus-Valgus

Add

Var

deg

Abd

Val

-20

-30

Hip Moment

2.0

Knee Moment

2.0

Val

Var

Nm/kg

Add

Var

Val

-1.0

Hip Power

W/kg

-2.0

Knee Power

3.0

50 Gait cycle

-2.0

W/kg

25%

50%

75%

-2.0

Gait cycle

CASE5 22 Left (1/23/2017) CASE5 22 Right (1/23/2017)

Brace post-op Page 36

Ankle Power

3.0

W/kg

Ankle Moment

2.0

Abd

3.0

Ankle Var/Val

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

Bilateral solid AFO POST-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE5 20.c3d 0.57 m 1.07 m 55.6 % 0.98 s 123 steps/min 1.10 m/s

CASE5 22.c3d 0.50 m 0.96 m 61.1 % 0.79 s 152 steps/min 1.21 m/s

CASE5 23.c3d 0.51 m 0.98 m 57.5 % 0.88 s 136 steps/min 1.11 m/s

CASE5 20.c3d 0.54 m 1.12 m 56.7 % 1.00 s 120 steps/min 1.12 m/s

CASE5 22.c3d 0.46 m 0.91 m 61.1 % 0.79 s 152 steps/min 1.15 m/s

CASE5 23.c3d 0.46 m 0.92 m 63.4 % 0.84 s 143 steps/min 1.10 m/s

GDI Side

Trial name

GDI value

Right 1

CASE5 20.c3d

Right 2

CASE5 22.c3d

Right 3

CASE5 23.c3d

Left 1

CASE5 20.c3d

Left 2

CASE5 22.c3d

Left 3

CASE5 23.c3d

Brace post-op Page 37

Connecticut Children’s Medical Center Center for Motion Analysis Right side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE5 12 Right (1/23/2017) CASE5 3 Right (7/2/2015)

Post vs Pre (kinematics) Page 38

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side comparison BAREFOOT (post operative vs. pre operative) Trunk Obliquity

Trunk Tilt

Trunk Rotation

Ant

Int

Pos

Ext

-30

-20

deg

Pelvic Obliquity

-40

Pelvic Tilt

Pelvic Rotation

Ant

Int

Pos

Ext

-20

deg

Hip Ab-Adduction

Add

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg Val -30

25%

50%

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

CASE5 12 Left (1/23/2017) CASE5 3 Left (7/2/2015)

Post vs Pre (kinematics) Page 39

25%

50% Gait Cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis CASE STUDY #5 – SECOND POST-OPERATIVE GAIT ANALYSIS AGE: 9+ 11 years (3.5 years post-surgery) DX: Cerebral Palsy Spastic Diplegia

GMFCS: II

TREATMENT: • Oral Baclofen – after long day of activity, before bed but patient does not like this and discontinued • Bilateral solid carbon fiber AFO’s at school only and not in summer time (broken two pairs in past few months) • Physical and occupational therapy ongoing (school and outpatient) PATIENT AND FAMILY RESPONSE CURRENT CONCERNS: • Mother is concerned with increasing incidence of tripping and falling (multiple times per day) in all environments (home, school and community) • No difference in barefoot vs. AFO walking in terms of number of falls • Wears holes in shoes on bilateral toes requiring frequent replacement FUNCTIONAL ABILITIES/PARTICIPATION: • Independent community ambulatory with bilateral solid AFO’s without aids. He uses the walker only at recess when at school. • Participates in baseball, horseback riding, swimming, lacrosse, hiking (Scouts), and karate. • Patient does not report any pain with typical activities. GAIT BY OBSERVATION: • Bilateral limited knee flexion in swing (worse when running) • Bilateral foot drag in initial swing GAIT ANALYSIS RELATED FINDINGS: • Bilateral reduced peak knee flexion in swing (barefoot and AFO’s) • Bilateral rectus femoris activity in mid swing (no vastus medialis/lateralis EMG activity) • Bilateral ELY 4/4 with limited rectus femoris activity at beginning of movement only – muscle tightness the primary issue versus spasticity • Bilateral passive peak knee flexion prone: 120-125 degrees (painful) following stretch. TAKE HOME MESSAGE: Surface EMG on the rectus femoris and vasti during gait, ELY and passive ROM testing can assist in understanding role of active muscle contraction in causing reduced peak knee flexion in swing during gait and resistance to stretch during the clinical assessment.

2nd post op Page 40

Connecticut Children's Medical Center Center for Motion Analysis Clinical Examination - Range of Motion and Strength Name: Case 5 Post-Operation 2

DOB: -

MRN: -

Date of Analysis:

Passive ROM

MMT Strength

Passive ROM

Hip Flexion

105

110

Ankle Dorsiflex. Knee @ 0

3+W

Hip Extension Knee @ 0

Ankle Dorsiflex. Knee @ 90

4-W

Plantar Flexion

Toe Flexor

Toe Extensor

Hip Extension Knee @ 90 Straight Leg Raise

Hip Abduction Hips @ 0

Hip Abduction Hips @ 90

Hip Adduction Knee @ 0

Hip Adduction Knee @ 90

Hip Internal Rotation

Forefoot/Hindfoot Adduction

Hip External Rotation

Hindfoot Inversion

Femoral Anteversion

Hindfoot Eversion

Knee Extension Hips @ 0

Knee Extension Hips @ 90

-50

-60

Hamstring Tightness

Knee Flexion Total

MMT Strength L

Subtalar (Foot) Inversion

(on side for myelo)

Subtalar (Foot) Eversion

(on side for myelo)

Forefoot/Hindfoot Abduction

Foot/Thigh Angle

(+ ext, - int)

Heel/Thigh Angle

(+ ext, - int)

M>L

(Med, Lat, Both)

Bi-malleolar Axis

(+ ext, - int)

120*

125*

Knee Q Angle @ 0 (deg)

Knee Q Angle @ 20 (deg)

Knee Coronal Movement

Knee Int. Rotation (@ 90)

(+ hyperextension)

Heel Bisector

1-2

(+var, -val)

Plantar Fascia Tightness

(Y=yes, N=no)

(+var, -val)

Knee Extensor Lag (active)

(to available range)

(1=mild, 3=severe)

Abdominal Strength

(1=mild, 3=severe)

Knee Ext. Rotation (@ 90)

(1=mild, 3=severe)

Ely Test

Gastroc-soleus Clonus

Peroneal Clonus

Hip Extensors (gluts)

Anterior Tibialis Clonus

Hip Adductors

Confusion w/o Resistance

(-,M=mid,S=sup,

Hip Internal Rotators

Confusion w/ Resistance

P=pro)

Hip External Rotators

Calf Girth (mm)

(at max bulk)

Knee Flexors (hamstrings)

Foot Length (mm)

Knee Extensors (quads/rectus)

Ankle Plantar Flexors Knee @ 0 (gastroc)

Ankle Plantar Flexors Knee @ 90 (soleus)

Ankle Invertors (post tib)

Ankle Evertors (peroneals)

Leg Length (to heel, mm) Galeazzi

Reverse Galeazzi

Leg Length (mm) Comments

680

(C=continuous)

680

Calluses

None

MODIFIED ASHWORTH SCALE

Hip Flexors (psoas)

Bilateral Pes Planus, * with pain

2nd post-op Page 41

Connecticut Children’s Medical Center Center for Motion Analysis Right vs Left (Barefoot 2nd Post-op) Trunk Obliquity

Trunk Tilt

Ant

Int

deg

Pos

Ext

-30

-20

-40

Pelvic Obliquity

Pelvic Tilt

Ant

Int

deg

Pos

Ext

-20

-40

Hip Ab-Adduction

Hip Flexion-Extension

Flx

Int

deg

Abd

Ext

-20

-40

Knee Varus-Valgus

Knee Flexion-Extension

Flx

Int

deg

Val

Ext

-20

-40

25%

50%

75%

Knee Rotation

Var

-30

Hip Rotation

Add

Pelvic Rotation

Trunk Rotation

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

deg

Pla

Ext

-40

25%

50%

75%

-40

Gait Cycle

CASE5 33 Left (7/19/2019) CASE5 33 Right (7/19/2019)

2nd post op Page 42

Foot Progression

25%

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis Right side sagittal plane kinetics (Barefoot 2nd post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50% Gait cycle

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

50% Gait cycle

CASE5 33 Right (7/19/2019) CASE5 35 Right (7/19/2019) CASE5 36 Right (7/19/2019)

2nd post op Page 43

75%

Connecticut Children’s Medical Center Center for Motion Analysis Left side sagittal plane kinetics (Barefoot 2nd post-op) Trunk Tilt

Ant

deg

Pos

-20

Pelvic Tilt

Ant

deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Power

Knee Power

3.0

Gen

W/kg

Abs

25%

50% Gait cycle

75%

-2.0

25%

50%

Ankle Power

3.0

Gen

-2.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

75%

-2.0

25%

Gait cycle

CASE5 33 Left (7/19/2019) CASE5 35 Left (7/19/2019) CASE5 36 Left (7/19/2019)

2nd post op Page 44

50% Gait cycle

75%

Connecticut Children’s Medical Center Center for Motion Analysis

BAREFOOT 2nd POST-Op Right Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

Left Side Step Length Stride Length Foot Off Cycle Time Cadence Walking Speed

CASE5 33.c3d 0.37 m 0.81 m 62.3 % 1.02 s 118 steps/min 0.80 m/s

CASE5 35.c3d 0.42 m 0.92 m 60.2 % 0.98 s 122 steps/min 0.93 m/s

CASE5 36.c3d 0.50 m 0.99 m 58.6 % 0.92 s 130 steps/min 1.07 m/s

CASE5 33.c3d 0.45 m 0.85 m 61.1 % 1.05 s 114 steps/min 0.81 m/s

CASE5 35.c3d 0.50 m 0.93 m 61.0 % 0.98 s 122 steps/min 0.94 m/s

CASE5 36.c3d 0.52 m 1.01 m 58.8 % 0.95 s 126 steps/min 1.06 m/s

GDI Side

Trial name

GDI value

Right 1

CASE5 33.c3d

Right 2

CASE5 35.c3d

Right 3

CASE5 36.c3d

Left 1

CASE5 33.c3d

Left 2

CASE5 35.c3d

Left 3

CASE5 36.c3d

2nd post op Page 45

Electives

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Clinical Relevance vs. Financial Reality Is There a Role for Clinical Motion Analysis is Sports Medicine? Some Thoughts Sylvia Õunpuu, MSc Center for Motion Analysis Connecticut Children’s Medical Center, Farmington, CT

Topic Areas • Motion analysis in understanding – “golden rule” of symmetry = criterion for return to sport (RTS) – RTS decision-making for concussion patients – Understanding complex movements such as pitching

• Case study – injury assessment

• Motion analysis can provide objective data to characterize movement mechanics such as loading asymmetries not possible to visualize/determine using standard assessments. 90

Knee Flexion-Extension

Flx

deg

- 10

-10

Knee Moment

Nm/kg

Knee Moment

Flx

- 3.0

-3.0

Knee Pow er

Gen

W/kg

Abs

Knee Pow er

Abs

-25

- 25

ACLR

Clinical Gait Analysis: A Focus On Interpretation

5.0

Ext

Knee Flexion-Extension

Ext

5.0

• Motion analysis may provide insight into possible injury mechanisms related to “poor” technique.

Flx

HEALTHY

RTS Post ACL Repair • “golden rule” = symmetry

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

The Clinical Problem •

•

Risk of re-injury (injured and contralateral side) after anterior cruciate ligament reconstruction (ACLR) is high (6 to 25%)1,2

• Causes of re-injury include: – Primary injury etiology (body structure or technique) – Surgical repair issue – Premature return to sport (inadequate recovery)

The decision to return to sport (RTS) following ACLR may negatively impact re-injury risk

1. Paterno, M.V., et al., (2010). Am J Sports Med, 38(10):1968-1978. 2. Paterno, M.V., et al., (2012). Clin J Sport Med, 22(2):116-121.

RTS Decisions

Question - Can motion analysis ADD to our understanding of readiness to RTS?

• Clinical criteria for RTS post-ACLR is varied and controversial1-3 • Current Standard of Care

• Added motion analysis to the functional tasks component of the RTS protocol. • Analyzed data for those who were ready to RTS only per standard evaluation

• Qualitative Criteria • Normal clinical exam for strength, pain, swelling • Visual assessment of “good” landing technique during functional tasks 1. Barber-Westin SD, Noyes FR. Arthroscopy. 2011;27:1697-705. 2. Petersen W, et al,. Arch Ortho Tr Surg. 2014;134:1417-28. 3. Noyes FR, et al., Am J Sports Med. 1991;19:513-8.

Side to Side Symmetry = Gold Standard

METHODS • A visual assessment of movement quality by a sports trained physical therapist with simultaneous motion data collection – walking/running – drop vertical jump (DVJ) – single leg long hop (SLLH) – triple hop (TH) – cross-over triple hop (CTH) – vertical jump and timed hop (not included)

Quantitative Criteria for RTS Passive knee ROM

•

Clinical Gait Analysis: A Focus On Interpretation

Isokinetic testing •

• 1. Noyes FR, et al., Am J Sports Med. 1991;19:513-8. 2. Davis R, et al., Hum Move Sci. 1991;10:575-88.

Symmetry peak flexion and extension (<15% side to side difference) Symmetry in knee extension/flexion concentric strength (<15% side to side difference)

Functional testing •

Symmetry in jump distances (<10% side to side difference)

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Goal Evaluate RTS symmetry in ACLR patients who have been approved to RTS following the current standard of care in terms of motion analysis parameters.

METHODS • Research Protocol • Motion analysis – Vicon MX system (VICON, Los Angeles, CA)

• Ground reaction forces – 5 force plates (AMTI, Watertown, MA)

• Following standard procedures (1) 1. Davis, R., et al., (2000). Analysis Biomedical Engineering Handbook, CRC Press: 1-9

Drop Vertical Jump

Triple Hop

Cross Over Triple Hop

Results • 45 patients have met RTS criteria following Standard of Care guidelines with motion analysis data completed

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Running – Knee Sagittal Plane

Single Limb Long Hop 90

• Parameters:

100

– Peak knee flexion – Peak knee extensor moment – Peak knee power absorption

• Healthy side > ACLR side

Knee Flexion-Extension

100 Flx

deg

Ext

-10

-20

5.0 3.0

Knee Moment

Nm/kg

Flx

Knee Pow er

Gen

Gen W/kg

Abs

-15

Ext -10

Knee Moment

Nm/kg Flx

Flx

Cross Over Triple Hop Knee Flexion-Extension

90 Flx

deg

Ext

Knee Moment

5.0

Ext

Nm/kg

Flx

-3.0

Knee Pow er

Gen

W/kg

Abs

-25

Gen

W/kg

Abs

Knee Pow er

-25

ACLR

HEALTHY

RESULTS – Comparison of Means

Knee Flexion-Extension

Peak Knee Flexion (deg) Mean ± SD

Peak Knee Extensor Moment (Nm/kg) Mean ± SD

Peak Knee Power Absorption (Watts/kg) Mean± SD

Knee Moment

Running

Knee Pow er

ACLR

healthy

41±5*

46±3

1.45±0.34* 1.85±0.33

ACLR

healthy

8.04±3.18* 10.28±3.00

ACLR

healthy

DVJ

89±12

90±12

1.17±0.34* 1.52±0.27

6.99±2.33*

Long Hop

59±13*

68±14

1.70±0.65

1.88±0.37

6.78±3.35

7.93±2.71

Triple Hop 55±5*

59±5

1.56±0.45* 1.95±0.64

4.89±2.61

5.46±2.24

CTH

60±6

1.59±0.49* 1.91±0.51

5.69±2.99

6.39±3.05

57±6*

9.95±2.66

*Significant difference (p≤0.05) between the ACLR and healthy knee (N=22)

-25

ACLR

HEALTHY

Frequency > 10% difference 22 20 18 16 14 12 10 8 6 4 2 0

Nm/kg

-10

5.0

Gen

Healthy

ACLR

Knee Moment

-3.0

Knee Pow er

-25

Flx

5.0 Ext Nm/kg

-3.0

Knee Pow er

W/kg

deg

Ext

-3.0

Knee Flexion-Extension

Knee Moment

3.0 Ext

90 Flx

deg

Flx

Ext

Knee Flexion-Extension

Flx

Knee Flexion-Extension

Peak Knee Flexion Angle Peak Knee Extensor Moment Peak Knee Power absorption

Clinical Gait Analysis: A Focus On Interpretation

Why these differences? • Trunk tilt at peak knee flexion • Single leg tasks showed increased forward trunk tilt on ACLR side

Trunk Tilt at Peak Knee flexion (deg) Mean ± SD ACLR healthy Running 12±5 12±4.7 DVJ 33±16.4 33±16.5 Long Hop 34±18.1* 28±14.5 Triple Hop 26±11.2* 18±6.1 CTH 30±7.9* 25±9.0 *Significant difference (p≤0.05) between the ACLR and healthy knee (N=22)

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Summary

However…

• Significant asymmetry in loading (knee kinematics and kinetics) in patients who have been RTS following standard of care • Less loading (flexion, moment and power absorption) on the ACLR side • Does this put these patients at risk for reinjury?

• In order to interpret asymmetry in outcomes measures in patients we need to know if persons without ACL injury and repair are symmetric!

– Injury of contralateral due to increased loads

Results – Subject Demographics •

Results – Peak Knee Flexion •

30 Subjects (14 Females) •

Age: 15 ± 1 years

•

Height: 169 ± 10 cm

•

Weight: 59 ± 14 kg

•

BMI: 20.4 ± 3.3 kg/m2

•

Tegner Activity Score7 (out of 10): • • •

•

No significant differences in PKF between Pref and NonPref knees for all functional tasks Asymmetry (>10%) in PKF present in majority of subjects for LH, TH (more than 50% of subjects) PKF (°) Mean ± St. Dev. % of subjects Pref Non-Pref LSI ≤90% LSI ≥110% Knee Knee

Median: 9, Range: 5 to 9 10 = competitive sports 0 = disability

DVJ LH TH CH Run

♦=Mean, Grey Band = 90% ≤ LSI ≤ 110%

Results – Peak Knee Extensor Moment •

•

Asymmetry in PKEM present in majority of subjects for all functional tasks

•

PKEM (Nm/Kg)

♦=Mean, Grey Band = 90% ≤ LSI ≤ 110%

40% 53% 43% 37% 37%

17% 27% 20% 23% 50%

Clinical Gait Analysis: A Focus On Interpretation

0% 37% 33% 17% 23%

3% 20% 23% 17% 7%

Significant difference (p<0.05) in PKPA between Pref and Non-Pref knees for LH Asymmetry in PKPA present in majority of subjects for all functional tasks PKPA (W/Kg)

Mean ± St. Dev. % of subjects Pref Non-Pref LSI ≤90% LSI ≥110% Knee Knee 1.57 ± 0.35 1.45 ± 0.40 1.80 ± 0.59 1.57 ± 0.59 1.92 ± 0.46 1.80 ± 0.51 1.90 ± 0.58 1.75 ± 0.43 1.64 ± 0.52 1.64 ± 0.55

87 ± 15 55 ± 10 53 ± 7 57 ± 7 43 ± 5

Results – Peak Knee Power Absorption

Significant difference (p<0.05) in PKEM between Pref and Non-Pref knees for LH

DVJ LH TH CH Run

87 ± 15 58 ± 8 56 ± 6 57 ± 7 44 ± 5

Mean ± St. Dev. % of subjects Pref Non-Pref LSI ≤90% LSI ≥110% Knee Knee

♦=Mean, Grey Band = 90% ≤ LSI ≤ 110%

Connecticut 2025

DVJ 11.35 ± 3.72 11.26 ± 4.56 LH 13.46 ± 5.90 10.9 ± 5.47 TH 12.30 ± 3.39 10.75 ± 4.27 CH 10.13 ± 4.17 8.87 ± 4.19 Run 9.66 ± 4.41 10.29 ± 4.90

37% 57% 53% 57% 30%

43% 30% 20% 30% 47%

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Control Group Findings • No significant statistical differences (mean preferred vs. non-preferred sides) in peak sagittal knee parameters • However, the majority of controls had clinical asymmetry of >10% in:

Discussion •

•

– PKF for the LH and TH – PKEM and PKPA for all functional tasks •

Ongoing Questions •

•

Evaluation of the dominant vs. non-dominant sides as a group showed no differences except for the LH kinetics An LSI of >10% was more frequent for PKEM and PKPA than for PKF for all functional tasks Greatest symmetry measured in PKF of the DVJ

Concussion and Motion Analysis

Should symmetry as measured using these metrics be the gold standard? Is a LSI goal of 10% unrealistic?

Background • About 2 million adolescents are diagnosed with a sports-related concussion annually • The impact of concussion on the young developing brain is not well understood • Clearly there are long-term health implications

• Athletes under-report concussions by nearly 50% (1) • Importance of following patients closely postconcussion (prevent cheating) • Among patients treated for concussion at Connecticut Children’s, 28% have had previously diagnosed concussions

1. McCrea M, et al. Clin J Sport Med. 2004;14(1):13-7.

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

• Challenge for physicians is to determine when it is safe for these patients to return to full athletic activity while minimizing the possibility of re-injury

Standard of Care • Return to sport decision-making – Resolution of patient’s description of current symptoms – Neuropsychological tests • IMPACT • Ability to perform normally at school

– Postural control tests • BESS

• Research evidence is suggesting that this is not enough

The beginning…

Research Summary • Lingering balance and cognitive deficits at RTS when measuring dynamic balance in combination with cognitive function – Catena RD, et al., Gait and Posture, 2007 – Catena RD, et al., J Neuroeng Rehabil, 2009 – McFadyen BJ, et al., Arch Phys Med Rehabil 2009 – Fait P et al., Brain Inj. 2009

• Adult patients focus (college and older)

Additional Research • Similar Findings in Youth – Gagnon I, et al., Arch Phys Med Rehabil, 2004 – Howell, Osternig and Chou, Am J Sports Med., 2015* • Total COM medial-lateral displacement • Youth mean age 15 (1.1) years and young adult 20 (2.4) years

Clinical Gait Analysis: A Focus On Interpretation

• Recovery of dual-task gait balance control is negatively affected after the clearance to return to physical activities – Howell, Osternig and Chou., Med Sci Sports and Exer., 2015* – Mean age 15 (1.4)

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Over all Goal • Improve the safety of RTS decisions • Specific Research Question/Purpose: – Determine if assessments of dynamic balance in a dual task environment provide additional information on readiness to safely RTS in adolescent and youth athletes

Level walking – no distraction • Dynamic balance, walking velocity

Methods • Patient and control groups – Complete same methods

• IMPACT • SCAT-3 • Dynamic balance – motion analysis/FP – Level walking only – Level walking – cognitive task – Level walking – auditory STROOP

• Static balance – motion analysis/FP – BESS - Eyes open – BESS - Eyes closed – Cognitive task

Level Walking - Cognitive stroop • Days of the week backwards • Months of the year backwards

BESS

Walking Speed 1.6

Walking Speed (normalized to height)

• With and with out cognitive task • Open and closed eyes • Error scoring and dynamic balance (motion analysis)

Results 1.4 1.2

* 1 0.8 Concussed Control

0.6 0.4 0.2 0 walk

Cognitive Load

STROOP

Trial Type

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Results Medial Lateral COM Displacement Displacement (% of subject height)

0.07 0.06 0.05 0.04 Concussed

0.03

Control

0.02 0.01 0 walk

Cognitive Load

STROOP

Trial type

Our Interpretation • The patients in this study were returned to sport when their dynamic balance was normalized – A good finding! • Cognitive and auditory STROOPS impact performance (walking velocity) and dynamic balance • Variability too high…

Next Steps • Large variation in injury mechanism and severity therefore recovery • Another methodology – Multiple assessments during recovery may be more relevant

– Does this reflect a developmental phase? – We need more patients/controls? – These measures are not relevant or sensitive enough?

Pitching

Starting Point for Research Goal #1 • Document the pitching biomechanics in healthy adolescent pitchers • Reference data base for healthy pitchers that can be used for injured pitcher assessment • Tested 32 healthy pitchers (10 to 14 years old)

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Upper Extremity & Trunk/Pelvis

Upper Extremity Moments

• Adolescent pitch well and consistently

• Peak elbow loads (internal varus moment) occurs at maximum external shoulder rotation

Carl W. Nissen, MD, Melany Westwell, PT, Sylvia Õunpuu, MSc, Mausam Patel, MS, Jan P. Tate, MPH, Kristan Pierz, MD, Joseph P. Burns, MD, James Bicos, MD, Adolescent Baseball Pitching Technique: A Detailed 3D Biomechanical Analysis, Medicine & Science in Sports & Exercise. 39(8):1347-1357, August 2007.

