ORIGINAL ARTICLE
Kinematics and Kinetics During Gait in Symptomatic and
Asymptomatic Limbs of Children With Myelomeningocele
Smita Rao, PT, PhD,* Fred Dietz, MD,w and H. John Yack, PT, PhDz
Background: Knee pain and early arthrosis have emerged as
significant problems in young adults with myelomeningocele
(MMC). The purpose of our study was to examine kinematics
and kinetics during gait in symptomatic and asymptomatic
limbs of children with an MMC to better understand the factors
that may predispose individuals with an MMC to potentially
debilitating knee problems.
Methods: Seven children with L3-L4 level MMC and 8 age-
matched typically-developing control children participated in
this study. Three-dimensional kinematic and kinetic data were
obtained bilaterally during gait. A custom-designed femoral
tracking device, with established reliability and validity was used
to track the thigh. The limbs in an MMC group were subdivided
into 2 subgroups (n = 6 and 8, symptomatic and asymptomatic,
respectively) based on history of pain at the knee joint after
walking/weight bearing activity in the last 6 months. An 1-way
analysis of variance with post hoc Bonferroni adjustments was
used to compare lower extremity kinematic and kinetic variables
between symptomatic, asymptomatic, and control limbs. The
Pearson product moment correlation (r) was used to assess the
relationship between variables of interest.
Results: Symptomatic limbs showed increased knee flexion in
stance (P = 0.01) compared with asymptomatic limbs. Symptom-
atic limbs showed trends toward increased knee extension,
adduction, and internal rotation moments (P = 0.031, P =
0.025, and P = 0.024, respectively) compared with asymptomatic
limbs. Hip internal rotation was positively associated with knee
internal rotation moment (r = 0.93, P = 0.008 and r = 0.76,
From the *Department of Physical Therapy, New York University, New
York, NY; wDepartment of Orthopedics and Rehabilitation,
University of Iowa Hospitals and Clinics; and zGraduate Program
in Physical Therapy and Rehabilitation Sciences, The University of
Iowa, Iowa City, IA.
Supported in part by funding from the Children’s Miracle Network.
This study was reviewed by Institutional Review Board 01 (Biomedical)
at The University of Iowa Hospitals and Clinics. All patients sought
care at the Pediatric Division of the Department of Orthopaedics and
Rehabilitation at the University of Iowa Hospitals and Clinics. All
testing was performed at the Orthopedic Gait Analysis Laboratory at
the University of Iowa Hospitals and Clinics.
The authors declare no conflict of interest.
Reprints: Smita Rao PT, PhD, Department of Physical Therapy, New
York University, 380 2nd Ave, 4th Floor, New York, NY 10010.
E-mail: smita.rao@nyu.edu.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Website,
www.pedorthopaedics.com.
Copyright r 2012 by Lippincott Williams & Wilkins
106 | www.pedorthopaedics.com
P = 0.08 in symptomatic and asymptomatic limbs, respectively)
and increased knee adduction moment (r = 0.84, P = 0.03 and
r = 0.91, P = 0.01 in symptomatic and asymptomatic limbs,
respectively).
Conclusions: Symptomatic limbs in children with an MMC
showed increased knee flexion and trends toward higher
extension, adduction, and internal rotation moments. Increased
knee flexion accompanied by inadequate control of hip trans-
verse kinematics may have significant implications for knee joint
loading in this population.
Level of Evidence: Level 4 (Case series with controls, motion
laboratory gait analysis).
