Case of the Week 20/12/98: What people said...

Hello CGA'ers,

This is our Lab's inaugural posting on this list so go easy on us.

After reviewing the videos and data on this 16 year old we have some
comments and some questions regarding the surgery done on this young man.

Some impressions first of all.  Judging from the video it looks as though
he has  an increased anterior pelvic tilt, increased hip flexion and
diminished knee flexion during stance post operatively.  These are
supported by the kinematic data.

He doesn't seem to have benefitted from the Rectus transfer as his knee
flexion during swing is not significantly increased. The anterior pelvic
tilt and hip flexion contractures are worse following the surgery.

We don't think the patient has improved.

Based on the data presented we agree with most of the choices of surgery.
The amount of anterior pelvic tilt would indicate psoas release is
required.  There is borderline data to support knee flexion contracture
treatment.  We don't support the need for the rectus transfer even though
there was some limitation of knee flexion during swing.

We would question the effectiveness of the psoas release.  From the post-op
data we see increased pelvic tilt, a result of either increased hip flexion
tightness or significant weakness of his hamstrings (almost as seen in
patients who have undergone proximal rather than distal hamstring
lengthenings).  We think he may require a repeat psoas release or even an
ilio-psoas release this time. We don't feel that this patient can be left
with this degree of pelvic tilt and hip flexion tightness even though he is
only 7 months post-op.

Richard Beauchamp, MD , Gait Lab Medical Director
Alec Black, MSc, Gait Lab Director

Shriners Gait Lab             phone:  (604)436 6502
Sunny Hill Health Centre      email:
3644 Slocan St.               homepage:  updated November 5, 1998
Vancouver, B.C., V5M 3E8

I have just finished downloading most of the information on this case. (
I can't wait for ADSL.)
I see a big improvement in leg extension in this case. There are many
problems with this patient, but from what I have seen; there is a right
shoulder drop BEFORE the right extremity hits the ground. This either
means a weak contra lateral hip abductor or a short right limb. Although
looking at the saggital view the right limb looks longer? It just might
be the view I am seeing. A close look at the right foot shows little if
any dorsiflexion at the ankle but a severe amount of pronation. There is
also premature heel lift on the right side.The midtarsal joint seems to
be breaking down and giving all of the dorsiflexion on the right side.
This gives me the impression of an equinus of the achilles on the right
side. I would first check for a limb length discrepancy then put a heel
lift on(the right side I believe). When you do another gait video the
right shoulder should be more level. As far as another surgical
procedure, If needed an anterior advancement of the Tendo achilles might
be in order on the right side.

Please let me know what you think.

Henry   <>

Dear Sir,
I have no experience as your professionals but I am trying to understand
the way you thinking when you analyze the gait data.

 If I summarize the  abnormalities as I can see in kinetic and kinematic
data; for the right side, - Excessive Dorsi-flexion of midtarsal joint
( broken foot) and inadequate plantar flexion in Psw and Isw. The Ankle
kinetic results indicate inadequate plantar flexion moment in the
related subphases in pre and post op periods.

- Inadequate knee extension of the knee in stance phase seems to be well
corrected by the surgery but I can not say the same thing for correcting
the inadequacy of knee flexion in swing.
-Hip is in flexion position in whole gait cycle in pre and post op
periods but the kinetics results show no abnormality.
- Pelvis is always in anterior pelvic tilt.

- Trunk is leaning to right side in stance likely because of the
contra-lateral gluteus medius weakness.

We can say the similar things for left side; Inadequate ankle plantar
flexion in Tst,Psw and premature heel rise and broken midtarsal joint,
inadequate knee flexion is continuing in swing after the surgery but
knee extension in stance is ok,increased hip flexion in whole gait
cycle, increased anterior pelvic tilt and pelvis is down in Tst, Psw,
 When we focus on kinetic values, the main problem seems like inadequate
plantar flexor power generation in Tst, Psw. Ýt might be one of the
reason of inadequate knee flexion in swing phase also. I think that the
operation was not as affective as we expected and we should also focus
on energy generation of the ankle in PT Department. The psoas
lengthening does not seem that corrected the anterior pelvic tilt and
increased hip flexion. Rectus transfer seems like effected knee pattern
in stance but not in swing.
Please contact with me If I had a mistake as understanding the
abnormalities from the gait data. As I said I have not much experience
to interpret the data as you.
Thank you

Ekin Akalan PT
Istanbul Medical University
Physical Therapy Department
Phone;011 90 (216) 356 3383   

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