Results - Upper Extremity

Additional Studies for Research Goal #1

• Fastball pitching lower extremity data base for healthy adolescent pitchers • Experienced adolescent pitch well and consistently • Their joint motions are similar to older pitchers • However, their peak joint velocities and loads (moments) are lower than older pitchers

• Fatigue protocol – to understand the impact of fatigue on the pitching biomechanics

Results Mound vs. No Mound

Summary – Mound vs. No Mound

• Differences were noted in timing (all peak kinematic and kinetic events are later in the pitch cycle) • Increased loads at the gleno-humeral and elbow joints on the mound

• Pitch from the flat ground - possible strategy to reduce injury during early season play or to aid in recovery returning from injury

– Pitchers pitched an inning – Motion data collection at multiple intervals over inning

• Pitching skill development over time to understand if poor skill results in increased loads – 3 pitching assessments starting with year 1 of pitching

• Mound vs no mound to determine if the mound results in increased loads on the pitching arm – Comparison on elbow loads

Nissen CW, Solomito M, Garibay E, Õunpuu S, Westwell M, A biomechanical Comparison of pitching from a mound vs flat ground in adolescent pitching. Sports Health: A multidisciplinary approach, September 4, 2013. DOI: 10.1177/1941738113502918

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Results – Research Goals #2 • Elbow and glenohumeral loads are higher in the fastball vs. than curve ball

Summary – Research Goals #2 • The rising incidence of shoulder and elbow injuries in pitchers may not be caused by the curveball mechanics • Not clear if “poor” mechanics for the curve ball technique would lead to the same result

internal rotation moment flexion moment

Our Research Goal #3 • Understand how the difference in mechanics between multiple pitching techniques with a focus on the loads at the elbow • Clinical Relevance: which pitching technique results in the greatest loads at the elbow joint provides the opportunity to discontinue/limit a pitching option if loads are very high • Tested 36 college level healthy pitchers (18 to 24 years)

Results – Research Goal #3 • No differences in elbow and gleno-humeral motion (kinematics) between pitch types

– Fast ball, curve ball, change up, slider/cutter

Results – Research Goal #3 • Fastball had the greatest gleno-humeral and elbow loads (moments) • Change-up had the lowest gleno-humeral and elbow loads (moments)

Our Research Goal #4 • Working with existing data base to test pitching “anecdotes” – Elbow drop and drag increase injury risk – Early vs late rotators increase injury risk – Etc…

Solomito M, Garibay E, Ounpuu S, Nissen, C. A Biomechanical Evaluation of the Kinetics for Multiple Pitching Techniques in College Aged Pitchers, OJSM, September, 2013. DOI: 10.1177/2325967113508255

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

Impact of Lateral Trunk Lean

Trunk Lean • Foot contact – neutral • Before MER – max lateral lean away from pitching arm

• To understand the impact of lateral trunk lean on performance and upper extremity joint loads (moments) • Clinical relevance: lateral trunk lean is considered an issue with increasing injury risk to the elbow • Tested 99 healthy college pitchers (mean age 19 years old) Contralateral Trunk Lean (leaning away from the pitching arm)

Trunk Lean • Increased lateral trunk lean results in increased ball velocity at the expense of increased elbow and glenohumeral joint loads (moments)

Our Current Pitching Data Base N Age (years) Pitches Thrown

Youth

Adolescent

College

73 <14 (12.0±1.6) Fastball

35 14≤ x >18 (16.3±1.2) Fastball or Curveball

105 ≥18 (19.9 ± 1.4) Fastball, Curveball, Slider, Cutter, Change-up

Solomito M, Garibay E, Woods J, Ounpuu S, Nissen C. Lateral Trunk Lean in Pitchers Affects Both Ball Velocity and Upper Extremity Joint Moments, Am J Sports Med May 2015 43 12351240; published online before print March 11, 2015, doi:10.1177/0363546515574060

What is next?

CASE STUDY: ADOLESCENT WITH PAIN

• The pitching motion is very complicated • Simple one to one relationships are likely not sufficient

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Motion Analysis in Sports Medicine – Sylvia Õunpuu

PATIENT HISTORY

PATIENT HISTORY • Current status – 17 years old – pain while running during loading – unable to achieve pre-injury performance and running speed – referred for a comprehensive gait analysis

• 15 year old male • Transverse fracture of his right tibia and fibula when playing baseball • Surgical fixation took place 4 days following injury – plate and screws – tibia and fibula • Post surgical care – casting and crutch walking for two weeks – boot for two months with full healing – 8 months of PT – approved to return to sport

GAIT ANALYSIS

• Video

• Gait analysis

– walking – running – standing – added following gait data collection and review

– shod – walking and running – self-selected velocity – multiple trials per side – reference data collected at same location – kinematics and kinetics (trunk and lower extremities)

• squatting and single limb heel touch tasks

• Clinical Exam – passive range of motion – strength – torsions (tibia and femur) – anatomical measures

CLINICAL DATA

representative marker placement for static data collection

GAIT DATA

Pain

Walking – Knee Sagittal Plane

• Located in middle 1/3 of anterior right shank • 3-4/10 when at its worst

Clinical Exam • Normal isometric strength • Difficulty with single leg hopping, squatting, and heel touch

Right

Left

Hip flexion strength

5/5

Knee flexion strength

5/5

Knee extension strength

5/5

Ankle plantar flexion strength

5/5

Knee extension (deg)

Popliteal angle (deg)

-55

-45

Ankle dorsiflexion with knee extended (deg)

Ankle plantar flexion strength

5/5

Ankle dorsiflexion strength

5/5

Quadriceps girth (cm)

57.8

60.0

1. Õunpuu et al., (2013) Gait & Posture, 38: 900-906.

Clinical Gait Analysis: A Focus On Interpretation

• Kinematic, moment and power • Asymmetry • Right quadriceps avoidance • During loading response o reduced knee flexion o no knee extensor moment o no knee power absorption

Connecticut 2025

Knee Flexion-Extension

Flx

deg

Ext

-20

Knee Moment

2.0

Ext Nm/kg

Flx

-1.0

Knee Pow er

3.0

Knee Moment

2.0

Ext Nm/kg

Knee Pow er

3.0

Gen

W/kg

Abs -2.0

Knee Flexion-Extension

Abs

25%

50%

75%

-2.0

25%

50%

Gait Cycle

Right

Left

75%

Motion Analysis in Sports Medicine – Sylvia Õunpuu

GAIT DATA

Running – Knee Sagittal Plane • Kinematic, moment and power • Asymmetry • Right quadriceps avoidance • During weight acceptance o no knee flexion o no knee extensor moment o no knee power absorption

100

Knee Flexion-Extension

Running – Ankle Sagittal Plane 100

Flx

deg

Ext

Ext -20

-20

Knee Moment

3.0

Ext

Nm/kg

Flx

-3.0

Knee Pow er

15 Gen

Gen W/kg

Abs

50%

Knee Pow er

W/kg

25%

Knee Moment

3.0

Ext

-15

Knee Flexion-Extension

75%

-15

2 5%

50%

G ait Cyc le

Right

7 5%

Gait C yc le

Left

TREATMENT DECISION & INDICATIONS • Physical therapy to address the asymmetry in knee and ankle strength • Indications: – right knee reduced loading response flexion vs. left during walking and more significantly in running – right ankle reduced kinematics and kinetics vs. left during running indicating no compensation at the right ankle

• Goal: – improve eccentric loading capacity of the right quadriceps and plantar flexors – improve right ankle power generation – distribute loading impact through both the knee and ankle thus reducing the load on the right tibia

Is There a Role for Clinical Motion Analysis is Sports Medicine?

• Kinematic, moment & power • Asymmetry • Right reduced loading • During weight acceptance o reduced ankle dorsiflexion o reduced plantar flexor moment o reduced ankle power absorption • During push-off o reduced right ankle power generation

Plantar-Dorsiflexion

Dor

deg

Pla

Pla -40

-40

Ankle Moment

3.0

Ext

Nm/kg

Flx

-3.0

Ankle Pow er

Ankle Moment

3.0

Ext

Ankle Pow er

Gen

W/kg

Abs -15

Plantar-Dorsiflexion

Abs

25%

50% Gait Cy c le

Right

75%

-15

25%

50%

75%

Gait Cy c le

Left

SUMMARY • The gait findings led to additional strength assessments immediately following the gait analysis testing • The isometric strength symmetry does not infer isokinetic strength symmetry • The gait analysis results, specifically knee and ankle sagittal plane kinetics, helped to identify ongoing impairment that required rehabilitation • Comprehensive gait analysis allows objective measurement of walking and running function that is not possible in the clinic setting

Thank You

• Can better understand complex movements – Documentation by kinematics and kinetics

• Document asymmetry in movement – Symmetry is the golden rule – Indication for treatment

• Document treatment outcomes • Diagnostic…? Depends on the circumstances.

Clinical Gait Analysis: A Focus On Interpretation

Connecticut 2025

Orthopaedic Imaging

Completing the Assessment Andrew G. Georgiadis, MD Emily Andrisevic, MD June 4th, 2025 Connecticut Gait Course

Spine → Foot

Spine No Hip Contractures

Hamstring Contractures

Spine – kinematics

Muscle Modeling – Medial hamstring

Spine X-ray – PA and lateral standing full spine

Spine

Strength

Spasticity

Leg length =

kinematics

PA full scoliosis

Normal Hip X-Ray

Coxa Valga

135° 175°

CP Hip

Neck-Shaft Angle

Anteversion

Lever Arm “Disease” - femur

Normal anteversion

Excessive anteversion Hip abductor mechanical disadvantage

Reimers 1980 Acta Orthop Scand

Spastic Hip - Radiography Reimer’s Migration Percentage (MP) epiphysis/head lateral to Perkins’ line = total epiphysis/head

= 0.3 (or 30)

Reimer’s Migration Percentage (MP)

65%

Reimers 1980 Acta Orthop Scand

Orthopaedic Issues

• Spastic Hip Subluxation

• Risk Increases with GMFCS

Soo 2006 JBJSAm

Surgical Solutions: - Femur: varus and/or derotation - Pelvis: Acetabuloplasty

30°

95° 65%

Femoral torsion / femoral anteversion • TL;DR – imaging is the gold standard • Physical examination is a screening tool

MD Problem List

• R hip dysplasia • R excessive femoral anteversion • R patella alta with ext lag • possible R ETT • R pes planovalgus abductus • R gastrocsoleus tightness • possible L genu varum • L pes planovalgus deformity • Leg length discrepancy

Gait Lab problem list

• R excessive femoral anteversion • R internal hip rotation • R hip flexor tightness • R hip adductor tightness • R hamstring tightness • R patella alta with ext lag • No tibial torsion • R gastrocsoleus contracture • Leg length discrepancy L>R

Initial Physical Exam 2017

Gait Lab

Hip Internal Rotation

Hip External Rotation

Trochanteric Prominence

Bimalleolar axis

Imaging - EOS* 8/4/2017

EOS

CT SCAN

Femoral torsion

Tibial torsion

This is a standing biplanar radiographs that predicts bony anatomy by statistical shape modeling (it is not a CT). But is accurate and precise.

Multi-level surgery 1. Right Ganz-type periacetabular osteotomy to correct retroversion and lateral uncoverage. 2. Right femoral varus derotational osteotomy (35 degrees anteversion derotated to 7 degrees anteversion). 3. Right intramuscular psoas lengthening at the pelvic brim. 4. Right open adductor lengthening. 5. Right patellar tendon advancement. 6. Right rectus femoris transfer to the gracilis. 7. Right open hamstring lengthening (single oblique stripe in semimembranosus, Z lengthening of semitendinosus). 8. Right Strayer gastrocnemius recession and soleal fascial lengthening (single stripe, 1 cm). CT/EOS/intraop pin in neck = 35°

Radiographic assessment

35° CT = 35 °

7°

LEFT SIDE – p

RIGHT SIDE ONLY PRE POST

Post-surgery Physical Exam/EOS Gait Lab

2017

2019

Internal Rotation

External Rotation

Trochanteric Prominence

EOS

2017

2019

Femoral Torsion

Tibial Torsion

“Your eyes can deceive you. Don’t trust them.”

Conclusions • Imaging is the gold standard way of assessing long bone torsions. • 3D EOS (there are other devices, now) is an accurate, precise, practical way of measuring torsional abnormalities of the femur and tibia • Imaging is part of our gait analysis standard of care @Gillette Children’s

Genu Valgum

Coronal Valgus - kinematics

Genu Valgum - EOS

Crouch

- No KFC - No Lag - Yes Alta

Radiographic Evaluation

Supine

Max Ext Lateral Knee Flexion Contracture

Koshino Index = A/B

Koshino et al., JPO, 1989

Insall Salvati Tendon / Patella = IS

Normal = .8 -1.2

Insall J, Salvati E. Patella position in the normal knee. Radiology. 1971;101:101–04

Lateral Knee X-ray in Maximum Extension

IS=1.25

IS=1.18

Post Patellar Tendon Advancement

Equinus Varus/Valgus Pronation/Supination Cavus Calcaneus Abduction/Adduction

Calcaneal valgus Equino varus Equino cavo varus Plano valgus Abducto plano valgus Equino plano valgus Calcaneal cavus Cavo varus

2005 J Pediatr Orthop

Varus = Inversion

Valgus = Eversion

Pronation

Supination

Cavus = hollow arch

Calcaneus

Abduction – Away from Midline

Adduction – Towards the Midline

Importance of weight bearing views Meary’s Angle

RADIOGRAPHIC ANALYSIS HINDFOOT MIDFOOT FOREFOOT

RADIOGRAPHIC ANALYSIS • HINDFOOT • MIDFOOT • FOREFOOT

Ankle/Foot

Planovalgus foot

Planovalgus foot - lateral

Varus foot

CP Gait Dysfunction – Natural History

AGE 3: Equinus

AGE 8: Malalignment

Case Example 1 – equinoplanovalgus foot 11y3m male GMFCS 2 Progressive crouch Moderate torsions

Radiographic assessment

Hindfoot valgus Midfoot abductus Midfoot planus Forefoot varus

Case 1 (pes planovalgus) outcome

Case: Equinovarus

Pre-treatment

14m post-treatment

Equinovarus foot – post-surgical XRs

Complex gait - multilevel

Georgiadis 2017 JBJS Rev Davids 2004 JBJS-Am

Thank You!