Key Words: adduction moment, spina bifida, knee
(J Pediatr Orthop 2012;32:106–112)
M yelomeningocele (MMC) is the most common
expression of neural tube defects, having an
incidence of 1.0 to 10.0 per 1000 births.1 Individuals with
an MMC experience substantial disability,2 and inde-
pendence in mobility and ambulation is a significant
predictor of health-related quality of life.2,3 Over the last
3 decades, the management of MMC has evolved to
include aggressive multidisciplinary intervention strat-
egies that seek to maximize the patient’s functional
ambulation ability.4–7 The success of these approaches is
evidenced in reports showing that 100% of patients with a
sacral lesion, and 54% to 80% with a lumbar lesion are
community ambulators, by their teenage and adult
years.8,9
The large percentage of successful community
ambulators belies the high rate of symptomatic knee
problems noted in adults with MMC.10–12 Knee pain and
early arthritis have been documented in approximately
25% of the adult lumbosacral MMC population,11,12 and
associated pathologic changes may be severe enough to
preclude ambulation. The development of anteromedial
instability and arthritic changes has been linked to
abnormal knee joint loading because of muscle paresis
and attendant compensatory gait patterns noted in
MMC.12
Clinical studies using gait analysis indicate that
children with lumbosacral MMC ambulate using gait
patterns that allow them to compensate for muscle
weakness and skeletal misalignment.13,14 Hip abductor
and plantar flexor weakness seen in children with MMC
J Pediatr Orthop  Volume 32, Number 1, January/February 2012
J Pediatr Orthop  Volume 32, Number 1, January/February 2012
have been associated with a lateral trunk lean, exagger-
ated pelvic motion, increased knee flexion, and increased
dorsiflexion.13–17 Along with stereotypical patterns of
motion, aberrant kinetic patterns indicative of abnormal
joint loading have also been reported in children with
MMC.18–20 In particular, at the ankle, children with
MMC demonstrated lower plantar flexor moment and
decreased power generation at terminal stance. At the
knee, increased knee extensor moment and reversed
frontal, that is internal adduction (varus) moment, have
been noted.11,19 Finally, at the hip, lower sagittal
moments (flexor and extensor) and decreased or reversed
frontal moment have been reported.18
During normal walking, an internal abduction mo-
ment consistent with medial compartment loading is noted
at the knee joint.19,21 (Supplementary Image) (Supplemen-
tal Digital Content1, http://links.lww.com/BPO/A5) In
children with an MMC, an internal adduction moment has
been noted and has been postulated to predispose to the
evolution of knee problems.11,19 Recent reports indicate
that external tibial torsion11,22 and lateral trunk lean 19,21
may contribute to the increased adduction moment in
children with MMC.
Although increasing evidence suggests that aberrant
kinematic and kinetic patterns during gait (specifically,
increased adduction moment accompanied by external
tibial torsion and/or lateral trunk lean) may contribute to
the evolution of symptoms in children with MMC, to
date, no studies have assessed kinematics and kinetics of
gait in symptomatic and asymptomatic limbs of children
with MMC. The purpose of this study was to examine
kinematics and kinetics during gait in the symptomatic
and asymptomatic limbs of children with MMC. The
findings of this study may help identify key patterns of
motion and loading that predispose individuals with
MMC to potentially debilitating knee problems.
METHODS
All procedures were reviewed and approved by the
Institutional Review Board (01-Biomedical). Informed
consent/assent was sought before initiation of study
procedures.
Subjects
Children with MMC were invited to participate in
this study with the following inclusion/exclusion criteria:
(1) able to ambulate independently without assistive
devices along a 10 m walkway, not limited by pain,
fatigue, or other symptoms (community ambulator23); (2)
no evidence of hip subluxation or dislocation. Of 11
subjects who responded, 2 did not meet these criteria as
they were not functional ambulators. One respondent had
moved from the area and was unable to participate. One
respondent walked with a swing-through gait pattern
(minimal weight bearing through the lower extremities)
and was not included in the study. A single fellowship-
trained orthopaedic surgeon (F.D.) screened all patients.
The control group comprised age-matched typically
developing children recruited from the community. Seven
r 2012 Lippincott Williams & Wilkins
Kinematics and Kinetics During Gait
children with L3-L4 MMC [5 females, mean (SD) age: 14
(2) y, height: 1.44 (0.07) m, mass: 46.5 (13.4) kg] and 8 age-
matched typically developing control subjects [3 females,
mean (SD) age: 11 (2) y, height: 1.54 (0.04) m, mass: 51.2
(2.6) kg] participated in this study.
Procedures
Kinematic data were collected bilaterally using
infrared markers placed on the foot, leg, thigh, pelvis,
and trunk as the subjects walked at self-selected walking
velocity along a 10 m walkway. All subjects with MMC
wore their floor-reaction ankle-foot orthoses during gait
testing. Foot markers were placed over subjects’ shoes,
shank markers were placed on subjects’ skin on the leg
segment, and a femoral tracking device was used to track
the thigh segment. The reliability and validity of this
device have been previously documented.24 Surface
markers were also used to track the pelvis and trunk
segments. Markers were tracked at 60 Hz using the
Optotrak motion analysis system (Northern Digital Inc.,
Canada). Kinetic data were collected at 360 Hz using a
forceplate embedded in the walkway (Kistler Inc., NY).
