Case of the Week 20/1/2003: What people said...

Great case, I would have liked having EMG data and sagittal video to complement the case
presentation. From the available data this appears to be a combination of weakness and
spasticity contributing to his gait deviations. I would suggest prior to surgery consideration
for a trial of Botox to right ankle PF and a  AFO (articulated with 10 PF, limited DF to 0).
Work on strengthening hip flexors and ankle musculature.

He may need surgery in the future but he is going to go through a couple of growth spurs and if
you can delay the surgery through Botox injections may reduce the number of surgeries. Good

Alberto Esquenazi, MD
MossRehab and Albert Einstein Med. Center
Director Gait & Motion Analysis Laboratory and
Regional Amputee Center
MossRehab a Member of the Jefferson Health Network
One of U.S. News & World Report  "Americas Best Hospitals"
1200 West Tabor Rd.
Philadelphia, PA 19141 USA
Voice: 215 456 9470  Fax: 215 456 9631

How many weeks after the last Botox-injection have passed when taking the video and kinematics? Seems that last Botox-injection (4 10/12) still is weakening gastrocnemius, is it?

Seems to be a combination of weakness and spasticity (especially psoas muscle leading to a hyperlordosis and right internal rotation in gait activity).

I also would suggest another 2-3 trials of Botox into psoas muscle (right > left) in order to reduce internal rotation and hyperlordosis during gait) and a  little dose to right medial gastrocnemius (in order to reduce toe walking and improve heel contact in stance phase). Botox-injections should be repeated every 4-6 months (not earlier in order to allow development of central inhibition patterns).

Work on strengthening hip external rotation and extension after chemodenervation of psoas muscles and strenghtening of
anterior tibial and peroneal muscles after chemodenervation of gastrocnemius.

Probably right tendon-achilles-lenghtening may be helpful in the next one or two years.

Dr. Klemens Fheodoroff
Gailtal-Klinik Hermagor
Abt. f .Neurologische Rehabilitation
Radniger Straße 12
A-9620 Hermagor

                      As a newcomer to the Clinical Gait Analysis network and a "returnee" to the
                      field of gait analysis after quite a long absence I have been watching with
                      interest all the discussions taking place over the past few weeks. I still
                      haven't got my brain round all these graphs - but I'm trying!

                      On the grounds that it will probably take me a lot longer than the two weeks
                      available to interpret all the gait analysis data supplied by our colleagues
                      in Tel Aviv I won't attempt this as I expect that there will be others in a
                      better position than I who will do so over the next few days.

                      However I do have some experience in the use of AFOs in cerebral palsy which
                      may be of some use to the mother and the clinical team looking after this
                      wee boy.

                      I would agree with Alberto when he suggests using an AFO. However from our
                      experience here we would suggest a rigid polypropylene AFO cast in
             sufficient dorsiflexion to maintain the shank at about 10 degrees anterior
                      to the vertical during stance phase, taking into consideration the
                      additional effect of any footwear. In this attitude (or thereabouts) the aim
                      is to align the ground reaction force in mid to late stance in front of the
                      knee and behind the hip joint to create extension moments (the hip being
                      extremely critical). If contractures prevent this then it is imperative that
                      these are reduced sufficiently to enable the establishment of the
                      appropriate external moments described above if the AFO is to work properly.
                      The good news is that clinical experience suggests that if you are able to
                      reduce the contractures conservatively to enable the initial successful
                      fitting and biomechanical functioning of the AFO, the continual stretching
                      of the muscles during each step during walking prevents recurrence (other
                      than sometimes when there is a quick growth spurt). I would think from
                      looking at the data supplied that this boy should do quite well.

                      I appreciate however that I am looking only at sagittal plane circumstances
                      and that this is really a three dimensional problem with other aspects to be

                      The subject of how you achieve the critical biomechanical alignment and
                      joint moments is a bit more complicated than I have described above. 10
                      degrees anterior lean of the shank is just a starting point to enable tuning
                      of the orthosis and associated footwear to optimise the moments and ground
                      reaction forces. It varies from child to child (and depending on how you
                      choose to measure it as well!) and the outcome is sensitive to very small
                      changes eg one or two degree by altering the heel wedge. If anyone is
                      interested in finding out some more, some of this is published in the ISPO
                      Consensus Conference Report on CP orthotics (1994) or, if you suffer from
                      insomnia, my PhD thesis (University of Strathclyde, 1984). If anyone wants
                      further info please email me and I would be happy to help.


             Dr C B Meadows
                      Head of Neurobiomechanics
                      Southern General Hospital
                      G51 4TF


                      Sure would like to see what his bilateral adductor emg activity looks like
                      during stance. His left LE looks relatively normal except for some
                      adduction/internal rotation during stance.