Thank You! Emily Andrisevic, MD - emilymandrisevic@gillettechildrens.com

Andy Georgiadis, MD - andrewgeorgiadis@gillettechildrens.com

Biomechanics of Gait In Myelomeningocele

The Biomechanics of Gait in Myelomeningocele Jean Stout, PT, MS, PhD James R. Gage Center for Gait and Motion Analysis

Remember: The neural tube, spine, and spinal cord defect is not simply a lower motor neuron condi on. Hydrocephalus & Chiari malforma ons can result in brain damage if uncontrolled. Both lower motor neuron and upper motor neuron components contribute to the impairment

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Issues to Consider: Loss of muscle func on Loss of physiologic remodeling of femurs, bia, feet Incomplete paralysis; asymmetric paralysis compensa ons for func onal loss myelomemingocele func on classiﬁca on system

Myelomenigocele Functional Classiﬁcation (MMFC) Dias et al. 2021

A 4-Level Classification system based on qualitative and quantitative information about functional level: Functional Hallmark, FMS Classification, & Assistive Devices

2009

2021

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Myelomenigocele Functional Classiﬁcation (MMFC) Dias et al. 2021

MMFC1 Functional Hallmark 1. Might retain iliopsoas function or not 2. Lack quadriceps function

FMS

Assistive Devices

2,2,1 (max)

Walker; wheelchair, RGO HKAFO

Myelomenigocele Functional Classiﬁcation (MMFC) Dias et al. 2021

MMFC2 Functional Hallmark 1. Retain quadriceps and medial hamstring function 2. Lack gluteus medius function

FMS

Assistive Devices

3,3,3 (max)

Walker or crutches; HKAFOs or AFO

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Myelomenigocele Functional Classiﬁcation (MMFC) Dias et al. 2021

MMFC3 Functional Hallmark 1. Retain quadriceps and gluteus medius function 2. Lack gastrocnemius-soleus function

FMS

Assistive Devices

5,5,5 (max)

No external support; AFOs only

Myelomenigocele Functional Classiﬁcation (MMFC) Dias et al. 2021

MMFC4 Functional Hallmark 1. Retain quadriceps and gluteus medius function 2. Retain gastrocnemius function

FMS

Assistive Devices

6,6,6 (max)

No external support; SMOs, insoles, or nothing

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Biomechanics of Myelo: Analysis by Subtraction

• Start with typical gait • Analyze dynamic function of muscles • implies consequences of loss • Consider possible compensations for loss

spinabifidaassociation.org

Muscle Paralysis by Level: S2 MMFC 4

Bowel & Bladder Weakness: gluteus maximus 4/5 gastrocnemius/soleus 3/5 toe flexors 3/5

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Gait Changes with Loss at S2 mild increased knee flexion

typical ankle kinematics (signs of weakness - red)

prolonged knee extensor moment (red)

typical plantarflexor moment

typical knee power

mild decreased A2 power burst (red)

Gait Changes with Loss at S2

typical abductor hip moment reduced valgus knee moment

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Muscle Paralysis by Level: S1 MMFC 4

Intrinsics of Foot Weakness: gluteus maximus 2/5 gastrocnemius/soleus 2/5 gluteus medius 3/5 lateral hamstring 4/5

Gait Changes with Loss at S1 increased knee flexion

excessive ankle dorsiflexion (signs of weakness - bilateral)

prolonged knee extensor moment

reduced plantarflexor moment

typical knee power

decreased A2 power burst (bilateral)

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Gait Changes with Loss at S1

reduced abductor hip moment zero valgus knee moment

Comparison Gait Changes S2 vs. S1 S2

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Comparison Gait Changes S2 vs. S1 S2

Lumbar – L5 (loss) Gluteus Maximus Gastroc-soleus Lateral Hamstring Flexor Hallucis Flexor Digitorum Weakness: gluteus medius 2/5 medial hamstring 3/5 posterior tibialis 3/5 long toe extensors peroneals

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Impact of Muscle Loss gastroc-soleus

• Typical Gait • Soleus (mono-articular) • control progression over stance foot • provide vertical support • Gastrocnemius (bi-articular) • support during stance • propel leg into swing • prevent knee hyperextension in late swing

Myelo Gait • Decreased support • Decreased propulsion • body • swing initiation • Increased knee flexion • loss of induced extensor effect

Impact of Muscle Loss gastroc-soleus

• Stance Compensations • Alternative Mechanisms for Support • passive moments at ankle • flexed knee • orthotics • Both require Center of Pressure to move posterior • keeping GRF close to ankle to minimize need for plantarflexors

Propulsive Compensations • Proximal (trunk) muscles generate energy • large pelvic rotations • Increased valgus (and rotary) stresses on knee • For both external and normal tibial torsion

Lim et al. (1998) J. Pediatr Orthop., 18, 428-33 Mednick et al (2015) J Pediatr Orthop, 35:721-724

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Impact of Muscle Loss abductors

Myelo Gait - Compensations • Reduce external lever arm of the trunk mass • Move center of mass over hip • COM/GRF aligned

• Typical Gait • Large abduction demand during single support • Keep pelvis level

• Increased coronal plane motion

COM GRF

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Gait Changes with Loss at L5 excessive ankle dorsiflexion (displaced into dorsiflexion)

greater knee flexion

increased knee extensor moment

minimal plantar flexor moment

no A2 power burst (bilateral)

Gait Changes with Loss at L5

reduced abductor hip moment reduced valgus knee moment

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Comparison Gait Changes S2 vs. S1 vs. L5 S2

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Comparison Gait Changes S2 vs. S1 vs. L5 S2

Lumbar – L4 (loss)

Gluteus Medius Gluteus Minimus Medial Hamstring Posterior Tibialis Peroneus Longus & Brevis Long Toe Extensors Weakness: anterior tibialis 2-3/5 quadriceps 3/5 adductors 3-4/5

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Gait Changes with Loss at L4 greater knee flexion

increased knee extensor moment

excessive ankle dorsiflexion (displaced into dorsiflexion)

minimal plantar flexor moment

no A2 power burst (bilateral)

Gait Changes with Loss at L4

zero abductor hip moment reduced valgus knee moment

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Comparison Gait Changes S2 vs. S1 vs. L5 vs L4 S2

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Comparison Gait Changes S2 vs. S1 vs. L5 vs. L4 S2

Lumbar – L3 (loss) Anterior Tibialis Adductor Magnus

Weakness: quadriceps 3/5 adductors 2-3/5 sartorius

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Gait Changes with Loss at L3

Comparison Gait Changes S2 vs. S1 vs. L5 vs L4 S2

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Summary 1. Gait changes are noted with increasing muscle loss 2. Changes are seen in knee & ankle kinetics and coronal plane hip kinetics 3. Changes occur in other planes & are influenced by lever arm dysfunction 4. Levels are never distinct or asymmetric

Common Gait Compensations 1. Excessive Pelvic Rotation 2. Maintenance of Continuous Knee Extensor Moment 3. Excessive Trunk Sway 4. Plantarflexor Moment Avoidance

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Common Gait Compensations

Levels Are Never Clear or Absolute: Asymmetry

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Transverse Plane Considerations 1. Persistent Physiologic Internal Tibial Torsion (early) 2. Persistent Physiologic Anteversion 3. External Tibial Torsion Develops 4. Foot Deformity 5. Visual Knee Valgus May or May Not be Valgus knee Joint Stress.

Transverse Plane Considerations

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Transverse Plane Considerations

Bracing Role in Support Supportive Control Moment Ries & Schwartz, DMCN 2019

Role in Propulsion Allow increased step length Allow COP to progress distally on foot

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Barefoot

Braced-PLS

Barefoot

Braced-PLS

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Barefoot

Braced-Hinged

Crutches vs. No Crutches

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Crutches Braced-Hinged

Crutches

Clinical Gait Analysis: A Focus on Interpretation 2025

Biomechanics of Gait In Myelomeningocele

Questions? Thank you!

jstout@gillettechildrens.com

Clinical Gait Analysis: A Focus on Interpretation 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Functional Outcomes Using the Gait Outcomes Assessment Questionnaire (GOAL) Jean Stout, PT, MS, PhD Unni Narayanan, MD Katie Walt, PT, DPT Andrew Georgiadis, MD Liz Boyer, PhD

Why The GOAL for Outcome Assessment? WeeFIM Bruininks Oseretsky Test of Motor Proficiency Pediatric Evaluation of Disability Inventory Pediatric Outcomes Data Collection Instrument (PODCI) Gillette Functional Assessment Questionnaire Functional Mobility Scale Children’s Assessment of Participation and Enjoyment Activity Scale for Kids

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Gait Outcomes by Gait Deviation Index

Is GDI the best measure by which to gauge a successful outcome?

International Classification of Function Disability and Health CONDITION OF INTEREST E.g. Cerebral Palsy

Walking, Running Spasticity, Contracture, Bone deformity

Mobility Aids; Environmental Barriers

Playing sport, going out with friends; School

Personal priorities, values & preferences slide courtesy of Unni Narayanan

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Successful Outcomes After Gait Intervention Whose Perspective? CHILD PARENT/S

FAMILY

CLINICIAN/ SOCIETAL

WeeFIM Bruininks Oseretsky Test of Motor Proficiency Pediatric Evaluation of Disability Inventory Pediatric Outcomes Data Collection Instrument (PODCI)

Which ask about priorities or goals?

Gillette Functional Assessment Questionnaire Functional Mobility Scale Children’s Assessment of Participation and Enjoyment Activity Scale for Kids

Development of the Gait Outcomes Assessment Questionnaire

Narayanan 2011

A unique structure assess family priorities for each item

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

What Are the Priorities/Goals of Patients and Caregivers for Gait Intervention? A specific patient perspective

reduction of Pain

Get rid of his knee pain

improve Mobility

Frustrated about getting tired easily

be more Physically Active

He wants to go out with his friends

participation in Sports/Recreation

He wants to do less therapy

improve Gait Appearance

He wants to trip and fall less

improve Fitness/Endurance

Wants to get rid of his braces

better Stability (lessen trips/falls)

He wants to look less different from others

more Independence in daily activities Narayanan 2011

Priorities/Goals and Construction of the GOAL Priorities/Goals

GOAL Domains (7)

reduction of Pain

Pain Discomfort & Fatigue (7)

improve Mobility

Gait Function & Mobility (10)

be more Physically Active

Physical Activities Sports & Recreation (8)

participation in Sports/Recreation improve Gait Appearance

Gait Pattern & Appearance (6)

better Stability (lessen trips/falls) improve Fitness/Endurance more Independence in Daily Skills

Activities of Daily Living & Independence (9) Use of Braces & Mobility Aids (3) Body Image & Self Esteem (6) () number of items

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Gait Outcomes Assessment Questionnaire ICF Domains

25% 43%

5% 11%

16 %

Narayanan 2011

Difficulty Assistance

4 domains measure function 2 domains measure happiness 1 domain measures frequency

Happiness

A. ADLs & Independence 9

G. Body Image & Self Esteem 6

Happiness

B. Gait Function & Mobility 10

Total

F. Use of Braces & Mobility Aids 3 Difficulty

Every Item queries priority Not incorporated into scoring

E. Gait Pattern & Appearance 6

Difficulty Assistance

C. Pain, Discomfort & Fatigue 7 D. Physical Activities, Sports & Recreation 8

Frequency Intensity

Difficulty graphic courtesy of Liz Boyer

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Validity Reliability Responsiveness & Goals

2011

2015

2018

2022 2022 Chapters 1,4, and 14

2024 2025

Patient and Family Priorities and GOAL results in Children (4-7, 8-12, 13-17) years old at Gillette Children’s Stout Boyer, Walt & Koop

How Do we Use it Clinically?

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

What About After Intervention? What is True Change?

