Cga ifa 2015 13 the role of cga in crouch

1. Crouch Gait
Some clinically related aspects
Geraint Davies
Salford
May 2015

2. Definitions
• Mindful of different sagittal
patterns of gait
Include attitude of ankle and
hip
• Consider degrees of severity
• Severe: In midstance:
kneeflexion >30 deg
ankle dorsiflexion >2SD
reduced hip extension
• Continuous (internal) knee
extensor moment
Left 212 (WHITN212.c3d) Right 212 (WHITN212.c3d)
Knee Flexion/Extension
% Gait Cycle
90
-15
Flx
Ext
deg
25 50 75
Knee Moment (sagittal plane)
% Gait Cycle
2.0
-2.0
Ext
Flx
Nm/kg
25 50 75
Total Knee Pow er
% Gait Cycle
2.0
-2.0
Gen
Abs
W/kg
25 50 75
Knee Varus/Valgus
% Gait Cycle
40
-30
Var
Val
deg
25 50 75
Knee Moment (coronal plane)
% Gait Cycle
1.0
-1.0
Val
Var
Nm/kg
25 50 75
Knee Moment (transverse plane)
% Gait Cycle
1.0
-1.0
Ext
Int
Nm/kg
25 50 75

3. Crouch
• Failure to control the GRF to an individual’s advantage
• Entrance to a vicious cycle of worsening biomechanics
and progression:-
Stiff knee gait
Loss of passive double pendulum effect
Reduced angular velocity of knee at terminal stance
Increased oxygen requirements and effort
Further weight gain: growth and inactivity
Derangement of muscle lengths and lever arms
Increased joint loads: pain and stress fractures

4. Attractors/pre-disposing factors
• Weakness: inherent; iatrogenic; inefficient (lever arms);
excess weight
• Spasticity (dynamic: ?psoas/hamstrings?)
• Joint contracture
• Balance
• Incidence rises with age; severity of diplegia; weight
gain.

5. Iatrogenic weakness
Patterns and methods of calf lengthening
operations (Vuillermin et al 2011)
• Delay between surgery and crouch averages 6y
• Associated with soleus lengthenings
• Often associated with adolescent growth spurt
• Can progress rapidly
• Previously reported at 36% 5-10y post surgery in same
unit
• Reduced to <4% following change of practice

6. Calf lengthening

7. Calf Lengthening
Gastrocnemius lengthenings
• Baumann (anterior fascial recession)
• Strayer (Release of Gastrocnemius fascia)
• (Have options of recessing soleus fascia)
Conjoined Lengthenings
• Vulpius
• Baker Slide
Achilles Tendon Lengthenings
• Percutaneous (White; Hoke)
• “Z”

8. Principles of Treatment
• Management of spasticity
• Correction of abnormal lever arms
• Correction of muscle contractures
• Correction of joint contractures
• Correction of over lengthened muscles
• Age; severity; natural history; motivation;
rehabilitation.

9. JS Post SDR + Distal Hamstring release
(US)

10. Severe crouch
• Knee flexion contractures
• Patella alta
• Other abnormal lever arms
• Co-spasticity

11. Severe Crouch
• Distal Femoral Extension
osteotomies, (+/- rotational
correction)
• Patella Tendon Advancements
• ?Rectus femoris
transfer/recession
• ??Hamstring release/transfer
(?pelvic tilt)
• Other lever arms
• Orthotic management