                      Bill Ogard

              William K. Ogard, P.T., Ph.D.
                      Department of Physical Therapy
                      University of Alabama at Birmingham
                      RMSB 337
                      1530 3rd Ave South
                      Birmingham, AL. 35294-1212


The EMG and additional video are useful. I would request that you ask the timing of toxin injection,  type, dose, the muscles injected and technique (EMG or E-Stim).

I would suggest obtaining EMG from hip adductors/abductors in the future. Treating the left hip adductors may need to be considered as well.

Alberto Esquenazi, MD
MossRehab and Albert Einstein Med. Center
Director Gait & Motion Analysis Laboratory and
Regional Amputee Center
MossRehab a Member of the Jefferson Health Network
One of U.S. News & World Report  "Americas Best Hospitals"
1200 West Tabor Rd.
Philadelphia, PA 19141 USA
Voice: 215 456 9470  Fax: 215 456 9631

Thanks again for the instructive comments so far. There seems to be a consensus emerging about trying an AFO and exploring the possibility of adductor spasticity.

I notice that nobody has taken my bait of offering a classification for this child's hemiparesis. I was thinking of Jim Gage's 1987 paper (Winters, TF, Gage, JR, Hicks, R Gait Patterns in Spastic Hemiplegia in Children and Young Adults. Journal of Bone and Joint Surgery, 69-A(3):437-441), in which the authors describe 4 grades:

Grade I - drop foot in the swing phase
Grade II - tight heel cord in stance phase as well as a drop foot in the swing
Grade III - stiff knee as well as an equinus
Grade IV - hip involvement

Seems to me this child would have to be Grade IV. I wonder what people think of this method of classification, whether it is of any help, or whether there is an alternative?

I also have a little more info from the child's mother about his previous treatment...

First of all I really want to thank you.  The responses are all so
informative - although there are a lot of terms I am unfamiliar with...
Luckily I have a wonderful team of PTs at the Childhood Development Center
in Beer Sheva, and they are all looking and learning from his gait analysis
and the comments - and then explaining to me.

The last Botox was September 5, 2002 - passive range in the hamstring
increased by 15* (pop test), active range was not affected.  Gait analysis
was Dec.3, 2002 - so three months after Botox.  Dose was 90 iu of Botoulium
Toxin A.  There were four injections - 2 in each hamstring muscle - at
different spots (don't know exactly where).

First Botox was March 2001, 70 iu, also to hamstring, also Botox A - one shot.

Full length casting was Dec. 2000 for hamstring stretch (3 weeks) - he had
terrible atrophy and it took him a few days to walk - and a month to regain
his strength and run - and this point all the range gained by casting was gone.

Half leg serial casting (5* and 10*) was Nov-Dec 1999.  Great gains in dorsiflexion.

Gait analysis was performed 3 December 2002.

Chris Kirtley

Apparently he has had AFOs in the past, and indeed has one at present. I agree that surgery would now seem appropriate. Would anyone like to suggest what procedures they would do?


Some of the comments have mentioned different AFO's and I wanted to mention
that he has had three different kinds of AFO's - none of which improved his

As of two weeks ago - he is back in a hinged AFO - as his SMO was too small
and cutting into his ankle.  His foot still turns in alot.

We have been told that he will probably need an osteotomy at about age 8
- and that that will help with the foot turning in.

What is the opinion on a spiral type brace?  Will this help?

We are pretty sure that he has antibodies and Botox will no longer work -
as it had little effect last time - so if he needs surgery - what surgery is
recommended?  All of his PT's are worried that his gait is getting worse and
he is developing bad gait habits - and don't want to delay things so that it
is hard to get rid of these bad gait habits later.

Although you should see him ride his bike - he is as fast as anyone - and
you can't tell he has hemiplegia at all...

                      Before I'd try surgery, there is a very good chance that the SWASH variable
                  abduction hip orthosis would help the adduction during gait.  An even
                      simpler solution would be TheraTogs to help reduce tone.  SWASH in
                      conjunction with Botox has done a lot to help situations like this.

                  Robert Meier
                      Director of Education
                      cell phone 734-604-0448

                      I have previously worked in a clinical gait analysis lab for 7 years. My
                      name is Mary Beth Moses, PT, MS, PCS and I am at Children's Health
                      System in Birmingham, Alabama.  I was intrigued by your study and wanted
                      to discuss some questions with you.

                      Nice case study. I have a few questions regarding video and plots. On
                      your transverse plane hip rotation plots, does positive correlate with
                      hip external rotation and negative correlate with hip internal rotation?
                      I would be interested to see pelvic plots saggital, coronal and
                      transverse plane?