Data Analysis
Kinematic data were filtered at 6 Hz and synchron-
ized with kinetic data (filtered at 8 Hz) to calculate joint
kinematics and kinetics (Mishac Kinetics, University of
Waterloo, Canada). Anatomic coordinate systems were
established using digitized landmarks.25 Tibial torsion
was measured as the acute angle subtended between 2
lines, 1 through the femoral condyles and the other
through the malleoli.26 Ankle, knee, and hip kinematics
were expressed with respect to local coordinate systems.
Pelvis and trunk kinematics were assessed in the global
(lab) coordinate system. All net joint moments are
expressed as internal moments. A minimum of 5 strides
were averaged for each limb.
The limbs in the MMC group were subdivided into
2 subgroups, symptomatic (n = 6) and asymptomatic
(n = 8), based on history of pain at the knee joint after
walking/weight bearing activity in the last 6 months. The
following question was used to determine whether a limb
was symptomatic or asymptomatic, “Over the last 6
months, have you experienced symptoms such as dis-
comfort or pain in your knee, after activities such as
walking or standing?” At the time of testing, none of the
subjects reported resting knee pain; no signs of inflam-
mation, or instability were present.
Statistical Analysis
Descriptive statistics were used to summarize
temporal and distance parameters of gait. A 1-way
analysis of variance with post hoc Bonferroni adjustments
was used to compare lower extremity kinematic and
kinetic variables between symptomatic, asymptomatic,
and control limbs. Between-group (MMC vs. control)
differences in pelvis and trunk kinematics were assessed
using 2 sample t test. The Pearson product moment
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Rao et al J Pediatr Orthop  Volume 32, Number 1, January/February 2012

correlation (r) was used to assess the relationship between
variables of interest.
RESULTS
Temporal and Spatial Parameters
Subjects with MMC walked at a slower velocity
compared with the control group [mean (SD)] walking
speed: 0.68 (0.12) and 0.93 (0.11) m/s, respectively).
Subjects with MMC had shorter stride lengths compared
with controls [mean (SD) stride length: 0.78 (0.10), 0.99
(0.08), and 1.09 (0.08) m in symptomatic, asymptomatic,
and control limbs, respectively). Subjects with MMC
showed longer stride time [mean (SD) stride time: 1.33
(0.28), 1.33 (0.34), and 0.98 (0.30) m in symptomatic,
asymptomatic, and control limbs, respectively], and
showed trends toward longer stance duration [mean
(SD) stance duration: 62.4 (2.4), 67.6 (1.8), and 67.6
(1.6) % in symptomatic, asymptomatic, and control
limbs, respectively).
Three-dimension Kinematics During Gait
Symptomatic limbs showed increased knee flexion
in stance (P = 0.01) compared with asymptomatic limbs
(Table 1). Symptomatic limbs showed lower knee sagittal
range (P<0.001), less knee extension in stance
(P = 0.002), more ankle dorsiflexion (P<0.001), more
hip flexion (P = 0.004), and increased hip transverse
range (P = 0.003) with higher hip internal rotation
(P = 0.007) compared with control limbs. Ensemble
average kinematic curves are presented in Figure 1. Tibial
torsion did not differ between limbs.
As a group, children with an MMC demonstrated
increased anterior pelvic tilt (P = 0.001), increased pelvic
frontal (P<0.001) and transverse (P<0.001) range, and
increased trunk frontal (P<0.001) and transverse
(P<0.001) range compared with the control group
(Table 1).
Three-dimension Kinetics During Gait
Symptomatic limbs showed trends toward increased
knee extension, adduction, and internal rotation moments
(P = 0.031, P = 0.025, and P = 0.024, respectively, Table 2)
compared with asymptomatic limbs. Ensemble averaged
kinetic curves are presented in Figure 2. Symptomatic
limbs showed higher knee sagittal and adduction mo-
ments (P<0.001), lower knee external rotation moment
(P<0.001) and higher knee internal rotation moment
(P<0.02), lower hip abduction moment (P<0.001), and
lower hip internal rotation moment (P = 0.002) com-
pared with control limbs.
As a group, children with MMC, showed reduced
ankle power generation (P<0.001), increased knee power
generation in midstance (P<0.001), decreased knee
power absorption at terminal stance (P<0.001), and
terminal swing (P<0.001) compared with control subjects
(Table 2).