12. ND Pre op

13. ND Post op

14. NW Pre op

15. NW Pre-op kinematics and knee kinetics
Adult PiG + OFM (Adult PiG + OFM.pxd) (WHITN309.c3d) (WHITN309.c3d)
TrunkTilt (Lab)
% Gait Cycle
30
-10
Ant
Pos
deg
25 50 75
Pelvic Tilt (ROT)
% Gait Cycle
30
-10
Ant
Post
deg
25 50 75
Hip Flexion/Extension
% Gait Cycle
60
-15
Flex
Ext
deg
25 50 75
Knee Flexion/Extension
% Gait Cycle
90
-15
Flex
Ext
deg
25 50 75
Ankle DF/PF
% Gait Cycle
40
-30
Dors
Plan
deg
25 50 75
TrunkLat Flex(Lab)
% Gait Cycle
15
-15
Ips
Cont
deg
25 50 75
Pelvic Obliquity(ROT)
% Gait Cycle
15
-15
Up
Down
deg
25 50 75
Hip Adduction/Abduction
% Gait Cycle
20
-15
Add
Abd
deg
25 50 75
Knee Varus/Valgus
% Gait Cycle
60
-30
Var
Val
deg
25 50 75
TrunkRotation (Lab)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Pelvic Rotation (ROT)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Hip Rotation
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75
Foot Progression
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75
Adult PiG + OFM (Adult PiG + OFM.pxd) (WHITN309.c3d) (WHITN309.c3d)
Knee Flexion/Extension
% Gait Cycle
92
-12
Flex
Ext
deg
25 50 75
Knee Moment (sagittal plane)
% Gait Cycle
2.0
-2.0
Ext
Flex
Nm/kg
25 50 75
Total Knee Power
% Gait Cycle
2.0
-2.0
Gen
Abs
W/kg
25 50 75
Knee Varus/Valgus
% Gait Cycle
40
-30
Var
Val
deg
25 50 75
Knee Moment (coronal plane)
% Gait Cycle
1.0
-1.0
Val
Var
Nm/kg
25 50 75
Knee Moment (transverse plane)
% Gait Cycle
1.0
-1.0
Ext
Int
Nm/kg
25 50 75

16. NW Post op

17. RJ Pre op

18. RJ Pre op
Knee Flexion/Extension
% Gait Cycle
90
-15
Flx
Ext
deg
25 50 75
Knee Moment (sagittal plane)
% Gait Cycle
2.0
-2.0
Ext
Flx
Nm/kg
25 50 75
Total Knee Pow er
2.0
Knee Varus/Valgus
% Gait Cycle
40
-30
Var
Val
deg
25 50 75
Knee Moment (coronal plane)
% Gait Cycle
1.0
-1.0
Val
Var
Nm/kg
25 50 75
Knee Moment (transverse plane)
% Gait Cycle
1.0
-1.0
Ext
Int
Nm/kg
25 50 75
Left File 1 (JENNR123.c3d) Right File 1 (JENNR123.c3d)
Pelvic Tilt (ROT)
% Gait Cycle
30
-10
Ant
Pos
deg
25 50 75
Pelvic Obliquity (ROT)
% Gait Cycle
15
-15
Up
Down
deg
25 50 75
Pelvic Rotation (ROT)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Hip Flexion/Extension
% Gait Cycle
60
-15
Flx
Ext
deg
25 50 75
Hip Moment (sagittal plane)
% Gait Cycle
2.0
-2.0
Ext
Flx
Nm/kg
25 50 75
Total Hip Pow er
3.0
Hip Adduction/Abduction
% Gait Cycle
20
-15
Add
Abd
deg
25 50 75
Hip Moment (coronal plane)
% Gait Cycle
2.0
-2.0
Abd
Add
Nm/kg
25 50 75
Hip Rotation
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75
Hip Moment (transverse plane)
% Gait Cycle
1.0
-1.0
Ext
Int
Nm/kg
25 50 75