                      On visual analysis(video) the right hemipelvis is trailing or in
                      external rotation and the right hip appears to be in relative hip
                      internal rotation.  Your hip rotation plot indicates a relatively
                      neutral hip on the right. Also your knee valgus varus plots indicate
                      varus alignment which does not exactly concur with video. When we saw a
                      large knee valgus or varus shift that was not confirmed with our video
                      in our lab, it was at times associated with slight misplacement of the
                      knee alignment device. We found that this could introduce error into the
                      transverse plane plots.  What is your experience with this?  Does this
                      lab use a knee alignment device?

                      I ask all of this because clinically this patient appears to have more
                      hip internal rotation and possibly more hip anteversion on the right.
                      The patient almost bumps his knees and has to at times circumduct the
                      right to prevent bumping it into the left. Was a CT scan or MRI of the
                      hips done to confirm amount of femoral anteversion?  This patient
                      appears to have type IV hemiplegia based on Dr. Gage's classification
                      and often these patients have excessive femoral anteversion on the more
                      involved side. Just wondering about the need for a femoral derotation
                      osteotomy on the right along with soft tissue procedures? Also do you
                      have any strength and selectivity grades for tibialis anterior? I am a
                      little curious about the need for a gastrocnemius lengthening on right.

                      I appreciate your work in maintaining this web site and look forward to
                      your reply.

                   Mary Beth Moses, MS, PT, PCS
                      Children's Health System
                      Birmingham, Alabama

This is a very interesting case.  We have found that using less than 100u/muscle in large muscles or 50 u/muscle in small children for gastrocs /post tib is
 not useful.  It is possible that the amount of botox used has not been sufficient to make a change.  I would suggest that larger amounts used less
 frequently may be more effective.  Most likely the adductors, medial hamstrings, gastroc and post tib are contributing to this gait.  A stretching and
 strengthening program post botox would be necessary.

 Mary Beth is likely right about some structural issues about the hip, but if the appropriate muscles are weakened enough strength to abductors may be
 gained to avoid the osteotomy.

 We use electrical stimulation after botox during gait training to teach appropriate timing of muscle use.  A treadmill is a very useful place to do this.  A
 SWASH may well be helpful during gait training.  None of these will be helpful unless sufficient tone management is gained to achieve appropriate
 alignment.  If Botox is not sufficient certainly muscle releases will be necessary.  The major concern of muscle release would be weakness post-surgery
 and casting.  We often see good alignment post surgery with poor function due to weakness.

 Lynne Logan
 Program Manager
 Tone Management and Mobility Program
 Upstate Medical University
 750 E Adams St
 Syracuse NY 13210

This is a very interesting case as the child was originally diagnosed with
mild cerebral palsy and yet it is said that he is getting worse and more so
than one would expect at this age.  I wonder if the weakening of very needed
muscles, the hamstrings and calf muscles, has lead to his increased loss of
motor control.  Could not the muscles been so weakened from the first
injections that the second injections did not have any effect as he was
already too weak?  Now he is growing and gaining weight and length with
muscles that were weakened instead of strengthened.  So one would expect loss
of skills.  We know from long-term cases of children who had multiple
surgeries that when they reach adolescence many are too weak to walk and have
to move into wheelchairs.  Adults with hemiplegia often wear out the
uninvolved leg from over use and from poor weight shifting to the involved
side and use of the involved side and then they too move into wheelchair use.

I would classify the child as a level IV due to the hip involvement.  His
strong Trendelenburg type of gait with internal rotation was very surprising
since he walks more like level I in the lower leg.  I wonder if the Botox
injection for the hamstrings has detrimentally weakened hip extension and
thus he had to compensate for that loss with the excessive trunk and hip
movement.  He must have had some good muscle function in the past to develop
the skills that he had, before the Botox and serial casting that weakened him

The child has some brace history with unknown flexibility at the joints.  We
do not know what were the cut lines of the braces and if dorsiflexion and/or
toe extension were limited.  Even when only toe extension is blocked, the
child needs to abduct and or rotate the leg in order to get the body over the
blocked joint.  It is not possible to weight shift appropriately onto the
blocked foot orthoses. Often the child uses the one brace as an outrigger.  I
would assume that the child did have some blockage of the digits on all the
braces he used, as that is, unfortunately, very common especially for toe
extension.  It takes only one-quarter inch of plastic distal to the
metatarsal heads to block a young child from getting digit extension or to
move the body over the stable foot. Without that mobility the child needs to
make undesirable compensations (Carmick J.  Managing equinus in children with
cerebral palsy: merits of hinged ankle-foot orthoses.  Dev Med Child Neurol.

