Case presentation

Authors: Adrienne D. Karolyi, BS., Freeman Miller, MD., Patrick W. Castagno, MS

Introduction: Case Number 2.

Diagnosis: Spastic Diplegia pattern cerebral palsy

This young male was born premature on 10/11/84 and was in the hospital for 3-1/2 weeks. Because of subluxation of the right hip, he had a varus derotation femoral osteotomy with dega pelvic osteotomy in January of 1991,pre-operative , post-operative . The VIDEO FROM AUGUST 1992 demonstrates his slow gait and very stiff knees prior to a 1993 bilateral hamstring lengthening with rectus transers and blade plate removal. Radiographs show normal hips . The VIDEO FROM JULY 1993 was compiled following the rectus transfers and shows an increase in knee motion.

He started walking by cruising at 18 months and is now walking using his crutches and a walker. He uses a combination of the bilateral Lofstrand crutches, a K-posture walker and a light-weight wheelchair depending on the distance that he has to ambulate. He is continuing to make some progress in his ambulation but continues to have toe dragging with rolling over of this feet. He does not have seizures and does not experience any pain. He does very well in school which is where he receives his therapy once a week. He has bilateral supramalleolar orthoses, but is not wearing them currently.

Case material is organized below:

Videotape, July '94                                  Videotape, November '95 
Physical Exam, July '94                              Physical Exam, November '95 
Kinematic Data, July '94                             Kinematic Data, November '95 
EMG Data, July '94 (N/A)                             EMG Data, November '95 
Oxygen Consumption Data, July '94 (N/A)              Oxygen Consumption Data, November '95 
Summary and duPont Recommendation, July '94 
Summary and duPont Recommendation, November '95 



The PT evaluation reveals good knee range of motion with very mild hyperextension of the knees bilaterally. There is mild to moderate spasticity or rectus femoris, left greater than right. There is also mild spasticity in bilateral adductors and iliopsoas. Gross motor functional testing in standing revealed rather poor function. He is able to stand independently for 1 - 2 seconds. He was not able to rise from the floor through a half kneeling position, even with assistance of the upper extremities. He uses hand suport to rise from a chair or lower to the floor. His parents report poor tolerance for orthotics presently; he complains significantly of pain while wearing orthotics.


                PROM/STRENGTH                   MUSCLE TONE/MOTOR CONTROL

                        R       L                         R       L

        Knee ext        0-4     0-3             Rectus    2       3

        Knee flex       0-135   0-135           


                                                Pop angle 45      50

                                                Ely test  125     120



        Sit/Reach       0 cm


Independent standing:  1-2 sec.

One leg stance:  <3 sec. on both legs

Short sit to stand:  only with both hands

Lowers to floor:  with hands controlled

Standing-picks pen from floor:  with hands (turning to side)



Examination of his hips demonstrates adequate flexion. He is really quite weak throughout. His knee extension and flexion is full. He has very little ability for any independent motor control in any of his lower extremities.



                     R       L                  R        L 

        Hip flex     115     120     Iliop      -        -

                     3       3                  -        -

        Hip abd(ext) 10      15      Glut med   -        -

                     -       -       Adductor   2        2

        Hip ext      20      20                 +/-      +/- 

                     -        -      Glut max   +/-      +/- 

        Int rot      25       25 

        Ext rot      5        40     FLEXIBILITY

                                     Thomas T   15       20

                                     Ober T     -        - 


               PROM/STRENGTH         MUSCLE TONE/MOTOR CONTROL                       

                      R       L                    R       L 

        Knee ext      0       0       Quads        -       - 

                      4+      4+      Rectus T     3       3

        Knee flex     130     130     Hamstring    0       0

                      2-       2-                  -       -

                                      Knee jerk    3+      3+

                                      Ankle jerk   1+      1+



                                      Pop angle    40 (35) 40(30)

                                      Ely test     120     120




                      R       L                   R        L 

        Dorsi (flex)  10      11      Ant tib     -        - 

                      2+      2+      Gastroc     1        1

              (ext)   1       5                   -        - 

        Plantar       50      45      Soleus      -        - 

                      -       -       Post tib    0        0

        Inv           25      20                  -        - 

                      -       -       Peroneals   -        - 

        Ever          25      45 

                      -       -       

                                      Babinski    -        - 

        TFA           20 ext  25 ext  Clonus   sustained sustained


                STRENGTH              MOTOR CONTROL

        Abdominals      20 sec.       Abdominals      +



This nine year old boy with a diagnosis of spastic diplegia, post - orthopaedic surgery, demonstrates obvious progress in gait. Specifically, he has improved knee flexion in swing phase, hip extension in stance phase, and trunk posture and balance. His balance and coordination have also improved, as noted by his improved use of the Lofstrand crutches.

The following recommendations are suggested:

  1. No present surgical procedures. Careful monitoring for increased crouched posture or any progression of external foot rotation will be necessary.
  2. Continued therapy program in order to improve transitions to and from the wheelchair as well as to and from the floor.
  3. Continued use of the present foot orthoses in order to slow the progression of the foot deformity, provided the existence of an increased tolerance.



This eleven year old boy with a severe diplegic pattern cerebral palsy is dependent on crutches or a walker for ambulation but appears to demonstrate adequate ability to ambulate in household and some community environments. He does, however, display significant difficulties with balance and motor control, and demonstrates severe muscle weakness as well as some BONY DEFORMITIES RELATED TO HIS FEET. Hip flexion is normal. He has mild circumduction which he uses for clearance. His knee flexion has good contact. Though hamstring length is substantial, they are very weak. Knee flexion and swing phase are somewhat diminished and occur quite late, especially on the right side. Rectus and vastus EMG patterns reveal that he is using these muscles predominantly for stance phase stability in co-contraction with the hamstrings. Ankle dorsiflexion was somewhat low on the right and occurred late. There is constant tibialis anterior activity with good appropriate stance phase gastrocnemius activity. The external foot progression appears mainly due to severe planovalgus deformity. This deformity has not caused an increase in knee flexion in stance phase. It is, however, making brace wear difficult.

The following recommendations are suggested:

  1. Triple arthrodesis or some combination of hindfoot stabilization in order to correct the severe planovalgus deformities and subsequently improve utilization of ground reaction forces. Attention must be paid to ensure that only limited external tibial torsion occurs.
  2. There is presently no consideration into other lengthenings or in addressing corrections at the knee as the current degree of knee stiffness appears to provide a significant portion of stability.
  3. An intensive course of physical therapy for 3 times a week over a 3 month period following the surgical healing, to improve ability and subsequently maximize gait patterns. An improved functional gait over what is currently seen is anticipated. Maintenance of the current home stretching program is indicated.



A comparison of findings from the first and second visits demonstrates that there is really no change in any of the hip motions.


Right Hip Flexion/Extension                     Left Hip Flexion/Extension


Right Hip Ab/Adduction                                 Left Hip Ab/Adduction


Right Hip Internal/External                     Left Hip Internal/External

When comparing knee motion, it appears that flexion is the same in magnitude in both gait analyses but occurs later in time in the second analysis than in the first. There are no other significant findings at the knee as there are almost all overlapping curves.


Right Knee Flexion/Extension                    Left Knee Flexion/Extension


Right Knee Varus/Valgus                                Left Knee Varus/Valgus


Right Knee Torsion                                     Left Knee Torsion

At the ankle, there is no change in tibial torsion or valgus from the first visit to the second visit. Foot progression angles are almost exactly the same, indicating again that ankle motion demonstrates essentially no change in the two gait analyses.


Right Ankle Plantar/Dorsi                              Left Ankle Plantar/Dorsi