Percentiles vs. Confidence Intervals G. Body Image & Self Esteem

score change

visit 1 visit 2 visit 3 33 42 48 +9 68%CI +6 -

score change

visit 1 visit 2 visit 3 33 46 21 +13 68%CI -25 95%CI

score change

visit 1 visit 2 visit 3 40 52 55 +8 68%CI +3 -

Total Standardized Score

E. Gait Pattern & Appearance

score change

visit 1 visit 2 visit 3 19 47 67 +28 95%CI +20 95%CI

B/P botox/phenol SDR selective dorsal rhizotomy SEMLS single event multilevel surgery

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

What Have We Learned About Goals/Priorities? Age 4-7

N=166 GMFCS I 31%; GMFCS II 39%; GMFCS III 31% Previous SDR excluded

walk feet flat top priority- all GMFCS getting dressed is priority unique for this age group tired while walking a common top 10 priority

2025

Boyer Stout Walt Koop

What Have We Learned About Goals/Priorities? Age 8-12

N=257 (112 prior SDR; 144 no prior SDR) GMFCS I 31%; GMFCS II 46%; GMFCS III 23%

Gait Pattern & Appearance dominate top 10 priorities- all GMFCS Gait Function & Mobility items common for GMFCS II & III tired while walking a common top 10 priority move vs others; Sports & Bracing top 10 priorities for GMFCS I

2025

Stout Boyer Walt Koop

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

What Have We Learned About Goals/Priorities? Age 13-17 N=163 GMFCS I 38%; GMFCS II 40%; GMFCS III 22% Gait Pattern & Appearance common top 10 priorities- all GMFCS Gait Function & Mobility items common for GMFCS II & III tired while walking a common top 10 priority for GMFCS II & III ADL activities among top 20 priorities for GMFCS III

2025

Stout Boyer Walt Koop

What Have We Learned About Responsiveness: SDR Domains

N=47

ADL Independence Δ 12

Age Pre-SDR: 5.6 y Time from Surg: 1.05 y

Gait Function Mobility Δ8

Gait Pattern Appearance

Braces Mobility Aids

Δ 22

Δ0

GMFCS I: 6; II: 21; III: 20

Pain Discomfort Fatigue Δ8

Sports Recreation Δ3

Domain

MDC (68% CI)

A-ADLI

6.5

B-GFM

C-PDF

Body Image Self Esteem

Total

D-PASR

8.5

Δ0

Δ9

E-GPA

F-UBMA

G-BISE TOTAL

9 4.4

Stout et al. 2022

pre-post positive change

pre-post negative change

pre-post no change

pre-post median change

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

What Have We Learned About Responsiveness: SDR

Top 5 priority items pre-SDR

Top 5 priority items post-SDR Stout et al. 2022

What Have We Learned About Responsiveness: Ortho GMFCS: I:8; II:24; III: 11 Interval: 1.5 y Age: 6-23 y (mean 10+9)

∆ GPS

r=-0.42 Surg

∆ GPS

r=-0.47

No Surg

GOAL (TOT)

Δ +2

Δ -1

GPS

Δ -2

Δ +1

Correlation

∆ GOAL Gait Appearance

∆ Total GOAL

N=43 N=22 surgery N=21 no surgery

Thomason P et al. The Gait Outcomes Assessment List (GOAL): Responsiveness to change in gait function for children with cerebral palsy. 2018; Develop Med Child Neurol 60(S1);54

-0.42

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Questions? Cases

SDR • CP, diplegia • Age: 6 years, 0 months • GMFCS II • FMS: 4, 2, 2 • Gillette FAQ: 8, 12/22 advanced functional skills • Orthosis: Solid AFOs • Assistive device: Reverse 4-wheeled walker at school and outdoors • Community Physical Therapy: None • Reason for Referral: Gait analysis as part of Spasticity Evaluation Clinic

case courtesy of Katie Walt, PT, DPT

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Family Concerns and Goals/Expectations FAQ Concerns: “Heels not touching the ground; Feet turning in.” FAQ Goals: “Walking flat-footed and unassisted.” Domain

Very Important Items

Standardized Score

Percentile for GMFCS II

Activities of Daily Living & Independence

2/9

62.96

Gait Function & Mobility

9/10

28.00

Pain, Discomfort, & Fatigue

4/7

65.31

Physical Activities, Sports, & Recreation

8/8

47.58

Gait Pattern & Appearance

6/6

16.67

Use of Braces and Mobility

2/3

Body Image & Self-Esteem

6/6

29.17

Total Score

37/49

35.32

case courtesy of Katie Walt, PT, DPT

Example Domain: Gait Pattern & Appearance

case courtesy of Katie Walt, PT, DPT

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Example Domain: Gait Pattern & Appearance

case courtesy of Katie Walt, PT, DPT

1 yr. Post SDR • Age: 7 years, 11 months • GMFCS II • FMS: 5-5-5 • Gillette FAQ: 7, 15/22 advanced functional skills • Orthosis: Bilateral Solid AFOs • Assistive devices: Reverse 4-wheeled walker for long distances (prefers to walk independently) • Community Physical Therapy: 2x/week • Reason for Referral: One year post selective dorsal rhizotomy

case courtesy of Katie Walt, PT, DPT

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Family Concerns and Goals/Expectations FAQ Concerns: None FAQ Goals: “Correct leg formation.”

Domain

Very Important items

Standardized Score PRE/POST

Percentile for GMFCS II PRE/POST

Change Score

Confidence Interval MDC

Activities of Daily Living & Independence

1/9

(62.96) 82.72

34th to 77th

19.8

95%

Gait Function & Mobility

10/10

(28.00) 47.00

3rd to 20th

95%

Pain, Discomfort & Fatigue

2/7

(65.31) 95.92

26th to 87th

30.61

95%

Physical Activities, Sports & Rec

8/8

(14.58) 25.00

23rd to 48th

14.58

68%

Gait Pattern & Appearance

3/6

(16.67) 66.67

12th to 91st

95%

Use of Braces and Mobility

2/3

(0) 25.00

NS to 33rd

68%

Body Image and Self-Esteem

6/6

(29.17) 37.50

13th to 30th

8.33

Total Score

42/49

(35.32) 57.52

7th to 59th

22.2

95%

case courtesy of Katie Walt, PT, DPT

Example Domain: Gait Pattern & Appearance

case courtesy of Katie Walt, PT, DPT

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Example Domain: Activities of Daily Living & Independence? Pre-op: 34th percentile_Post-op :77th percentile

• 34th percentile >> 77th percentile • Maturation? • intensive rehabilitation following his selective dorsal rhizotomy?

case courtesy of Katie Walt, PT, DPT

8 yo, GMFCS III, Diplegia, Crouch, 25 degree knee flexion contractures

GOALs • Walking taller, more upright • Less knee pain • Feet straight ahead • Dissatisfied with AFOs • Walk without assistive devices • Increase endurance/ease of walking

case courtesy of Andrew Georgiadis, MD

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Previous Treatment

Botox: 19 mo.-3 yrs 2-3 x/year 3 years B adductor B hamstrings B gastrocnemius

SDR: age 4

Cauda L2-S1 (38.8% L; 41% R)

GOAL Function Data

Standardized GOAL Domain Scores

date

GMFCS III Percentile Rank

Standardized Total Score

31.1

A) Activities of Daily Living

32.1

B) Gait Function and Mobility

C) Pain, Discomfort, and Fatigue

69.4

D) Physical Activities, Sports, Recreation

10.4

E) Gait Pattern and Appearance

22.2

F) Use of Braces and Mobility

G) Body Image and Self-Esteem

37.5

case courtesy of Andrew Georgiadis, MD

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Data

case courtesy of Andrew Georgiadis, MD

Provider Options for Treatment: Meeting Technical and Family Goals DFEO+PTA:

Walking more upright Feet straight ahead Less Knee Pain Increase Ease of Walking Unhappy AFOs Walk without assistive devices

Stout et al., J Bone Joint Surg 2008

HOWEVER:

Patient crawls (deep knee flexion for many ADLs influence of PTA) going up/downstairs very difficult & important to maintain substantial growth remaining

?Guided Growth Hamstring Lengthening

Bittman 2018 Gait Posture

Boyer 2017 Gait Posture

case courtesy of Andrew Georgiadis, MD

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Post Surgery Pre-Op Goals

Post-Op Goals Less Knee Pain: More Foot Pain Feet straight ahead: remains a goal Tired while walking How moves compared to others

Expectations for Surgery Met? Definitely Yes Overall Satisfaction: Extremely Satisfied

School-Based Therapy JT 10 yr. old GMFCS Level II 1 yr post SEMLS 4th grade at a new school changes classrooms 3x during the day 4 steps between cafeteria & classrooms sections of school GOAL completed at beginning end of school year

Family has identified 6 Very Important Goals

(for the current school year) 1. carrying an object while walking 2. going up and down stairs 3. walking faster 4. walking > 250 meters 5. running 6. climbing

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

School-Based Therapy

Pre SEMLS

Post SEMLS

School-Based Therapy Pre SEMLS

Post SEMLS

4 of 6 items exhibit a positive change but do not reach the 68% CI Based on scores that qualify for services, all 6 items could potentially be the focus of therapies to increase independent function and participation with peers in his new classroom and school setting.

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Functional Outcomes using the Gait Outcomes Assessment List Questionnaire (GOAL)

Questions? Thank You!

photo used with family permission

jstout@gillettechildrens.com

Clinical Gait Analysis: A Focus on Interpretation CCMC 2025

Toe Walking: How do you know who to worry about? Learning Through Case Examples Using Gait Analysis

Kristan Pierz, MD and Jennifer Rodriguez-MacClintic, PT, DPT, PCS

Purpose: • Describe the many variations of toe walking to help clinicians understand the diversity of presentation, underlying diagnoses, and treatment options. • Gait analysis will be used to help – define the many variations of presentation of toe walking in terms of gait analysis parameters – understand the underlying diagnosis of toe walking

Learning Objectives: • Be familiar with the limitations of assessing toe walking by observation alone. • Be familiar with many of the underlying diagnoses associated with the clinical presentation of toe walking. • Be familiar with the components of computerized gait analysis relevant to the assessment of toe walking. • Be aware of “red flags” or gait features of toe walkers that warrant additional evaluation or treatment.

Background • Toe walking is a commonly encountered gait problem and often results in referral of patients to medical professionals. • Various neurologic, traumatic, and developmental diagnoses have been associated with toe walking as well as habitual or idiopathic type • All can cause great concern for patients, parents, and providers.

Background • Watch the following videos – Note similarities as well as differences – Do you know the diagnosis at first glance?

Background • We all agree that these patients lack a normal heel contact and weight bear through the forefoot; hence, they are all “toe walkers”. • What is the underlying diagnosis? • Is there a need to treat? • What is the appropriate treatment?

Review of Common Diagnoses Associated with Toe Walking • Prior to age 2, toe walking is very common • Cases lacking definitive etiology are called “idiopathic” (or we just haven’t figured it out yet) • Search for neurologic, developmental, pathologic conditions • May be dynamic or due to structural contracture/deformity

Causes of Toe Walking • Cerebral palsy • Congenital muscular dystrophy • Tethered Cord Syndrome • Diastematomyelia • Spina bifida • Autism/Sensory • Schizophrenia • Global Developmental Delay

• Charcot-Marie-Tooth Disease • Transient dystonic rxn • Venous malformation or tumor (posterior calf) • Ankylosing spondylitis • Congenital or aquired LLD • Other? • Unilateral = “Red” Flag

Where to begin? • History – Birth (premie?; breech?) – Onset of walking – Trauma – Pain – Family

• Physical Exam – ROM/Contracture – Motor strength/isolation and spasticity

• Imaging – Xray (DDH/LLD) – MRI (Neural axis; limb)

• Gait analysis – Visual inspection/Video – “Doctor Walk” – Gait Patterns: Kinematic/Kinetic data – Electromyography (EMG)

Basis for 3D Gait Analysis Goals: • Highlight the role and importance of gait analysis in understanding toe walking – Focus on components relevant to toe walking – Introduction to ankle and knee kinematic data – Gait terminology – Typical developing vs. toe walking joint kinematic and kinetic patterns

Gait Analysis • Definition: – Systematic and Objective Documentation of Human Locomotion

• Why? – Improve understanding of pathomechanics at the individual joint and segment level – Determine causes of gait abnormalities – Define treatment – based on objective data – Evaluate treatment – based on objective data

Is visual observation of gait enough? What is the role of gait analysis in understanding and treating toe walking? Let’s look at some examples…

Case Examples • visual characteristics • relevant history and clinical exam information • gait data patterns • treatment options

Idiopathic Toe Walking

Idiopathic Toe Walking • Persistent toe walking after 2 years of age • No identified underlying diagnosis • May or may not have equinus contractures • Knee not affected – full knee extension at initial contact • No clearance problems

D29234

Eastwood et al., JPOB, 1997.; Hicks et al., JPO, 1988.; Williams et al., J Child Neurol, 2013

Idiopathic Toe Walking Clinical Exam Features: • Ability to isolate voluntary control at foot and ankle • Typical strength • No evidence of spasticity

Ant

Int

deg

Idiopathic Toe Walking - Kinematics Dn

Pos

-20

Hip Ab-Adduction

• Increased ankle plantar flexion through out stance and swing • Full knee extension at initial contact • Full knee flexion in swing • Compensatory increased hip flexion Add

Ext

-40

Hip Flexion-Extension

Hip Rotation

Flx

Int

Abd

Ext

-20

deg

Knee Varus-Valgus

Var

-40

Knee Flexion-Extension

Knee Rotation

Flx

Int

Ext

deg

Val

-30

25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Foot Progression

Int

deg Pla -40

Ext

25%

50%

75%

-40

25%

Gait Cycle

429234 2 Left (7/30/2012) 429234 3 Left (7/30/2012) 429234 6 Left (7/30/2012)

50% Gait Cycle

Ant

deg

Idiopathic Toe Walking - Kinetics Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

• Typical peak power generation in terminal stance • Consistent with typical ankle plantar flexor strength

Flx

Dor

deg

Ext

Pla

-20

-40

2.0

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Plantar-Dorsiflexion

Ankle Moment

Ankle Power

429234 2 Right (7/30/2012) 429234 3 Right (7/30/2012) 429234 6 Right (7/30/2012)

