Authors:

Moon Suk Bang, MD, PhD

Sun Gun Chung, MD, PhD
Sang Beom Kim, MD, PhD Spasticity
Sang-Jun Kim, MD

Affiliations:
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From the Department of Research Article

Rehabilitation Medicine, Seoul
National University College of
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 04/11/2023

Medicine and Seoul National

University Hospital Clinical Research
Institute (MSB, SGC, SJK), Seoul,
Korea; and the Department of
Physical Medicine and Rehabilitation,
Dong-A University College of
Medicine (SBK), Busan, Korea.
Correspondence:
All correspondence and requests for
reprints should be addressed to Moon
Suk Bang, MD, PhD, Department of
Rehabilitation Medicine, Seoul
National University College of
Medicine, 28 Yongun-dong, Chongno-
gu, Seoul 110-744, Korea.
0894-9115/02/8110-0760/0
American Journal of Physical
Medicine & Rehabilitation
Copyright © 2002 by Lippincott
Williams & Wilkins
DOI: 10.1097/01.PHM.0000027421.68357.8A
Change of Dynamic Gastrocnemius
and Soleus Muscle Length After
Block of Spastic Calf Muscle in
Cerebral Palsy
ABSTRACT
Bang MS, Chung SG, Kim SB, Kim SJ: Change of dynamic gastroc-
nemius and soleus muscle length after block of spastic calf muscle in
cerebral palsy. Am J Phys Med Rehabil 2002;81:760 –764.
Objective: The purpose of this study was to evaluate the efficacy of
gastrocnemius and soleus muscle length measured by gait analysis for
characterizing the spastic calf muscles in ambulant cerebral palsy.
Methods: A total of 20 limbs in the 16 children with diplegic or hemi-
plegic cerebral palsy showing spasticity of the calf muscle were ana-
lyzed by three-dimensional gait analysis before and after botulinum toxin
injection.
Results: The mean maximal ankle dorsiflexion angle, the minimal knee
flexion angle in stance, and the dynamic gastrocnemius and soleus
muscle lengths increased after the block. Paradoxically the dynamic
gastrocnemius muscle lengths decreased in the eight patients after the
block, all of whom had a common characteristic of the genu recurva-
tum. In contrast, dynamic soleus length, knee angle, and ankle angle
improved after the injection.
Conclusion: Gastrocnemius length and soleus length are useful vari-
ables to evaluate the antispastic effect of botulinum toxin in patients
with cerebral palsy. When the genu recurvatum is present, the soleus
muscle length is more informative than gastrocnemius length.
Key Words: Dynamic Gastrocnemius Length, Soleus, Cerebral
Palsy, Gait Analysis

