Case of the Week 17/09/98 (ESMAC conference, Belfast 1998):

Feedback from the expert speakers at the ESMAC meeeting is here.

What people said...

Q. What is the primary cause of this gait pattern?

A. He walks with stiff knees, complicated by rotational deformities
(femoral anteversion and/or tibial torsion). I find it surprising,
though, that both knees hyperextend on clinical examination to -10

Q. What is the cause of the high energy consumption?

A. He is vaulting with the stance ankle in order to compensate for lack
of toe-clearance. This causes increased rise and fall of the trunk,
requiring more energy (mainly from the planarflexors).

Q. What treatment would you recommend in relation to energy consumption?

A. He needs to improve toe-clearance. This could be done by freeing the
knees by a combination of hamstrings lengthening and rectus transfer to
gracilis. I also wonder whether he has tried walking with a stick (cane)?

Dr. Chris Kirtley MD PhD
Dept. of Rehabilitation Sciences
The Hong Kong Polytechnic University
Hong Kong
Special Administrative Region of The People's Republic of China

Perhaps some trunk stability exercises would assist in his ability to control
the lower extremities.

I am a relatively novice clinician, and am fortunate enough to work with one
who is very experienced.  I evaluated a child who toe walks the other day
(although he was referred for hamstring tightness).  He definitely needed his
hamstrings stretched, but his trunk was very weak.  My counterpart was telling
me how when the trunk is weak the hamstrings will substitute as trunk
extensors to add stability, and therefore get very tight.  Ankle
plantarflexion is part of that strategy as well, to keep him from falling
backwards.  If only his hamstrings were stretched, his overall stability would
be compromised, so trunk stability activities were added.

In regards to the case, perhaps the gastroc lengthenings, while well-intended,
decreased his stability overall. (Does more dorsiflexion without stability
result in an increased crouch gait?) Range of motion also needs to be
addressed,because he cannot be expected to walk any better without the
necessary range.  However, he obviously needs to be able to control the range.

Maybe the answer is not in the legs....

Melanie Weller MPT 

I regret that I have not followed the entire discussion on this case, but from a PT stand
point, looking at the fact that the client already has hyperextension at the knees and decreased toe
clearance during swing, would it be possible to correct the swing-thru with an AFO set into
dorsiflexion?  This may prevent some of the knee hyperextension, depending on where his COG
falls in relation to the knee. It would also provide increased toe clearance during swing, and
increased stability at the ankle joint.
        Also, if the cause were from increased tone in the hamstrings, requiring lengthening,
how would that decrease the toe clearance on swing-thru?  I understand that it would decrease the
step length on the same side due to a shorter limb length at heel strike, which would also
increase the energy consumption.  Just a thought...

Kristin Dart, PT

So most of you out there missed ESMAC. Chat to those who were there it was a
great event. You've still got time to register for next year's event in
Heidelberg! Its on 23-25 September 1999, put the date in your diary now.

I'll give an account of the case discussions for all three cases over the
next few weeks. Hopefully these will spark yet more discussion. As
discussion flags on one I'll put the next set of comments on.

We'll start with the case published on 17-09-98 as the patient asked to be
removed from the web after the conference. We'll leave him on for say three
weeks more to facilitate any further discussion. Inevitably discussion
centred more on clinical options than on the questions which had been posed
when the cases where published.

In presenting the case a little more information was given regarding EMG
than had been given on the web. The Rectus Femoris was continuously active
throughout gait and the Vastus Lateralis throughout stance (bilaterally). It
was also commented that there was a large population of these older patients
now attending rehab hospitals.

Speaker A thought the subject would definitely benefit from surgery. He
identified internal rotation, short hamstrings, short TAs, short hip flexors
and thought all required surgical correction. It was important to appreciate
that the subject was experiencing increasing difficulties with walking and
intervention was needed soon to prevent this continuing.

Speaker B first drew attention to this as an example of a failed isolated
early TAL and drew parallels with a paper presented earlier in the
conference (Morton et al) highlighting the dangers of such procedures. He
also saw the need for bilateral psoas, hamstrings lengthenings and
derotation osteotomies and also added that the feet should be made
braceable. He concluded by suggesting that the patient would probably end up
taller and straighter but would also be weaker and slower. He thought it
unlikely the subject would become independent of crutches and thought that
the objectives of surgery should be clearly explained in counselling the

Speaker C added his support to this opinion, particularly with regard to
crutches, but added that post-operatively the gait might be more energy

Speaker D asked about the length of time needed to rehabilitate adults after
such major surgery.

Speaker A agreed that this was a concern and reiterated that keeping the
subject walking in the long term was the aim of surgery. He drew attention
to the fact that these subjects have been used to walking in this fashion
for many years and that this needs to be taken into account when planning
surgery. He suggested not completely derotating the femurs for example as
the subject is used to an internally rotating gait.

Speaker C suggested the use of intrathecal baclofen. With such a patient the
procedure he would adopt is to have a trial dose of baclofen before
implanting the pump. A low dose is required because if the tone is taken
away completely the subject will lose the ability to walk at all.

Speaker C also emphasised the need to keep the subject on his feet and
suggested the possibility of operating on right and left separately to avoid
confining the subject to a wheelchair completely during rehab.

Speakers included Reinhold Brunner, Jim Gage, Kerr Graham and Sybil Farmer.
The above account is based on notes I took during the discussion which may
well contain misunderstandings and errors which are mine and not those of
the original speakers.

Richard Baker
Gait Analysis Service Manager
Musgrave Park Hospital

Tel: +44 (0)1232 669501 ext 2155
Fax: +44 (0)1232 611064

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