EMG – Idiopathic Toe Walking • Premature onset gastrocnemius activity in terminal swing • Early termination tibialis activity in terminal swing and activity in mid stance • Very similar findings for same muscles in CP toe walking • No EMG response to passive stretch Right Side EMG 5

Right Gastrocnemius

V -5 5

Right Gastrocnemius*

V % Gait Cycle

Right Anterior Tibialis

V -5

-5 5

-5

Right Gastrocnemius**

V % Gait Cycle

Right Anterior Tibialis*

V % Gait Cycle

-5 5

% Gait Cycle

Right Anterior Tibialis**

V % Gait Cycle

-5

% Gait Cycle

Right Gastrocnemius

V -5 5

Right Gastrocnemius*

V % Gait Cycle

Right Anterior Tibialis

V -5

-5 5

-5

Right Gastrocnemius**

V % Gait Cycle

Right Anterior Tibialis*

V % Gait Cycle

-5 5

% Gait Cycle

Right Anterior Tibialis**

V % Gait Cycle

-5

% Gait Cycle

EMG – Idiopathic Toe Walking • Premature onset gastrocnemius activity in terminal swing • Early termination tibialis activity in terminal swing and activity in mid stance • Very similar findings for same muscles for toe walking in persons with CP • No EMG response to passive stretch Right Side EMG 5

Right Gastrocnemius

V -5 5

Right Gastrocnemius*

V % Gait Cycle

Right Anterior Tibialis

V -5

-5 5

-5

Right Gastrocnemius**

V % Gait Cycle

Right Anterior Tibialis*

V % Gait Cycle

-5 5

% Gait Cycle

Right Anterior Tibialis**

V % Gait Cycle

-5

% Gait Cycle

deg Add

Flx

Int

Val deg

Ext

-20 Ext

-40 Ext

Idiopathic Toe Walking -30 Abd

25%

50%

75%

Gait Cycle

-20

-20 40

Plantar-Dorsiflexion

-40 40

Foot Pro

Knee

• May be able to Knee Varus-Valgus Knee Flexion-Extension normalize some D56647 kinematic and kinetic variables on demand 456647 5 Leftregular (9/30/2013)gait 456647 5 Right (9/30/2013) pattern • “Doctor walk” may Plantar-Dorsiflexion look better but still have subtle differences 30

Dor 80

Int 40

Var

deg Flx

Int

deg

Pla

Ext

Val

-40 Ext

25%

50%

75%

-40 Ext

25%

Gait Cycle

-30

25%

50%

75%

-20

-40

Dor

Int

5 Gai

Gait Cycle

Foot Pro

deg

Pla -40

Ext

25%

50%

75%

-40

Gait Cycle

456647 7 Left (9/30/2013) “doctor”456647 walk7 Right (9/30/2013)

Pendharkar et al., Gait Posture, 2012

25%

Gai

“Dr.” Walking

C51623 Pre op 1118 - 10 Post op 1154 –11

(Plantar grade foot possible with knee hyperextension)

Idiopathic Toe Walking Treatment • Treatment depends on severity – Reassurance/monitor over time – Stretching/PT – Casting – Bracing/night splinting – Surgery (level depends on Silfverskiöld test) – No role for BOTOX due to lack of spasticity Alvarez et al., Gait Posture, 2007.; Engstrom et al., JBJS, 2013.; Stricker & Angulo, JPO, 1998

Pre vs. Post Surgical Intervention

Pelvic Tilt

40 Ant

Pre – Post Sx for Toe Walking deg

Pos

-20

Hip Flexion-Extension

Knee Flexion-Extension

Ankle: • Kinematic changes in stance and swing • Heel initial contact and increased dorsiflexion stance and swing • Power generation at push off maintained

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

Hip Pow er

Gen

W/kg

Abs -2.0

Knee Pow er

3.0

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

Ankle Pow er

3.0

W/kg

Pre – dashed line Post – solid line Abs

25%

50% Gait Cycle

75%

-2.0

25%

50%

75%

-2.0

Gait Cycle

351623 12 Left (4/30/2013) 351623 5 Left (7/29/2011)

25%

50% Gait Cycle

75%

Ant deg

Pre – Post Sx for Toe Walking Pos

-20

Hip Flexion-Extension

Knee: • Kinematic changes in stance • Decreased hyperextension in stance • Decreased associated knee flexor moment and power absorption

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

-20

-40

Hip Moment

2.0

Knee Moment

2.0 Ext

Ext

Nm/kg

Flx

-1.0

Hip Pow er

Gen

W/kg

Pre – dashed line Post – solid line Abs

-2.0

25%

50%

Gait Cycle

Knee Pow er

3.0

75%

Ankle Moment

2.0

Ext

3.0

Plantar-Dorsiflexion

Ankle Pow er

3.0

W/kg

Abs -2.0

25%

50%

75%

-2.0

Gait Cycle

351623 12 Left (4/30/2013) 351623 5 Left (7/29/2011)

25%

50% Gait Cycle

75%

Cerebral Palsy

Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth Disease • Hereditary Motor and Sensory Neuropathies – > 120 genes associated with different forms of disease (CMT 1A, CMT 1B, CMT 2, CMT 3, CMT 4, CMT X, etc, etc) – Abnormalities in myelin sheath or axon – Peripheral nerves affected – motor and/or sensory

CMT is characterized by: distal muscle weakness and imbalance associated foot and ankle deformities resulting compromised gait function

CMT – toe walking Least common presentation in CMT

Õunpuu et al., Gait and Posture, 2013

Ankle Function

Plantar-Dorsiflexion

Dor

Deg

• Equinus stance and swing • Toe contact pattern • Plantar flexor contracture (-10 deg knee flexed/extended) • Reduced power generation in terminal stance • Strength profile variable - plantar flexor weakness

Pla

-40

Ankle Moment

2.0

Pfl

129704

Nm/kg

Dfl

-1.0

3.0

* Ankle Power

Gen

W /kg

Abs

-2.0

Hip Flexion-Extension

Knee Function

Knee Flexion-Extension

Flx

deg

Ext

Pla

-20

-40

• Typical extension at initial contact • Reduced peak flexion in swing (typical flexion not needed for clearance due to toe walking) • Knee flexor moment -20

2.0

Hip Moment

* Knee Moment

2.0

Dor

deg

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

Plantar

Ankl

-1.0

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Ank

CMT Toe Walking Treatment • Concerns: – Progressive disorder – increasing weakness over time at varying and unpredictable rates – understanding natural history on a patient by patient basis is important (1) – Plantar flexor weakness confounded by plantar flexor contracture (2) – Plantar flexor contracture in part related to common cavus deformity (2) 1) Õunpuu et al., Gait and Posture, 2023 2) Õunpuu et al., JPO, 2025.

Treatment Implications • Relationship between cavus and ankle dorsiflexion capability (plantar flexor length)? • Consider “benefit” of some plantar flexor tightness with simultaneous plantar flexor weakness? • Implications of progressive weakness? Õunpuu et al., Gait & Posture, 2022. Õunpuu et al., Gait & Posture, 2023. Rethlefsen et al., Clin Orthop Relat Res, 2024. Õunpuu et al., JPO, 2025.

Surgical Lengthening • Appropriate in some patients but must be clear about individual gait findings and joint level impairments to make an informed treatment decision (JPO, 2025) • Gait analysis is a great tool to evaluate outcomes (short and long-term) • Complicated by progressive pathology

Add Post video

Pelvic Tilt

Ant

Treatment Outcomes Experience deg

Pos

Case 1

-20

tension

Knee Flexion-Extension Hip Flexion-Extension

• With gait analysis we can better understand surgical outcomes

Case 2

Plantar-Dorsiflexion Knee Flexion-Extension

Flx

Dor

Flx

Dor

Deg

deg

Deg

deg

Ext

Pla

Ext

Pla

-20

-40

-20

-40

2.0

Ext

Knee Moment Hip Moment

Pre = dashed

Ankle Moment Knee Moment

2.0

Ext

Pfl

Ext

Nm/kg

Flx

Dfl

Flx

-1.0

3.0

Gen

W /kg

W/kg

W /kg

W/kg

Abs

-2.0

Knee Power Hip Power

25%

50% Gait Cycle

75%

50% Gait Cycle

Ankle Moment

2.0

Ankle Power Knee Power

25%

Plantar-Dorsiflexion

Post = solid

Ankle Power

3.0

75%

-2.0

25%

50% Gait Cycle

75%

Hip Dysplasia

Hip Dysplasia • Toddler w/ unilateral toe walking left (unilateral hip dislocation) • Limited hip abduction • Supple ankle/knee • May be associated with h/o other “packaging problems” (torticollis, metatarsus adductus)

(C Wisialowski?)

Hip Dysplasia

(toe walking compensation for left side to equalize leg lengths)

(elimination of toe walking compensation results in increased COG vertical excursion)

deg

Hip Dysplasia

Val -30

Ext

25%

50%

75%

Ext

-20

-40

Gait Cycle

• Toe walking is a Plantar-Dorsiflexion 40 40 compensation for the Dor Int leg length difference deg due to dislocated hip • A60628 Pla Ext • Apparent leg length difference since hip is -40 -40 high riding 160628 4 Left (7/29/2008) 160628 4 Right (7/29/2008) • Treat the hip not the hip dislocation = dashed line limp 25%

50%

Gait Cycle

75%

Leg Length Difference

Leg Length Difference • Similar to DDH, but there is an actual LLD rather than just “apparent” • Scoliosis may also give “apparent” LLD if associated w/ pelvic obliquity • Too many reasons to cover here (list included for reference) • Careful history (congenital vs. acquired)

Congenital • Hypoplasia syndrome • Proximal femoral focal deficiency • Tibial deficiencies • Fibular deficiencies • Hemiatrophy • Hemihypertrophy • Idiopathic • Klippel-Trenaunay-Weber syndrome

• Beckwith-Wiedemann syndrome • Proteus syndrome • Skeletal dysplasia • Ollier disease • Fibrous displasia • Neurofibromatosis • Multiple hereditary exostosis

Aquired • • • • • • • • • • • • •

Trauma Acute bone loss Physeal Injury Fracture healing Burns Irradiation Iatrogenic Infection Osteomyelitis Septic arthritis Pupura fulminans Inflammation Juvenile rheumatoid arthritis

• • • • • • • • • • • • •

Hemophilia Pigmented villonodular synovitis Neurologic Acute brain injury Spinal cord injury Peripheral nerve injury Cerebral palsy Myelomeningocele Poliomyelitis Tumors Tumor treatment Enchondromatosis Hemangiomas

Leg Length Difference

deg Val

Ext

-30

Ext

Leg Length Difference 25%

50%

75%

-20

-40

Gait Cycle

Plantar-Dorsiflexion • Which is the 40 40 abnormal limb? Dor Int (shortening vs deg overgrowth) • B41910 Pla Ext • Toe walking is one compensation -40 -40 • Patients may also 241910 21 Left (4/28/2008) 241910 21 Right (4/28/2008) compensate w/ short leg = dashed line asymmetric knee/hip/pelvis ROM 25%

50%

Gait Cycle

Song et al., JBJS, 1997

75%

Leg Length Difference – Shoe Lift

Hereditary Spastic Paraparesis (Familial Spastic Paraplegia)

Hereditary Spastic Paraparesis (Familial Spastic Paraplegia) • Progressive lower extremity weakness and increased tone/spasticity • Selective voluntary control including ankle • MRI brain/spine usually normal • Positive family history • Genetically linkage Fink JK, Acta Neuropathol, 2013; Wolf et al. Gait Posture, 2011

C41858 2007 and 2010

Disease Progression

2007

2010

Hip Ab-Adduction

Add

60 Flx

Hip Flexion-Extension Hip Ab-Adduction

Add

Hip Rotation Hip Flexion-Extension

Int

Flx

Int

Ext

Disease Progression deg

deg

Abd

Ext

Abd

-20

• Bilateral crouch maintained • Bilateral increasing toe walking due to increasing equinus • Bilateral increasing plantar flexor contracture: 15 to -20 deg (R) 15 to -10 deg (L)

Flx

-40

Knee Flexion-Extension Knee Varus-Valgus

-20

-30

Knee Flexion-Extension

Flx

Int

Ext

C41858

deg Val

-40

Var

Ext

-20

25%

50%

-20

75%

-40

Gait Cycle

Plantar-Dorsiflexion

Dor

Int

Dor

deg

40 Int

deg

Pla -40

Foot Progression Plantar-Dorsiflexion

Ext

25%

50% Gait Cycle

75%

-40

Pla -40 25%

Ext

50% 25%

75% 50%

Gait Cycle

75%

-40

341585 6 Left (3/13/2007) 341585 6 Right (3/13/2007) 341858 12 Left (1/13/2010) 341858 12 Right (1/13/2010)

2007

2010

right (solid) / left (dashed) knee and ankle sagittal plane kinematics

Treatment • Defined by comprehensive motion analysis procedures • Follows patterns for cerebral palsy • Concerns: progressive deformity • Importance of objectively documenting decline

Tumors

Unilateral Toe Walking • Red flag • If diagnosis of hemiplegia is negative • Examine for other possibilities – Spinal – Tumor – Etc.