760 Am. J. Phys. Med. Rehabil. ● Vol. 81, No. 10

 P atients with spastic cerebral
palsy (CP) may have the characteris-
tic gait patterns of toe walking, which
are caused by gastrocnemius and so-
leus muscle spasticity or contracture.
Toe walking is often accompanied by
genu recurvatum. Gastrocnemius
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muscle spasticity has been managed
by many nonoperative methods, in-
cluding antispastic medications,
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physical modalities, phenol motor
point block,1–3, and intramuscular
botulinum toxin injection.4 Many
double-blind studies on the effect of
botulinum toxin have been done, and
they have revealed the effectiveness
of this treatment.5– 8 Their antispastic
effects have been measured by using
range of motion of the ankle, modi-
fied Ashworth scale, locomotion rat-
ing scale,1 or physician rating scale.9
Recently, Eames et al.10,11 ele-
gantly measured the dynamic gas-
trocnemius muscle length using the
three-dimensional gait analysis sys-
tem that is considered to be useful in
evaluating calf muscle spasticity in
ambulant CP. The dynamic gastroc-
nemius muscle length consists of
three components: a knee part, an
ankle part, and a tibial part. The knee
part is calculated by using the knee
radius (distal femoral insertion dis-
tance) multiplied by the knee correc-
tion factor minus the radian knee an-
gle, and the ankle part is measured by
the distance between the ankle joint
and the gastrocnemius insertion site
(the tendo Achilles insertion dis-
tance) multiplied by the sine value of
the ankle dorsiflexion angle plus an
ankle correction factor.
There have been many other at-
tempts to devise a muscle model that
reflects the dynamic length during
movement. In addition to the mea-
surement of the dynamic gastrocne-
mius muscle using the gait analysis
system, Ettema12 devised a gastroc-
nemius muscle length model in the
rat similar to the model by Eames et
al. The former differed from the latter
in that, if there is more than 90 de-
October 2002
grees of knee flexion, the gastrocne-
mius muscle is attached straight in
the proximal portion to the medial
femoral condyle. Davies13 determined
the soleus muscle length by comput-
ing the quantitative relationship of
the angle of the ankle joint.
Patients with CP who walk by tip
toeing often show an associated genu
recurvatum caused by the laxity of
the soft tissues. We have often ob-
served patients in whom the dynamic
gastrocnemius length obtained by
the method of Eames et al. paradox-
ically decreased after the botulinum
toxin injection in the spastic calf
muscles, despite a clinical improve-
ment of the tip toeing. In those cases,
genu recurvatum was also present
during the stance phase. In the
method of Eames et al., the knee part
of the gastrocnemius muscle length
is lengthened according to the degree
of genu recurvatum and will not be
indicative of the real state of the gas-
trocnemius muscle. The soleus mus-
cle has a similar insertion site, but
unlike the gastrocnemius muscle, it
is a muscle that crosses a single joint
and is not affected by the knee mo-
tion. The most proximal origin site is
the fibular head and tibia site at the
same level. If we assume that the
dynamic soleus length is the dynamic
gastrocnemius length minus the
knee part, it reflects the dynamic im-
provement better than gastrocne-
mius length in those patients in
whom tip toeing is associated with
genu recurvatum.
The aim of this study was to eval-
uate the clinical efficacy of gastroc-
nemius and soleus muscle length
measured together with gait analysis
for evaluating the spastic calf mus-
cles in ambulant CP after botulinum
toxin injection.
SUBJECTS AND METHODS
Subjects
A total of 16 children with spastic
CP who were referred to the Seoul
Change in Muscle Length After Injection
National University Hospital were re-
cruited for the study. Children were
excluded from the study if they were
too young to permit an accurate gait
analysis and muscle length calcula-
tions while walking. A total of 20
limbs in the 16 children showing
spasticity of calf muscles and a tip-toe
gait were selected. Of these 16 pa-
tients, 13 were diplegics and the oth-
ers were hemiplegics. Among the 13
patients with diplegic CP, four pa-
tients showed the spasticity on both
sides and were injected bilaterally.
Four patients were girls and 12 were
boys, ranging in age from 3 to 15 yr
(mean, 5.56 ⫾ 3.1 yr). All the chil-
dren walked independently.
Methods
Injection Procedure. Two commer-
cially available preparations of botu-
linum toxin were used. A total of 14
children (18 muscles) received 2– 4
units/kg per limb of BOTOX (Aller-
gan, Irvine, CA). Two children (two
muscles) received 12–16 units/kg per
limb of Dysport (Ipsen Biotech, Paris,
France). For injections of the gas-
trocnemius and soleus muscles, the
visible bulk of the calf is divided into
four equal quadrants. The centers of
upper two quadrants correspond to
the motor points of the gastrocne-
mius. The soleus muscle is injected
through the same points as in the
distal two quadrants of gastrocne-
mius, but the needle is advanced
deeper and directed toward the axis of
the limb to penetrate the muscle
bulk.14 This method was originally
used for alcohol motor point injec-
tion of calf muscles. Bakheit15 rec-
ommended this method for botuli-
num toxin injection later.
Assessment. Gait analysis using a six-
camera Ariel three-dimensional gait
analysis system was performed on the
day of injection and, subsequently,
about 4 wk after the injection. In
dynamic gait analysis, six cameras
and 13 passive retro-reflective mark-
761
 ers were used, and 19 markers were
used in static gait analysis. TABLE 1
The following are the positions of Gait variables before and after botulinum toxin injection
the markers. MAXDFA, degree MINKFA, degree MAXGL, cm MAXSL, cm
1. For the dynamic gait analysis, Before block ⫺1.24 4.47 22.31 20.53
markers were placed on both lateral After block 5.19 9.81 22.75 21.24
malleoli, both second metatarsal Change 6.43 5.34 0.44 0.71
heads, both femoral condyles, both MAXDFA, maximal ankle dorsiflexion angle; MINKFA, minimal knee flexion
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anterior superior iliac spines, midway angle; MAXGL, maximal gastrocnemius length; MAXSL, maximal soleus length.
between both posterior superior iliac
spines, on both tibial wanders (in the
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line between the lateral knee and an-