I feel that this child should have a period of strengthening needed muscles
about the hip and ankle, and wear an orthosis that holds the foot in subtalar
neutral posted as needed so that he can stand on the right foot correctly
with stability and swing the left leg forward. The brace should allow digit
extension so he would not need to pivot on the toes in order to move the body
over the stance leg.   Muscle normally becomes stronger with normal use.
Strengthening muscles is very difficult in children with cerebral palsy
unless electrical stimulation is used to the child's tolerance during
task-specific activities.  In this case the task would be walking with the
use of a remote switch to stimulate muscles at the timing that they would
normally be contracting.  In my experience I have seen that it is even
possible to correct the internal rotation of gait over time with muscle
strengthening to the hip extensor muscles.  If the child is prevented from
strengthening needed muscles the derotational osteotomies will be necessary
but one wonders if the child will be interested in walking if it is too
difficult due to weak muscles.

Judy Carmick, PT, MA 

I am a Paediatric orthopaedic surgeon working in the management &
rehabilitation of cerebral palsy.I deal with these kind of cases very often.

Regarding this child:

It is a case of Spastic hemiperesis where bipedal locomotion is no
problem due to one normal limb & usually in such children there is
no disturbance of equilibrium thus he can walk though the gait is

I think that the proposed surgical plan is not right as it will
cause severe weekness of hip flexors due to ilipsoas tenotomy
which will cause altered gait as he will have dificulty in hip
flexion & heal strike.

Percutaneous tenotomy of hamstrings is not a procedure of choice
in CP as it will weeken the muscles on the medial aspect & can
cause an extermal rotation deformity of the knee due to un-opposed
action of the long head of biceps which is a multiarticular

Repeated injections of Botox do not help as the body develops
antitoxin. In my experience Botox is indicated only in mild
spasticity of one limb involvement.

My plan would be

Sincerely yours
Dr. Girish Datar

Dear Chris,

Thank you for sending the case.  Your web site is very impressive.  When I
watch the AP video, I see persistent internal rotation on the right side
and, to my eye, the knee is internally rotating as well as the foot.  I did
not see a kinematics of the pelvis, but most of these children retract the
pelvis on the hemiplegic side and protract it on the left.  Your clinical
examination did not indicate anteversion, nor did I see much evidence on the
transverse plane hip rotation graphs, but nevertheless he is turning in from
some where, so I suspect that he either has anteversion or internal tibial
torsion (the former being more likely).  I do not think he has diplegia
because the lateral videos show a nice heel strike on the left side and his
kinetics are normal at the left ankle.  If he were diplegic, that would not
be the case.  Furthermore, he rides a two-wheel bicycle, which is unusual
for a diplegic.

His hip flexors are not tight on clinical examination nor are the right hip
kinetics particularly abnormal.  Consequently, I would not have much
enthusiasm for operating on the right hip flexor.  Similarly, I would be
fairly conservative with hamstring lengthening, as the length of the
hamstrings is very dependent on the position of the pelvis.  We actually
have a print out that gives us true hamstring length compared to normal, and
I depend a lot on that graph when I'm trying to decide on whether or not to
lengthen the hamstrings.  One clinical way to do this is to compare
hamstring tightness with a without hip flexion on the contralateral side,
since by flexing the contralateral hip, you reduce pelvic lordosis.  If he
has a lot of hamstring tightness with the contralateral hip extended and
very little with the contralateral hip flexed, you are probably dealing with
"hamstring shift", rather than "hamstring contracture".  I certainly would
agree with the gastrocnemius recession. He has 15 degrees of dorsiflexion in
stance on the right, so the soleus is not tight.

Finally, as you know, I'm very big on correcting "lever-arm dysfunction"
(long bone torsions and/or foot deformity) if present.  Furthermore, when we
correct anteversion we do it with an A-O hip spline and make the osteotomy
proximal to the lesser trochanter so that the osteotomy itself  has the
effect of unwinding the psoas, which in turn functionally lengthens it.
Tibial torsion is easily corrected with just a tibial osteotomy proximal to
the distal tibial epiphysis (it isn't necessary to cut the fibula) using a
straight four-hole A-O plate and short leg cast for fixation.  Consequently,
if he does prove to have anteversion and is walking with pelvic retraction
and/or tibial torsion on the hemiplegic side, I would certainly consider
intertrochanteric derotational femoral osteotomy with the A-O hip spline
and/or tibial derotation to correct it.  Post-operative casting is not
necessary for femoral osteotomy and we only keep them non-weightbearing for
three weeks post surgery and with crutches or a walker for three weeks
thereafter.  With tibial osteotomy we use a short leg cast plus the plate
and, again, allow weight bearing three weeks post surgery.