Examples later…

Tumors

Tumors • Concern: unilateral toe walking • increasing tightness in his left ankle plantar flexors, atrophy • Pain/discomfort with left rapid passive dorsiflexion and palpation around the musculo-tendon junction of the left gastrocnemius

561135

Tumor • Tumor can put pressure on calf muscle or nerve • Vascular malformation may result in gastrocnemius spasm/contracture • Unilateral Domb et al., CORR, 2004. Skabelund & Andrews, J Orthop Sports PT, 2013

deg

Pos

-20

Tumors con’t Hip Flexion-Extension

• Equinus of left ankle in stance and swing

Knee Flexion-Extension

Flx

Dor

deg

Ext

Pla

– Plantar flexor contracture of -15 deg (knee 0 & 90 deg) -20

-20

Hip Moment

• Toe initial contact with absence of dorsiflexor moment at loading response • Reduced ankle power generation 2.0

2.0

-40

Knee Moment

2.0

Ext

Nm/kg

Flx

-1.0

3.0

Hip Power

3.0

– Unable to test plantar flexor strength due to limited ROM

Plantar-Dorsiflexion

Knee Power

3.0

Gen

W/kg

Abs

-2.0

Ankle Moment

Ankle Power

Treatment • Clinical exam findings of pain would suggest imaging to identify possible problem • Address the primary problem • Depending on the tumor type: – Interventional radiology – Surgical revision

Toe Walking Diagnostic Matrix TOE WALKING NEUROMUSCULAR CEREBRAL PALSY TRAMATIC BRAIN INJURY CVA, etc.

OTHER

Diagnostic Matrix Neuromuscular Determining Diagnosis

History Clinical Examination Imaging Verifying Level of Gait Pathology – Gait Analysis (equinus and/or knee flexion)

Differentiating Between Primary or Secondary

Diagnostic Matrix OTHER Determining Diagnosis History of Toe Walking (patient and family) Unilateral vs. Bilateral Clinical Examination Imaging

IDIOPATHIC Dx of Exclusion

Verifying Level of Gait Pathology – Gait Analysis (equinus, proximal origin)

Differentiating Between Primary or Secondary

Assessment of Toe Walking • What you need to know to make treatment decisions: – Medical and birth history and age of onset of walking – Family history of similar problems – Ankle passive ROM – Ability to isolate function at the ankle/strength – Assessment of spasticity – Ankle function during gait (kinematics and kinetics) – Knee function during gait (kinematics and kinetics) – EMG during gait and in response to passive stretch – Imaging when appropriate

Role of Gait Analysis • Improved understanding of relationship between visual assessment and joint function • More precise definition of what is actually happening: “toe walking”, “excessive equinus” and “knee flexion”, etc. • Objective documentation of change in severity of toe walking over time • Objective evaluation of treatment outcomes = better understanding of treatment indications

Thank You

References •

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• •

Alvarez C, De Vera M, Beaucham R, Ward V, Black A: Classification of idiopathic toe walking based on gait analysis: development and application of the ITW severity classification. Gait Posture. 2007 Sept;26(3):428-35. Armand S, Watelain E, Mercier M, Lensel G, Lepoutre FX: Identification and classification of toewalkers based on ankle kniematics, using a data-mining method. Gait Posture. 2006 Feb;23(2):240-8. Bonnefoy-Mazure A, Turcot K, Kaelin A, De Coulon G, Armand S: Full body gait analysis may improve diagnostic discrimination between hereditary spastic paraplegia and spastic diplegia: a preliminary study. Res Dev Disabil. 2013 Jan;34(1):495-504 (Epub 2012 Oct 17). Davids JR, Foti T, Dabelstein J, Bagley A: Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: a kinematic, kinetic, and electromyographic analysis. J Pediatr Orthop.. 1999 Jul-Aug;19(4):461-9. Domb BG, Khanna AJ, Mitchell SE: Frassica FJ: Toe-walking attributable to venous malformation of the calf muscle. Clin Orthop Rel Res. 2004 Mar;(420):225-9. Eastwood DM, Dennett X, Shield LK, Dickens DR: Muscle abnormalities in idiopathic toe-walkers. J Pediatri Orthop B. 1997 Jul;6(3):215-8.

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Engstrom P, Bartonek A, Tedroff K, Orefelt C, Haglund-Akerlind Y, Gutierrez-Farewik EM: Botulinum toxin A does not improve the results of cast treatment for idiopathic toe-walking: a randomized controlled trial. J Bone Joint Surg Am. 2013 Mar 6;95(5):400-7. Engstrom P, Van’t Hooft I, Tedroff K: Neuropsychiatric symptoms and problems among children with idiopathic toe-walking. J Pediatr Orthop. 2012 Dec;32(8):848-52. Ferrarin M, Bovi G, Rabuffetti M, Mazzoleni P, Montesano A, Moroni I, Pagliano E, Marchi A, Marchesi C, Beghi E, Pareyson D: Reliability of instrumented movement analysis as outcome measure in Charcot-Marie-Tooth disease: results from a multitask locomotor protocol. Gait Posture. 2011 May;34(1):36-43. Fink JK: Hereditary spastic paraplegia: clinico-pathologic features and emerging molecular mechanisms. Acta Neuropathol. 2013 Sep;126(3):307-28. Hicks R, Durinick N, Gage JR: Differentiation of idiopathic toe-walking and cerebral palsy. J Pediatr Orthop. 1988 Mar-Apr;8(2):160-3. Hirsch G, Wagner: The natural history of idiopathic toe-walking: a long-term follow-up of fourteen conservatively treated children. Acta Paediatr. 2004 Feb;93(2):196-9. Kelly IP, Jenkinson A, Stephens M, O’Brien T: The kinematic patterns of toe-walkers. J Pediatr Orthop. 1997 Jul-Aug;17(4):478-80. Klebe S, Stolze H, Kopper F, Lorenz D, Wenzelburger R, Volkmann J, Porschke H, Deuschl G: Gait analysis of sporadic and hereditary spastic paraplegia. J Neurol. 2004 May;251(5):571-8. Kogan M, Smith J: Simplified approach to idiopathic toe-walking. J Pediatr Orthop. 2001 NovDec;221(6):790-1. Oetgen ME, Peden S: Idiopathic toe walking. J Am Acad Orthop Surg. 2012 May;20(5):292-300.

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Õunpuu S, Garibay E, Solomito M, Bell K, Pierz K, Thomson J, Acsadi G, Deluca P: A comprehensive evaluation of the variation in ankle function during gait in children and youth with Charcot-Marie-Tooth disease. Gait Posture. 2013, 38(213): 900-906. Ounpuu S, Pierz K, Garibay E, Acsadi G, Wren T. Stance and swing phase ankle phenotypes in youth with Charcot-Marie-Tooth type 1: An evaluation using comprehensive gait analysis techniques. Gait & Posture 98 (2022) 216–225. Ounpuu S, Pierz P, Mack W, Rodriguez-MacClintic J, AcsadiG, Wren TAL. Natural History of Ankle Function During Gait in Youth with Charcot-Marie-Tooth Disease Types 1 and 2, Gait & Posture (2023), 103:146-152. Ounpuu S, Pierz K, Rethlefsen S, Rodriguez-MacClintic J, Acsadi G, Kay R, Wren TAL. Outcomes of Triceps Surae Lengthening Surgery in Children with Charcot-Marie-Tooth Disease: A Multisite Investigation, J Oediatr Orthop, 45(4), 226-233, 2025. Pendharkar G, Percival P, Morgan D, Lai D. Automated method to distinguish toe walking strides from normal strides in gait of idiopathic toe walking children from heel accelerometrydata. Gait Posture. 2012 Mar;35(3):478-82. Piccinini L, Cimolin V, D’Angelo MG, Turconi AC, Crivellini M, Galli M: 3D gait analysis in patients with hereditary spastic paraparesis and spastic diplegia: a kinematic, kinetic and EMG comparison. Eur J Paediatr Neurol. 2011 Mar;15(2):138-45 (Epub 2012 Sep 15). Rethlefsen SA, Ounpuu S, Rodriguez-MacClintic J, et al. Is a Three-component Video-based Version of the Foot Posture Index Valid for Assessing Pediatric Patients With Orthopedic and Neurologic Foot Conditions? Clin Orthop Relat Res (2024) 00:1-9.

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Rose J, Martin JG, Torbum L, Rinsky LA, Gamble JG: Electromyographic differentiation of diplegic cerebral palsy from idiopathic toe walking: involuntary coactivation of the quadriceps and gastrocnemius. J Pediatr Orthop. 1999 Sep-Oct;19(5):677-82. Song KM, Halliday SE, Little DG: The effect of lim-length discrepancy on gait. J Bone Joint Surg Am. 1997 Nov;79(11):1690-8. Skabelund J, Andrews RS: Venolymphatic malformation of the proximal gastrocnemius muscle in a girl. J Orthop Sports Physical Therapy. 43(5):349, 2013. Stricker SJ, Angulo JC: Idiopathic toe walking: a comparison of treatment methods. J Pediatr Orthop. 1998 May0Jun;18(3):289-93. Westberry DE, Davids JR, Davis RB, de Morais Filho MC: Idiopathic toe walking: a kinematic and kinetic profile. J Pediatr Orthop. 2008 Apr-May;28(3):352-8. Williams CM, Tinley P, Curtin: Idiopathic toe walking and sensory processing dysfunction. J Foot Ankle Res. 2010 Aug 16;3:16. Williams CM, Tinley P, Curtin M, Wakefield S, Nielsen S: Is idiopathic toe walking really idiopathic? The motor skills and sensory processing abilities associated with idiopathic toe walking gait. J Child Neurol. 2013 Jan 24 (Epub ahead of print). Wolf SI, Braatz F, Metaxiotis D, Armbrust P, Dreher T, Doderlein L, Mikut R: Gait analysis may help distinguish hereditary spastic paraplegia from cerebral palsy. Gait Posture. 2011 Apr;33(4):556-61 (Epub 2011 Feb 16).

Clinical gait analysis A Focus on Interpretation

Unraveling gait decline in Duchenne Muscular Dystrophy: Insights from 3D motion analysis Kaat Desloovere Ines Vandekerckhove Marleen Van den Hauwe, Anja Van Campenhout, Nathalie Goemans, Liesbeth Dewaele

Clinical Motion Analysis Laboratory University Hospital Leuven, Belgium

Duchenne muscular dystrophy (DMD) • X-linked degenerative disorder • Most common neuromuscular disease in children • 1/3000-5000 boys

Sussman, 2002, J Am Acad Orhtop Surg Emery et al., 1991, Neuromuscul Disord

Absence of dystrophin in DMD Protein dystrophin • Stability of muscle cell membrane • Protects the muscles from contraction induced damage Connective tissue and fatty tissue Muscle => fibrous and fatty tissue

Gao et al., 2015, Compr Physiol

Duchenne muscular dystrophy (DMD) • Muscle degeneration • Progressive loss of muscle mass • Proliferation of fat and fibrotic tissue Underlying muscle impairments

Weakness 4

Altered muscle morphology

Stiffness and contractures

Sussman, 2002, J Am Acad Orhtop Surg Wokke et al., 2014, Neuro Disorders Choi et al., 2018, BMC Musculoskeletal Disorders Goudriaan et al., 2018, Gait & Posture

Timeline Delayed motor development

5 Difficult climbing stairs and rising from floor

Proximal weakness

Distal weakness

Arm function

Ankle hypertrophy contracture

Hip and knee contractures

Spinal deformities

Loss of ambulation

Respiratory or cardiac dysfunction

Kim et al., 2018, Ann. Rehabil. Med.

Treatments  Corticosteroids (long-term use)  Gait rehabilitation, orthopaedic and orthotic interventions  Promising novel drugs 12 years of age or older

 Aim 6

prolong ambulation

Goemans, KU Leuven PhD thesis, 2013 Heberer et al, 2016, Gait & Posture

Hind et al. 2017 Pilot and feasibility studies. De Souza et al. 2016 Clinical biomechanics.

