Case presentation

Introduction: Case Number 1.

A 14 year old male was born at term without post natal problems. His walking was delayed to 2.5 years. Medical treatment till age 14 included mainly observation with several short episodes of physical therapy aimed at stretching contracture at the knees. Two episodes of inhibitive casting were preformed at age 10 and 11 with no impact according to the family. He is in grade eight doing well academically and lives on a farm where he is able to do most farm tasks. The family seeks a new opinion because in the last year it has become more difficult for him to walk because his knees rub together to the point of developing contusions from the direct contact. After working on the farm or walking long distances he is having increasing right knee pain. He has never had hip pain, does have decrease fine motor skills with some minor problems with writing especially if he has to write fast. He has no seizures, bowel or bladder problems. Spinal xrays are normal. His diagnosis is asymmetric diplegia pattern cerebral palsy.

The boy and his parents agree that they want him to walk better and to have less knee pain in the right knee as well as decreasing the direct contact from the knees hitting each other during gait.

Case material is organized below.

Physical Examination:

Physical Examination Data was obtained by a physical therapist experienced in gait analysis using established protocols.

Case Number 1.

TEST Passive ROM Strength Spasticity Motor Control Comments

                     Rt    LT    Rt   LT   Rt   LT   Rt    LT                       

Hip Flexion          120   115   4    5    1    1    yes   yes                      

hip abduction (EXT   25    22    4    3    4    0    yes   yes                      


Hip extension        8     0     5    5              yes   yes                      

Hip Int Rotation     40    55                                                       


Hip ext Rotation     25    15                                                       


Thomas test          23    18                                                       

Knee extension       -9    5     5    5    4    3    yes   yes   Rectus spasticity  

Knee Flexion         135   145   5    4    1    2    yes   yes                      

Knee reflex                                2    3                                   

Popliteal angle      70    70                                                       

Ely Test             85    85                                                       

Ankle Dorsiflexion   8     0                                     With knee Flexion  

Ankle dorsiflexion   3     -10   5    4              yes   no    With Knee          


Ankle Plantar        35    50    4    5    3    1    yes   yes                      


Foot inversion       45    40    5    5    3    3    yes   yes   Tibialis           


Foot eversion        33    -5    5    5              yes   yes   Perineals          

Thigh Foot angle     e-35  e-10                                  done with knee     


Babinski                                             no    no                       

Clonus                                     5    12                                  

                                           bts  bts                                 

Standing GMFM                                                    32 of 36           

                                                                 possible points    

Leg length measured  87.5  87                                    Measured supine    

Kinematic Charts:

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The kinematics were obtained using a six camera Motion Analysis System and data calculated using Orthotrac Soft Ware. The data was collected using the Cleveland Marker Set.

This 14 year old boy was tested walking barefoot without assistive devices at free walking speed.

The major findings on the kinematic were slow speed, normal cadence, and symmetrical but short step lengths.

Characteristic:                        Trial        Normal       % Normal

TEMPORAL CHARACTERISTICS:                                                          

Velocity, cm / sec                      91.3        120.0          76.1      

Cadence, steps / min                   118.0        122.0          96.7   

Stride Time, sec                         1.0          1.0          101.7

SPATIAL CHARACTERISTICS:                                                           

Stride Length, cm                       92.8        119.0           78.0       

Right Step Length, cm                   47.7         59.4           80.3    

Left Step Length, cm                    45.1         59.4           76.0     

Step Width, cm                          17.1         12.0          142.7  

Pelvic Width / Ankle Spread Ratio        0.98         2.0           48.9

The pelvis was rotated leading with the right forward 5 to 30 degrees . The left hip was adducted 5 to 25 degrees and internally rotated 20 degrees. the right was externally rotated 10 degrees . The right knee had increased mid-stance flexion of 30 degrees and good flexion in swing. The left had flatted and decreased swing flexion and both had increased knee flexion at foot contact at 35-40 degrees. The right tibia demonstrated valgus of 25 degrees and external rotation of 20 degrees. Dorsiflexion of the right ankle was good but plantar flexion was limited to neutral. The left had limited dorsiflexion coming only to neutral. Foot progression on the right was external 20-30 degrees and on the left was internal 5 degrees .

EMG Charts:

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The EMG was collected on an eight channal FM transmitted system made by B & M Electronics and data was collected using a customized data aquistion program written on Lab view. Collection was concurrent with the kinamatics with gait cycles determined by the foot markers, data was collected at 1000 hertz, filtered at a low of 60 hertz and high of 450 hertz Butterworth bandpass filter.

The recording of the Rectus muscle shows significant swing phase activity bilaterally and very minimal stance activity. Both hamstring muscles show significant constant activity but do have additional activity early stance phase . Tibialis anterior muscle has predominantly early swing phase activity with significant underlying constant activity. The right gastrocnemius has predominantly stance activity with good late stance phase contraction. The left gastrocnemius has no recognizable pattern .

Kinetics (force data)

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The force data is collected using two AMTI Force Plates. The data aquistion used was customized on Lab View software.

Pediobarograph (foot pressure data):

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The foot pressures demonstrate normal loading forces in at foot contact but some what low push off force since it is less than the loading force.[GRAPH] Joint moment demonstrates a high valgus stress on the right. [GRAPH]

The pediobargraph was collected using the Techscan floor mat and the data was reduced using software developed at University of Delaware Laboratory running on Lab View.

The foot pressure demonstrates toe striking and all weight bearing over the lateral forefoot on the left. There is no heel contact on the left side. The right side develops good heel contact but no medial mid-foot contact. For-foot pressure is predominantly over the lateral border with high pressure over the 5th metatarsal head. He does toe off of the great toe at the end of stance phase. [GRAPH]

The normal data base includes 112 feet from 56 individuals age 9 to 23 who had normal feet by history and no deformities by physical inspection. The normal data was collected at the duPont Laboratory. [GRAPH]

Charts to be presented here


[table of contents]

Relevant xrays for this case include an AP pelvis xray which demonstrates severe acetabular dysplasia on the left with lateral migration of 40% MP. Acetabular index is 40 degrees. There is no evidence of degenerative changes and the acetabular and femoral head are very congruent.

Standing xrays of the lower extremities demonstrate 26 degrees of valgus of the right knee most of which appears to be coming from the tibia. There is severe narrowing of the growth plate on the lateral tibia. Scanogram demonstrate 4 mm shortening of the right limb from the head of the femur to the distal tibia measured as a straight line. However the femoral head on the left is 16 mm higher than the right.

duPont Recommendation:

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Based on the final assessment we recommend doing the following procedures: