Gait Patterns in Cerebral

Palsy
• Winters, Gage & Hicks first described a gait classification system for children with
Spastic Hemiplegia.
• They identified four homogenous groups of gait patterns that are observed in the
sagittal plane and also described the major muscle groups affected.
• Rodda and Graham continued with this theme by including a sub-division for group
two and suggested an Ankle Foot Orthosis (AFO) prescription for each of the groups.
• In the Type IV group, Rodda and Graham also provided a description of the deformity in
the coronal plane.
• Further work by Rodda and Graham saw them develop and describe a gait classification
system that included Bilateral lower limb spasticity.
• They identified four subgroups of bilateral lower limb spasticity observed in the sagittal
plane. Again details of the major muscle groups affected were provided and an AFO
prescription to manage each of the clinical presentations was proposed.
Spastic Hemiplegia / Unilateral CP

• Type 1 – weak or paralysed/silent dorsiflexors (= dropfoot)

• Type 2 – type 1 + triceps surae contracture
• Type 3 – type 2 + hamstrings and/or Rectus Femoris spasticity
• Type 4 – type 3 + spastic hip flexors and adductors
Type 1 Hemiplegia

• In Type 1 hemiplegia there is a `drop foot' which is noted most clearly

in the swing phase of gait due to the inability to selectively control the
ankle dorsiflexors during this part of the gait cycle.
• There is no calf contracture and therefore during stance phase, ankle
dorsiflexion is relatively normal.
• In the experience of the original author of this article, this gait pattern
is rare, unless there has already been a calf lengthening procedure.
The only management maybe needed is a leaf spring or hinged ankle
foot orthosis (AFO). Spasticity management and contracture surgery are
clearly not required.
• Orthotic management may include a leaf spring or hinged AFO.
 Type 2 Hemiplegia
• is by far the most common type in clinical practice. True equinus is noted in the stance
phase of gait because of the spasticity and/or contracture of the gastroc-soleus muscles.
There are two sub-categories to type 2 hemiplegic gait patterns, which are:
• Equinus plus neutral knee and extended hip.
• Equinus plus recurvatum knee and extended hip.

• There is usually a variable degree of drop foot in swing

because of impaired function in tibialis anterior and the
ankle dorsiflexor. A pattern of true equinus can be seen,
with the ankle in the plantar flexion range through most
of the stance phase.
The plantar flexion / knee extension couple is overactivee and the knee may adopt a
position of extension or recurvatum.
Management of type 2
• If there is a mild contracture, supplemental casting can be very effective. The
majority of children will also require orthotic support, both to control the tendency
to `drop foot‘.
• Once a significant fixed contracture develops, lengthening of the gastrocnemius and
soleus may be indicated.
• Type 2 hemiplegia with a fixed contracture of the gastroc-soleus constitutes the only
indication for isolated lengthening of the tendon achilles.
• If the knee is fully extended or in recurvatum, then a hinged AFO with an appropriate
plantar flexion stop is the most appropriate choice of orthosis. A plantarflexion stop
or posterior stop in an AFO is designed to substitute for inadequate strength of the
ankle dorsiflexors during swing phase of gait. This stop is effective by limiting the
plantarflexion range of motion of the talocrural joint. Older children with progressive
valgus deformities are likely to become brace intolerant and require bony surgery.
• Common characteristics of types 2, 3 and 4 are a limb length discrepancy
(hemiplegic leg is shorter)
Type 3 Hemiplegia
• Type 3 hemiplegia is characterized by gastroc-soleus spasticity or
contracture, impaired ankle dorsiflexion in swing and a flexed, `stiff knee
gait' as the result of hamstring/quadriceps co-contraction. At a later stage,
management may comprise muscle-tendon lengthening for gastroc-soleus
contracture.
Management
• A solid or hinged AFO may also be helpful; the choice should be according to
the integrity of the plantar-flexion, knee-extension couple'.
Type 4 Hemiplegia
• In Type 4 hemiplegia there is much more marked proximal involvement and the pattern
is similar to that seen in spastic diplegia.
• However, because involvement is unilateral, there will be marked asymmetry, including
pelvic retraction.
• In the sagittal plane, there is equinus, a flexed stiff€ knee, a flexed hip and an anterior
pelvic tilt.
• In the coronal plane, there is hip adduction and in the transverse plane, internal rotation.
• Management is similar to Type 2 and Type 3 hemiplegia, with respect to the distal
problems. However, there is a high incidence of hip subluxation and careful radiographic
examination of the hip is important.
• The adducted and internally rotated hip will usually require lengthening of the
adductors and an external rotation osteotomy of the femur. Failure to address the hip
adduction and hip internal rotation will usually mean that any distally focused
intervention will fail and the overall outcome will be poor.
 Common Postural/Gait Patterns Bilateral Spastic Cerebral Palsy

• Torsional deformities of the long bones and foot deformities are frequently
found in bilateral spastic CP, in association with musculo-tendinous
contractures. These are collectively referred to as `lever arm disease‘.
• The most common bony problems are medial femoral torsion, lateral tibial
torsion, midfoot breaching, with foot valgus and abduction.
• Rotational osteotomies and foot stabilization surgery are often required, in
association with spasticity and contracture management.
• This shows the features of `lever arm disease'. There is an out-toed
stance and gait pattern because of midfoot breaching and lateral tibial
torsion. The right image is a sagittal view demonstrating a crouch gait
pattern. When the bony lever (the foot) is both bent and maldirected,
the already weakened gastroc-soleus is unable to control the
progression of the tibia over the planted foot and a crouch gait
results.
 Type 1. True Equinus
• When the younger child with bilateral cerebral palsy begins to walk with or
without assistance, calf spasticity is frequently dominant resulting in a `true
equinus' gait with the ankle in plantar flexion throughout stance and the hips
and knees extended.
• The patient can stand with the foot flat and the knee in recurvatum. The
equinus is real but hidden. A few children with bilateral cerebral palsy remain
with a true equinus pattern throughout childhood and, if they develop flexed
contracture, may eventually benefit from isolated gastrocnemius lengthening.
The persistence of this pattern is unusual and seen in only a small minority of
children with bilateral CP.
• Orthotic management: solid or hinged AFO
Type 2. Jump Gait (With or Without Stiff
Knee)
• The jump gait pattern is very commonly seen in children with diplegia, who
have more proximal involvement, with spasticity of the hamstrings and hip
flexors in addition to calf spasticity.
• The ankle is in equinus, the knee and hip are in flexion, there is an anterior
pelvic tilt and an increased lumbar lordosis.
• There is often a stiff knee because of rectus femoris activity in the swing
phase of gait.
• In younger children, this pattern can be managed effectively by botulinum
toxin type A injections to the gastrocnemius and hamstrings and the
provision of an AFO. In older children musculotendinous lengthening of the
gastrocnemius, hamstrings and iliopsoas may be indicated with transfer of
the rectus femoris to semi-tendinosus for co-contraction at the knee.
Type 3. Apparent Equinus (With or
Without Stiff Knee)
• As the child gets older and heavier, a number of changes may occur which
may render the calf muscle and the plantar flexion–knee extension less
competent. Equinus may gradually decrease as hip and knee flexion
increase.
• There is frequently a stage of `apparent equinus' where the child is still
noted to be walking on the toes and simple observational gait analysis
may mistakenly conclude that the equinus is real when it is in fact
apparent.
• Sagittal plane kinematics will show that the ankle has a normal range of
dorsiflexion but the hip and knee are in excessive flexion throughout the
stance phase of gait.
Type 3. Apparent Equinus (With or Without
Stiff Knee)
• Management should be focused on the proximal levels where the
hamstrings and iliopsoas may benefit from spasticity treatment or
musculotendinous lengthening.
• Redirection of the ground reaction vector in front of the knee can
best be achieved by the use of a solid or a ground reaction AFO.
• Orthotic management: ground reaction (Saltiel) AFO, solid AFO or
hinged AFO according to the integrity of the plantar flexion–knee
extension.
 Type 4. Crouch gait (With or Without Stiff
Knee Gait)
• Crouch gait is defined as excessive dorsiflexion or calcaneus at the ankle in
combination with excessive flexion at the knee and hip. This pattern is part
of the natural history of gait disorder in children with more severe diplegia
and in the majority of children with spastic quadriplegia.
• Regrettably, the commonest cause of crouch gait in children with spastic
diplegia is isolated lengthening of the heel cord in the younger child.
• Once the heel cord has been lengthened, if the spasticity/contracture of the
hamstrings and iliopsoas has not been recognized and is not managed
adequately, there will be a rapid increase in hip and knee flexion. The result
is an unattractive, energy-expensive gait pattern, followed by anterior knee
pain and patellar pathology in adolescence
 Type 4. Crouch gait (With or Without Stiff
Knee Gait)
• Crouch gait is always difficult to manage and usually requires lengthening of
the hamstrings and iliopsoas, a ground reaction AFO and adequate
correction of bony problems such as medial femoral torsion, lateral tibial
torsion and stabilisation of the foot. By the time it is recognised, the
musculoskeletal pathology is usually too advanced to respond to
intramuscular BTX-A.
• Orthotic management: long-term use of a ground reaction (Saltiel) AFO until
the integrity of the plantar flexion- knee extension couple is clearly re-
established.