Correlations
Tibial torsion was not associated with knee valgus
moment (r = 0.09, P = 0.94 and r = 0.04, P = 0.98 in
symptomatic and asymptomatic limbs, respectively). Hip
internal rotation was positively associated with knee
internal rotation moment (r = 0.93, P = 0.008 and
r = 0.76, P = 0.08 in symptomatic and asymptomatic

TABLE 1. Summary of Mean (SD) Ankle, Knee, and Hip, Pelvis and Trunk Kinematics in Control, Symptomatic, and Asymptomatic
Limbs (Units: Degrees)
Control Symptomatic Asymptomatic
Peak ankle dorsiflexion 9.6 (2.8)w 22.0 (5.1)y 22.0 (6.8)8
Tibial torsion 12 (3) 16 (5) 22 (10)
Peak knee extension in stance* 5.7 (3.1) 19.8 (9.9)y 7.7 (13.4)
Peak knee flexion in stance 13.6 (5.1)w 32.0 (3.6)z,y 19.8 (10.0)
Knee sagittal range 61.7 (7.6)w 37.1 (11.4)y 37.0 (5.6)8
Knee frontal range 9.0 (6.2) 11.1 (3.9) 7.5 (3.6)
Knee transverse range 7.4 (2.9) 11.8 (8.8) 14.7 (7.6)
Peak hip flexion in stance 17.3 (6.6)w 33.7 (10.5)y 30.1 (15.4)
Hip frontal range 15.0 (4.4) 19.2 (4.5) 24.9 (16.0)
Hip transverse range 12.6 (2.1)w 27.9 (11.5)y 29.7 (11.8)8
Pelvis peak anterior tilt 8.6 (5.5)w 19.4 (9.0)y 17.3 (12.3)8
Pelvis frontal range 8.9 (1.7)w 23.1 (7.5)y 31.1 (18.3)8
Pelvis peak external rotation 1.6 (3.2)w 14.1 (10.2)y 15.6 (6.3)8
Pelvis peak internal rotation  4.2 (3.8)w 16.7 (3.3)y 14.3 (4.8)8
Pelvis transverse range 5.9 (1.6)w 30.8 (9.1)y 29.8 (8.3)8
Trunk peak posterior tilt  0.6 (5.4) 1.2 (3.5) 4.0 (3.8)
Trunk peak anterior tilt  4.9 (5.5) 7.4 (2.6) 11.3 (4.7)
Trunk frontal range 3.2 (1.2)w 31.0 (1.8)y 35.9 (4.8)8
Trunk transverse range 5.7 (1.3)w 21.2 (3.6)y 19.1 (4.3)8
*Positive numbers indicate knee flexion.
wIndicates statistically significant difference between control and myelomeningocele limbs.
zBetween symptomatic and asymptomatic limbs.
yBetween symptomatic and control limbs.
8Between asymptomatic and control limbs.

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J Pediatr Orthop  Volume 32, Number 1, January/February 2012
FIGURE 1. Sagittal (top row), frontal (middle row), and transverse plane (bottom row) kinematics of the ankle, knee, and hip joint
normalized to a gait cycle. Data from symptomatic limbs (circles) and asymptomatic limbs (dashed line) are shown on each
graph. Data from control limbs ( ± 1 SD) are shown shaded in gray.
limbs, respectively) and increased knee adduction mo-
ment (r = 0.84, P = 0.03 and r = 0.91, P = 0.01 in
symptomatic and asymptomatic limbs, respectively).
Trunk frontal kinematics were not associated with knee
frontal range (r = 0.14, P = 0.88 and r = 0.31, P = 0.37
in symptomatic and asymptomatic limbs, respectively) or
valgus moment (r = 0.24, P = 0.78 and r = 0.16, P =
0.75 in symptomatic and asymptomatic limbs, respec-
tively). Trunk transverse kinematics were not associated
with knee transverse range (r = 0.22, P = 0.62 and
r = 0.08, P = 0.87 in symptomatic and asymptomatic
limbs, respectively) or transverse moment (r = 0.21,
P = 0.55 and r = 0.22, P = 0.67 in symptomatic and
asymptomatic limbs, respectively).
DISCUSSION
The chief findings of our study indicate that
symptomatic limbs in children with MMC showed
increased knee flexion and trends toward higher ex-
tension, adduction, and internal rotation moments.
Symptomatic limbs showed more ankle dorsiflexion,
more hip flexion, and increased hip transverse range of
r 2012 Lippincott Williams & Wilkins
Kinematics and Kinetics During Gait
motion with higher hip internal rotation during gait
compared with control limbs. These findings highlight key
factors associated with knee joint symptoms in children
with MMC and may be indicative of their potential role
in the evolution of symptoms.