Promising novel drugs Evaluation of the successes of clinical trials • NSAA (North Star Ambulatory Assessment) • 6MWT (6 minutes walking test) • 100m run test • Timed tests

• Global function outcome • Not sensitive • Do not assess the underlying muscular impairments 7

Lu et al, 2014, Mol. Ther. - Nucleic Acids Kirschner et al, 2010, Lancet Neurol. Lynn et al, 2015, Neuromuscul. Disord. Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Promising novel drugs Evaluation of the successes of clinical trials • NSAA • 6MWT • 100m run test • Timed tests

Strong need for new sensitive functional markers

• Global function outcome • Not sensitive • Do not assess the underlying muscular impairments 8

Lu et al, 2014, Mol. Ther. - Nucleic Acids Kirschner et al, 2010, Lancet Neurol. Lynn et al, 2015, Neuromuscul. Disord. Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

3D gait analysis

Quantitative description of the gait deviations

Heberer et al, 2016, Gait & Posture

Evolution of DMD gait Knowledge on the evolution of the gait pattern is required

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Early stage

Transitional stage

Sutherland et al. (1981)

Late stage

Early stage

Transitional stage

Late stage

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Early stage Compensation weak hip extensors Lumbar lordosis Backward trunk leaning

GRF behind hip

Transitional stage Compensation weak knee extensors Pelvic anterior tilt GRF before knee

Late stage Compensation weak knee extensors Pelvic anterior tilt GRF before knee

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Early stage Compensation weak hip extensors Lumbar lordosis Backward trunk leaning

GRF behind hip

Transitional stage Compensation weak knee extensors Pelvic anterior tilt GRF in front of knee Compensation weak hip abductors Shoulder sway GRF lateral of hip (?) base of support

Late stage Compensations more pronounced

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Early stage

• TRUNK: Slight backward leaning with lumbar lordosis • PELVIS: Pelvic posterior tilt • HIP: Full (hyper)extension in stance and increased flexion in swing • KNEE: Minor deviations • ANKLE: Reduced dorsiflexion in stance and swing • FOOT: External foot progression 15

• No heel strike => Weakness tibialis anterior

Transitional stage

• TRUNK: Backward leaning with lumbar lordosis • PELVIS: Anterior tilt • HIP: Increased flexion in stance and swing • KNEE: Reduced range of motion in stance • ANKLE: Reduced dorsiflexion in stance and swing + reduced 3° rocker • FOOT: Variable: transition from external to internal foot progression 16

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

• No heel strike => Gastrocnemius contracture

Late stage

• TRUNK: Backward leaning with lumbar lordosis • PELVIS: Anterior tilt • HIP: Increased flexion in stance and swing • KEE: Reduced ROM in overall flexed position • ANKLE: Plantar flexion in stance and swing • FOOT: Internal foot progression 17

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

• No heel strike => Gastrocnemius contracture

Early stage

Transitional stage

Late stage PELVIS in frontal and tranverse plane: Gradually increased ROM

Early stage

Kinetics (internal moments) Transitional stage

Ext

Plan

Flex

Dors

Late stage

Flex

Ext

Plan

Flex

Dors

Flex

Late

Late Ext

Transitional

Transitional Ext

Early

Ext Plan

Flex

Dors

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Early stage

Hip kinetics (sagittal) 1. Decreased hip extension moment

Transitional stage

Early

• Weak trunk muscles and hip extensors • Lumbar lordosis • Backward trunk leaning • Arms kept slightly backwards • GRF quickly close to hip joint center

Late stage

2. Continuous hip flexion moment Transitional

• Start of hip flexion contracture • Arms kept clearly backwards • GRF behind (but close to) hip joint center 3. Hip extension moment • Hip flexion contracture • Increased anterior tilt • Increased hip flexion

Late

• Arms continously kept backwards • GRF gradually more anterior to hip center!

Predictor of loss of ambulation ?

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Early stage

Knee kinetics (sagittal) Transitional stage

Early

1. Reduced knee flexion moment • Slight weakness in knee extensors • Normal knee kinematics • GRF mainly behind knee joint center (caused by hip compensations)

Late stage

Transitional

2. Knee moment decreases • Weak knee extensors • Towards zero moment 3. Increased knee extension moment • Knee flexion contracture • Increased knee flexion

Late

• GRF behind knee

predictor of loss of ambulation ? 21

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Hip kinetics (frontal) Abd

Abd

Add

Early

Transitional

Late

Hip abduction normal? – Weak hip abductors – Slight lateral trunk movement (only in late stage) – Base of support gradually increasing – From external to internal foot progression – Increasing lateral arm position Stiffness / contracture hip abductors? Trunk weakness seems dominant over hip abductor weakness

Early stage

Ankle kinetics Early

Transitional stage Transitional

1. No dorsiflexion moment •

Stiff gastrocnemius

•

Reduced dorsiflexion in swing

•

Initial contact with foot flat

•

GRF anterior to ankle joint center

2. Premature plantairflexion moment •

Gastrocnemius contracture

•

Initial contact with forefoot

3. Reduced plantairflexion moment

Late stage Late

•

Gastrocnemius contracture

•

Initial contact with forefoot or continuous equinus

Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Challenges at the ankle

Simple foot models are not appropriate to capture foot deformities (Mid-foot break, forefoot adduction, varus/valgus)

Early stage

Transitional stage

Late stage

Sutherland et al. (1981) Few additional studies, with discrepancies

Systematic review by Goudriaan et al. (2018) Mostly cross-sectional studies 25

Sutherland et al., 1981, Develop. Med. Child. Neuro. Goudriaan et al., 2018a, Gait & Posture Goudriaan et al., 2018b, Gait & Posture Ganea et al., 2012, J Child Neurol

D’Angelo et al., 2009, Gait Posture Gaudreault et al., 2010, Gait Posture Doglio et al., 2011, Eur J Phys Rehabil Med Heberer et al, 2016, Gait & Posture

Progressive gait pathology in DMD Complex to integrate results from literature that could delineate the full picture of pathological gait Longitudinal studies are necessary A lack of studies quantifying the gait pattern and the underlying muscle impairments to investigate the underlying mechanisms of the progressive gait pathology An integrated assessment of the pathological gait pattern, combined with assessments of all muscle impairments is essential

Longitudinal follow-up of boys with DMD Progressive alterations in gait deviations, muscle strength and altered muscle morphology in growing children with DMD Ines Vandekerckhove

Participants Duchenne muscular dystrophy

Typical developing children

 Diagnosed with DMD

 CMAL database

 Muscle biopsy  Immunohistochemistry  Mutation of the dystrophin gene

 No history of lower limb surgery  Able to walk independently for at least 100m  Age: 3 – 16 years old  Inclusion at different ages  Chronic treatment with corticosteroids and participation in clinical trials are permitted

 Age: 3 – 18 years old

Participants Duchenne muscular dystrophy

Typical developing children

 Repeated measurements

 Cross-sectional

 Mixed longitudinal

6 months

6 months 4 29

6 months

6 months 12

Age (years)

6 months 14

Mixed longitudinal database

Number of participants with DMD

Age range (years)

4.6 - 17

Number of measurements per participant

1 to 11

Total number of measurement sessions

187

Assessments

Research question 1 How do gait features evolve over time in children with DMD?

Methods 3DGA

31 pre-defined gait features • 4 Spatio-temporal parameters • 17 Kinematic parameters • 10 Kinetic parameters

Participants Measurements

DMD

113

Gait profile score

Statistics  Mean structure Fixed effects • Baseline age • Time course • Interaction  Covariance structure • Random effects • Serial correlation

Gait parameter (degrees)

Linear mixed effect models

β6= 0.10* Age (years)

Normalized step length

Non dimensional value

steps per second (steps/s)

Cadence

β1= -0.016*

β1= -0.058* Age (years) 35

Age (years)

Gait profile score

Degrees (°)

Honey moon period

β6= 0.10*

Age (years)

Maximal anterior pelvic tilt

Minimal hip flexion angle in stance

Ant

Degrees (°)

Flex

β1= 1.33* Age (years) 37

Ext

β1= -1.88* Age (years)

Dorsiflexion angle at initial contact

Maximal dorsiflexion angle in swing

Dors

Degrees (°)

Dors

Plan

β1= -1.20*

Plan

β6= -0.35* 38

Age (years)

Minimal hip adduction angle

Degrees (°)

Non dimensional value

Add

Step width

β1= -0.027* β2= 0.005* β6= 0.005*

Abd

β1= -0.42* Age (years) 39

Age (years)

Maximal internal foot progression angle

Degrees (°)

Int

Ext

β1= 2.10*

Age (years) 40

Conclusion 21/31 gait features changed significantly over time Gait features may constitute promising functional markers to evaluate the efficacy of treatments in children with DMD 2022

Classification of Sutherland Outdated ? Impact of treatment ? Early stage

Transitional stage

2024

Late stage

Classification of Sutherland Outdated ? Impact of treatment ?

Mildly affected gait Tiptoeing gait

Flexion gait

2024

Research question 2 How do muscular impairments evolve over time in children with DMD?

Progressive muscle weakness

Challenge Take into account the natural growth For example: Strength gradually increases in growing children

Progressive muscle stiffness

Knee Extension (Nm)

Extension (Nm)

Hip

(kg*m)

Dorsiflexion (Nm)

Muscle strength Percentiles typically developing children (N>150) Ankle

(kg*m)

TD Centiles 5 10 25 50 75 90 95 Boy with DMD

Knee Extension (Nm)

Extension (Nm)

Hip

(kg*m)

Dorsiflexion (Nm)

Muscle strength Percentiles typically developing children (N>150) Ankle

TD Centiles 5 10 25 50 75 90 95 Boy with DMD

(kg*m)

Z-scores based on percentiles • Non-dimensional • No impact of growth

Z-score = -5

Longitudinal trajectory of strength defecits in DMD Knee

(kg*m) Dorsiflexion (z-scores)

(kg*m) Extension (z-score)

Extension (z-score)

Ankle Dorsiflexion (Nm)

Extension (Nm)

Hip

(kg*m)

TD Centiles 5 10 25 50 75 90 95 Boy with DMD

Longitudinal trajectory of muscle impairments STRENGTH Hip Strength

Knee

Ankle

Longitudinal trajectory of muscle impairments STRENGTH Hip Strength

Knee

Ankle

Longitudinal trajectory of muscle impairments MUSCLE SIZE Rectus Femoris muscle size Muscle size

Medial Gastrocnemius muscle size

Longitudinal trajectory of muscle impairments MUSCLE SIZE Rectus Femoris muscle size Muscle size

Medial Gastrocnemius muscle size

Longitudinal trajectory of muscle impairments JOINT ROM Hamstrings range of motion Range of motion

Dorsiflexion range of motion

Longitudinal trajectory of muscle impairments JOINT ROM Hamstrings range of motion Range of motion

Dorsiflexion range of motion

Research question 3 How do development of gait features associate with the development of neuromuscular impairments in children with DMD? GAIT

NEUROMUSCUMAR IMPAIRMENTS Strength

• Jointly model muscular impairments and gait features • Selection of outcomes based on • Previous longitudinal analysis of • gait data • muscular impairment data

GAIT Pelvic tilt

• Clinical reasoning

Hip extension strength (z-scores)

• Joint random-effect models

Maximal anterio pelvic tilt (°)

Association between the longitudinal development of muscle impairment and gait deviations STRENGTH IMPAIRMENT Hip extension strength

Correlation random intercept: -0.543 (p=0,0040) Correlation random slopes:

-0.812 (p<0.0001)

• Jointly model muscular impairments and gait features • Outcome parameters based on • Previous longitudinal analysis of • gait data • muscular impairment data

GAIT Dorsiflexion at initial contact

MOBILITY IMPAIRMENT Dorsiflexion ROM Dorsiflexion ROM (z-scores)

• Joint random-effect models

Dorsiflexion angle initial contact(°)

Association between the longitudinal development of muscle impairment and gait deviations

• Clinical reasoning Correlation random intercept: 0.732 (p<0,0001) Correlation random slopes:

0.627 (p=0.0202)

Association between the longitudinal development of muscle impairment and gait deviations

= Moderate-Strong Association of starting levels = Moderate-Strong Association of progression rates

Increased posterior trunk leaning Decreased hip extension strength

Reduced hip extension moment Decreased hip extension strength

Reduced knee extension moment Reduced knee power absorption Decreased knee extension strength

Increased internal foot progression Decreased hip abduction strength

Increased anterior pelvic tilt Decreased hip extension strength

Reduced dorsiflexion in swing Reduced dorsiflexion range of motion Reduced dorsiflexion at initial contact Decreased knee extension strength Reduced dorsiflexion range of motion Increased step width Decreased hip abduction strength

Integrated evaluation platform with promising outcome measures and history data could be used in clinical trials to prove the effect of novel therapies Integrated evaluation platform

Quantified trajectories

Promising outcome measures

Case 2

Case 1

Treatments: Patient-tailored recommendations

Prediction of loss of ambulation 14 years 9 months

14 years 9 months 15 years 3 months

15 years 3 months

Increasing pelvic anterior tilt and hip flexion Hip flexor contracture

Increasing knee flexion Knee flexor contracture

Failure of keeping hip flexion moment

Failure60of keeping knee flexion moment

Prediction of loss of ambulation

14 years 9 months 15 years 3 months

Decreasing hip abduction moment ?

Remaining questions to be solved • Predictions of loss of ambulation ? • • • •

Hip flexion moment => hip extension moment Knee flexion moment => knee extension moment Impairment thresholds? Other predictors?

• Mechanism of preserved hip abduction moment ? • Trunk weakness dominates hip abductor weakness ? • Stiffness / contractures of hip abductors ?

• Mechanism of ankle power generation • Gastrocnemius/soleus stiffness / contracture ?

• Indications to prolong gait capacity ?

• Prevention of hip and knee contractures ? • Orthoses (light weight) to replace lack of hip/knee flexion moments Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium

Thank you! Any questions?

This study is funded by Duchenne Parent Project NL (17.011) and by the Research Foundation – Flanders (FWO-1188921N)

Kaat.Desloovere@uleuven.be and ines.vandekerckhove@kuleuven.be