19. RJ Post op

20. RJ Post op
Normal Adult PiG + OFM 050614 (Normal Adult PiG + OFM 050614.pxd) Post 250714 (JENNR307.c3d) Post 250714 (JENNR307.c3d)
Pre 020811 (JENNR123.c3d) Pre 020811 (JENNR123.c3d)
TrunkTilt (Lab)
% Gait Cycle
30
-10
Ant
Pos
deg
25 50 75
Pelvic Tilt (ROT)
% Gait Cycle
30
-10
Ant
Post
deg
25 50 75
Hip Flexion/Extension
% Gait Cycle
60
-15
Flex
Ext
deg
25 50 75
Knee Flexion/Extension
% Gait Cycle
90
-15
Flex
Ext
deg
25 50 75
Ankle DF/PF
% Gait Cycle
40
-30
Dors
Plan
deg
25 50 75
TrunkLat Flex(Lab)
% Gait Cycle
15
-15
Ips
Cont
deg
25 50 75
Pelvic Obliquity(ROT)
% Gait Cycle
15
-15
Up
Down
deg
25 50 75
Hip Adduction/Abduction
% Gait Cycle
20
-15
Add
Abd
deg
25 50 75
Knee Varus/Valgus
% Gait Cycle
60
-30
Var
Val
deg
25 50 75
TrunkRotation (Lab)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Pelvic Rotation (ROT)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Hip Rotation
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75
Foot Progression
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75
Normal Adult PiG + OFM 050614 (Normal Adult PiG + OFM 050614.pxd) Post 250714 (JENNR307.
Pelvic Tilt (ROT)
% Gait Cycle
50
0
Ant
Post
deg
25 50 75
Pelvic Obliquity(ROT)
% Gait Cycle
15
-15
Up
Down
deg
25 50 75
30
-30
Pro
Re
deg
Normal Adult PiG + OFM 050614 (Normal Adult PiG + OFM 050614.pxd) Post 250714 (JENNR307.c3d) Post 250714 (JENNR307.c3d)
Knee Flexion/Extension
% Gait Cycle
92
-12
Flex
Ext
deg
25 50 75
Knee Moment (sagittal plane)
% Gait Cycle
2.0
-2.0
Ext
Flex
Nm/kg
25 50 75
Total Knee Power
% Gait Cycle
2.0
-2.0
Gen
Abs
W/kg
25 50 75
Knee Varus/Valgus
% Gait Cycle
40
-30
Var
Val
deg
25 50 75
Knee Moment (coronal plane)
% Gait Cycle
1.0
-1.0
Val
Var
Nm/kg
25 50 75
Knee Moment (transverse plane)
% Gait Cycle
1.0
-1.0
Ext
Int
Nm/kg
25 50 75

22. LB Pre-op
Normal 10-15 PiG + Trunk+ OFM 160614 (Normal 10-15 PiG + Trunk+ OFM 160614.pxd) (BOUGL104.c3d) (BOUGL104.c3d)
TrunkTilt (Lab)
% Gait Cycle
30
-10
Ant
Pos
deg
25 50 75
Pelvic Tilt (ROT)
% Gait Cycle
30
-10
Ant
Post
deg
25 50 75
Hip Flexion/Extension
% Gait Cycle
60
-15
Flex
Ext
deg
25 50 75
Knee Flexion/Extension
% Gait Cycle
90
-15
Flex
Ext
deg
25 50 75
Ankle DF/PF
% Gait Cycle
40
-30
Dors
Plan
deg
25 50 75
TrunkLat Flex(Lab)
% Gait Cycle
15
-15
Ips
Cont
deg
25 50 75
Pelvic Obliquity(ROT)
% Gait Cycle
15
-15
Up
Down
deg
25 50 75
Hip Adduction/Abduction
% Gait Cycle
20
-15
Add
Abd
deg
25 50 75
Knee Varus/Valgus
% Gait Cycle
60
-30
Var
Val
deg
25 50 75
TrunkRotation (Lab)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Pelvic Rotation (ROT)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Hip Rotation
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75
Foot Progression
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75

23. Thank you
Questions

24. JS Post SDR + distal hamstring lengthening (US). Pre torsional correction
Trunk Tilt (Lab)
% Gait Cycle
30
-10
For
Bac
deg
25 50 75
Pelvic Tilt
% Gait Cycle
30
-10
Ant
Pos
deg
25 50 75
Hip Flexion/Extension
% Gait Cycle
60
-15
Flx
Ext
deg
25 50 75
Knee Flexion/Extension
% Gait Cycle
90
-15
Flx
Ext
deg
25 50 75
Ankle DF/PF
% Gait Cycle
40
-30
Dor
Pla
deg
25 50 75
Trunk Lat Flex (Lab)
% Gait Cycle
15
-15
Ips
Cont
deg
25 50 75
Pelvic Obliquity
% Gait Cycle
15
-15
Up
Dow
deg
25 50 75
Hip Adduction/Abduction
% Gait Cycle
20
-15
Add
Abd
deg
25 50 75
Knee Varus/Valgus
% Gait Cycle
40
-30
Var
Val
deg
25 50 75
Trunk Rotation (Lab)
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Pelvic Rotation
% Gait Cycle
30
-30
Pro
Ret
deg
25 50 75
Hip Rotation
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75
Foot Progression
% Gait Cycle
40
-40
Int
Ext
deg
25 50 75