Increased knee flexion in children with MMC has
been attributed to loss of plantar flexor muscle strength.14
Weak plantar flexors may result in inadequate tibial
restraint,27 leading to increased stance phase knee flexion.
Weakness of the soleus and gluteus maximus,28 and the
vastii,29 have also been hypothesized to play a role in the
development of increased stance phase knee flexion.
Previous studies have demonstrated dichotomy between
neurological level and muscle function in children with
MMC,30 indicating that the possibility of weakness of the
soleus and gluteus maximus exists in children with L3 to 4
level MMC.
The increased knee flexion seen in our symptomatic
group may suggest that larger demands are being placed
on the knee extensor muscles because the ground reaction
force vector acts further away from the knee joint
center.31 In the presence of knee flexion, the forward
trunk lean noted in children with MMC did not mitigate a
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Rao et al J Pediatr Orthop  Volume 32, Number 1, January/February 2012

TABLE 2. Summary of Peak Internal Moments and Net Joint Powers in Control, Symptomatic, and Asymptomatic Limbs
Control Symptomatic Asymptomatic
Ankle plantar flexion moment (N m/kg) 1.218 (0.074)z 0.827 (0.222)8 0.803 (0.325)z
Knee extension moment (N m/kg) 0.346 (0.153) 0.694 (0.351)8 0.633 (0.194)z
Knee adduction moment (N m/kg)* 0.212 (0.053)z 0.407 (0.225)8 0.033 (0.267)
Knee external rotation moment (N m/kg)w 0.105 (0.018)z 0.001 (0.034)8 0.030 (0.055)z
Knee internal rotation moment (N m/kg)w  0.065 (0.028) 0.097 (0.054) 0.027 (0.035)
Hip extensor moment (N m/kg) 0.486 (0.230) 0.310 (0.130) 0.438 (0.148)
Hip flexor moment (N m/kg) 0.479 (0.112) 0.438 (0.244) 0.572 (0.245)
Hip abductor moment (N m/kg) 0.873 (0.105)z 0.124 (0.146)8 0.367 (0.273)z
Hip external rotation moment (N m/kg)w 0.090 (0.057) 0.049 (0.014) 0.122 (0.090)
Hip internal rotation moment (N m/kg)w  0.128 (0.065)z 0.015 (0.019)8 0.048 (0.041)
A2 (J s/kg) 1.410 (0.524)z 0.533 (0.274)8 0.710 (0.439)
K1 (J s/kg)  0.280 (0.203) 0.438 (0.309) 0.654 (0.423)
K2 (J s/kg) 0.141 (0.114)z 0.303 (0.154) 0.393 (0.130)z
K3 (J s/kg)  0.776 (0.275)z 0.166 (0.154)8 0.268 (0.258)z
K4 (J s/kg)  0.493 (0.153)z 0.192 (0.069)8 0.137 (0.041)z
H1 (J s/kg) 0.433 (0.215) 0.296 (0.176) 0.334 (0.434)
H2 (J s/kg)  0.274 (0.249) 0.355 (0.249) 0.705 (0.436)
H3 (J s/kg) 0.412 (0.105) 0.250 (0.111)8 0.299 (0.308)
Notations used to designate intervals for joint power taken from Schwartz et al.36
*Negative sign denotes adduction moment.
wNegative sign denotes internal rotation moment.
zIndicates statistically significant difference between control and myelomeningocele limbs.
yBetween symptomatic and asymptomatic limbs.
8Between symptomatic and control limbs.
zBetween asymptomatic and control limbs (a = 0.0167).

substantial increase in the sagittal moment. Contrary to
the control group, children with MMC sustained higher
extension moments throughout stance. Increased knee
flexion accompanied by elevated and sustained net joint
moments may be expected to increase the compressive
forces sustained at the tibiofemoral and patellofemoral
joints and contribute to the evolution of knee pain. In
addition, trends toward increased knee adduction and
internal rotation moments were noted in symptomatic
limbs compared with asymptomatic limbs.
Our findings of increased lateral lean and trunk
rotation in subjects with MMC agree with previous
reports.13,16,18,19,21 Excessive lateral lean, typically asso-
ciated with hip abductor weakness in this population, has
been implicated as an important factor in the evolution of
aberrant frontal and transverse plane knee joint loads.
Trunk lateral lean shifts the line of action of the ground
reaction force vector laterally,11,21,32 resulting in reversal
of the normal (internal) abduction moment to an
adduction moment at the knee joint. (Supplementary
Figure) Our findings underscore that aberrant kinematic
patterns are not associated with universal knee pathology.