Finally, I doubt that you would get too much benefit from Botox.  However,
an AFO nightsplint overwrapped with a knee immobilizer on the right to keep
the right gastrocnemius on tension during the hours of sleep will go a long
way towards preventing the redevelopment of a gastrocnemius contracture post-surgery.

I hope this is helpful.

With warm regards,


James R Gage" <>

Hello there -
I just happenend to find you on the net and I was astonished - why didn´t I know about this? I am a PT with many years of experience from
the neurological clientel. As a simple clinician, with absolutely no academic knowledge about biomechanical analyses of the more
advanced kind and working at a country hospital where no such assessments are available - here is my humble suggestion:

1. He seems happy and very active as he is - why operate at all?
2. There is an overuse of the non-affected leg (well, of course). When he puts weight on his affected leg his hip drops and the non-affected
leg becomes "too long" which makes him compensate with an exaggerated kneeflexion in his non-affected leg to make it possible to move
it forward. That is the easy and automatic solution to this problem but it helps his affected leg to stay weak.. IF you put a stiff orthosis on
his non-affected leg that prevents kneeflexion you might find that he starts using his hip abductors on the affected side when he walks. It
may take a few minutes, but it will probably happen. It happens to my adult stroke patients.
If it happens - would somebody please check, via for example an EMG, if this intervention increases muscular activity in the affected leg to
the extent that it would be a meaningful and effecient strengthening exercise for both children and adults with light to moderate
I need an excuse to ask my stroke patients to walk around with a stiff brace on their good leg for hours! And a stiff knee on the
non-affected leg is a perfect way to force the patient to stand up from sitting on his affected leg - each time. The same goes of course for
sitting down.

Please excuse my butting in, and a bit late for this paricular case at that, but I so much would like some factual knowledge about this
particular exercise!

Yours sincerely,
Bodil Carle Smedley,PT


                      Hi Chris

                      Surgery went well - had all the surgeons that I wanted and first class
                      treatment from everyone.  In the end he had his achilles tendon released
                      percutaneously, and his medial and lateral hamstrings released.  In the
                      medial they released both the facia (fractional lengthening of
                      Semimembranosus) and a z lengthening of the semitendinous.  In the lateral,
                      just the facia was released, and to a lesser extent so that the lateral and
                      medial hamstring are now equal tightness.

                      I have to tell you that I shared your web site with the children's
                      hemiplegia and stroke association list server ( - and told them
                      that it is a great site for learning about gait analysis (I hope you don't
                      mind....).  There are 700 on the list - who followed my surgery questions,
                      second guessings, etc - so the emails from parents were probably from the
                      list.  There are quite a few kids in similar situation as him.

                      Another funny side note - one of his fellow patients was taking a class in
                      understanding and evaluating gait analysis - and they used his gait
                      analysis (from your web site) as one of the choices for the test!

                      He is doing great with his stretches and exercises - he has been so
                      cooperative - a real trouper - he understands that he needs to stretch and
                      exersize for the operation to work so he will be able to run faster, etc.
                      He can't wait for the huge cast to come off!

                      Thank you for you concern and help through this ordeal - I am so happy the
                      operation is behind me....

Oct 2003

Hi Chris,
                      I am happy to say that the operation was
                      good for him.  He has regained a lot of strength in his right leg since the
                      cast came off in March (and his leg was as thin as a twig after only 3 weeks
                      in the cast!), and now the calf diameter is almost equal to his good leg.  It
                      took him almost a month after the cast to be back on his bike (at first
                      with training wheels), and almost two months to be running again.  There
                      were points where I was discouraged as it seemed like he had really gone
                      backwards, but by summer I definitely saw the improvements.  The first few
                      weeks were the worst, with him in a wheel chair and barely walking.
                      We are now working on hopping on the right leg - not at all easy, and
                      constantly encouraging weight bearing.  He still does not have much active
                      dorsiflexion, but full range passive, and he is in a hinged AFO about 6
                      hours a day, which seems to encourage a pretty good gait.  His hamstring
                      range is also good, but his psoas is a bit tight, and I have wondered if
                      maybe we should have had this lengthened too.

                      All his PTs have been impressed with his improvement.  He is playing soccer
                      in a club here, and floor hockey with his sibblings.  His walking speed has
                      improved, but is still slower than normal.

                      All in all, we are happy with the results, and I am grateful to your web
                      site for giving me a great deal of information going into the operation.


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