The effect of trunk motion on knee adduction moments
may be modulated by alignment of intervening joints and
limb segments.19,20 Our data, albeit for this relatively
small population, demonstrated that hip internal rotation
is associated with increased knee adduction and internal
rotation moments, particularly in symptomatic limbs.
Taken together, these results may indicate that poor
transverse plane hip control combined with increased
knee flexion (greater degree of crouch gait) may place the
knee at risk for large loads during stance phase. These
findings are consistent with the anterior-medial problems
that have been identified in MMC patients with
symptomatic knee problems. Future studies are indicated
to investigate the effect of intervention strategies that
target improved control of stance phase hip internal
rotation and knee flexion.
As a group, our subjects with MMC demonstrated
gait patterns consistent with those described by previous
studies.13,14,18,19 Increased ankle dorsiflexion, reduced
sagittal knee range of motion, and increased hip flexion
secondary to anterior pelvic tilt were noted in children
with MMC.13,14 These findings have been explained as
a consequence of plantar flexor, hamstring, and hip
extensor weakness. Increased dorsiflexion may also reflect
that the ability of the floor-reaction ankle-foot orthoses to
control ankle motion is compromised and that more
aggressive bracing strategies are indicated.33 Patterns of
sagittal knee loading were similar to those reported by
Õunpuu and colleagues who found increased knee
extension and adduction moments in children with L4
level lesion. Three limbs in the asymptomatic group
showed an extension pattern, characterized by 0 degree
knee extension attained in midstance described by Gutier-
rez and colleagues. Similar to Õunpuu and colleagues, we
did not find evidence of change in frontal plane knee
kinematics (range, peak, or mean). Contrary to previous
reports,19,34 we did not find increased transverse plane knee
motion in children with MMC. Rotational motion at the
knee is susceptible to errors because of soft tissue
movement artifacts.35 To address this issue and improve
confidence in tracking the knee joint, we used a femoral
tracking device with established validity and reliability.24

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J Pediatr Orthop  Volume 32, Number 1, January/February 2012
FIGURE 2. Sagittal (top row), frontal (middle row), and transverse plane (bottom row) kinetics of the ankle, knee, and hip joint
normalized to a gait cycle. Data from symptomatic limbs (circles) and asymptomatic limbs (dashed line) are shown on each
graph. Data from control limbs ( ± 1 SD) are shown shaded in gray.
The lack of excessive frontal and transverse plane knee
motion combined with the absence of resting knee joint
pain in the symptomatic limbs may indicate that the
current study represents a relatively early time point in the
evolution of knee problems in children with MMC. Future
investigations incorporating a longitudinal design are
indicated to assess changes in knee kinematics that occur
with the development of symptoms.
The chief limitation of our study comes from its
relatively small sample size. However, this cohort also
provided an opportunity to focus on a homogenous
group of subjects similar in age and neurological level.
The study afforded us a window of opportunity to
address clinically relevant issues by examining 3-dimen-
sional kinematics and kinetics of the knee joint in
functionally ambulant, adolescent children with MMC
who had encountered knee problems, but were not limited
by pain or instability during gait. Longitudinal studies are
indicated to assess changes in knee kinematics that occur
with the evolution of symptoms in children with MMC.
Another limitation of this study was that we used a
dichotomous grading scale to sort limbs into symptomatic
or asymptomatic categories. The use of standardized self-
r 2012 Lippincott Williams & Wilkins
Kinematics and Kinetics During Gait
reported outcomes scales to characterize self-reported
knee function would be preferable. In addition to robust
psychometric properties (reliability, validity) in adoles-
cents, the self-reported measure should not be susceptible
to floor or ceiling effects. Given that most subjects
traveled a few hours for their clinic appointment and gait
analysis, and the possibility of fatigue with gait analysis,
the testing session was kept as brief as possible from a
logistical standpoint. Consequently, the inclusion of a
more detailed evaluation was precluded. However, based
on the findings of the current study, future studies should
include a clinical examination including the evaluation
of contractures, range of motion, and muscle strength.
Walking speed has a significant effect on net joint
moments during walking,36,37 and matching the walking
speed of the control group to that of the study group may
have allowed us to discern statistically significant differ-
ences. However, to maintain external validity and not
introduce variability by manipulating walking speed, both
groups were asked to walk at self-selected speed. Future
studies in larger groups of children with MMC may help
elucidate the effect of aberrant knee kinematics and
kinetics on self-reported pain and function.
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Rao et al
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