kle markers), and on both femoral The degree of improvement of the muscle lengths in these patients in-
wanders (in the line between the lat- soleus muscle length was greater creased by 0.72 cm, on average, but
eral knee marker and the imaginary than that of the gastrocnemius mus- the gastrocnemius muscle lengths
hip joint center). cle length. This was due to the in- paradoxically decreased by 0.10 cm,
2. Additional static markers were crease of the knee flexion that short- on average, after the injection. There
placed on both heels at the same ened the knee part of gastrocnemius was an improvement in the knee and
height as the second metatarsal head, muscle measurement (Fig. 1). We ankle angles (Table 2, Fig. 2).
on both medial malleoli, and on both found that nine limbs in the eight
medial femoral condyles. patients showed a paradoxical de-
The patients walked several
DISCUSSION
crease in the gastrocnemius muscle
times during the gait analysis, and lengths (23.65 cm to 23.55 cm), all of Patients with CP who showed a
the most natural gait posture was an- which shared the common character- tip-toe gait may have spasticity or
alog-to-digitally captured by the Ariel istic of genu recurvatum. The soleus contracture of the calf muscle. Con-
capture system. The joint center, the
length in the compartment, and the
joint angles were calculated using the
MATLAB 5.3 (MathWorks, Novi, MI).
The gastrocnemius muscle length
and other anthropometric data were
used by the method invented by the
Eames et al.,10 and the soleus muscle
length was calculated by the gastroc-
nemius muscle length minus the
knee part of it.
We also calculated the maximal
dorsiflexion angle of the ankle to
evaluate the degree of tip toeing and
the minimal flexion angle of the knee
joint to evaluate the degree of genu
recurvatum.

RESULTS
The maximal dorsiflexion of the
ankle and the minimal flexion of the
knee joints improved by 6.43 degrees
and 5.34 degrees, respectively, after
the botulinum toxin injection. The
maximal gastrocnemius and soleus Figure 1: Knee and ankle flexion angle and gastrocnemius and soleus muscle
muscle length as calculated by the length graph in 20 limbs in the 16 children with spastic cerebral palsy. The
gait analysis improved by 0.44 cm horizontal axis is the gait cycle (%). All values were increased after the block.
and 0.71 cm on average (Table 1). Dashed line, curve after the block; solid line, curve before the block.

762 Bang et al. Am. J. Phys. Med. Rehabil. ● Vol. 81, No. 10
 to exercise stress using the treadmill
TABLE 2 and endurance time 2 mo before and
Gait variables before and after botulinum toxin injection 6 mo after botulinum toxin A injec-
in eight patients showing the genu recurvatum tion. Eames et al.11 developed length
tests for the dynamic gastrocnemius
MAXDFA, degree MINKFA, degree MAXGL, cm MAXSL, cm
muscle and soleus muscle and used
Before block ⫺5.87 ⫺7.66 23.65 21.50
After block 8.49 13.04 23.55 22.22 them to evaluate the effect of botuli-
Change 14.36 21.68 ⫺0.10 0.72 num toxin in spastic CP. Boyd et al.2
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MAXDFA, maximal ankle dorsiflexion angle; MINKFA, minimal knee flexion devised two new measures of the an-
angle; MAXGL, maximal gastrocnemius length; MAXSL, maximal soleus length. kle kinetics (the ankle moment quo-
tient and the ankle power quotient)
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and was able to demonstrate im-

sequently they may touch the ground
toe first, and they may show a hyper-
extension of the knee during the
stance phase. O’Byrne et al.16 ana-
lyzed the sagittal kinematics of 55
hemiplegic and 91 diplegic patients
using an opto-electronic scanner
(CODA-3) and proposed a classifica-
tion system to be a new technique
that uses gait analysis data in auto-
matically classifying abnormal move-
ments of the lower limb.
provements in the typical abnormal
Many trials have been done re-
ankle kinetics of patients with CP af-
cently to evaluate objectively and
ter botulinum toxin injection.
quantitatively the effect of the botu-
We used the model of Eames et
linum toxin on spasticity in cerebral
al. to evaluate the effect of botulinum
palsies. A locomotion rating scale
toxin in the management of spastic
that was composed of equinus foot,
gastrocnemius and soleus muscles.
hind foot instability, genu recurva-
Most patients with CP showed an in-
tum, crouch gait, scissoring gait,
crease of the gastrocnemius and so-
speed of gait, deviation from normal
leus muscle lengths after the injec-
gait, and instability in walking was
tion, but eight children showed a
used for estimation.1 Massin et al.17
decrease of gastrocnemius muscle
analyzed the oxygen-uptake response
length and an increase of soleus mus-
cle length after the injection. They all
had the common characteristic that
genu recurvatum occurred in the
stance phase before the management.
This was remedied by the injection.
We found that the increase of the
tibia and ankle part of the gastrocne-
mius length, resulting from the im-
provement of tip toeing, was over-
whelmed by the decrease in the knee
part of the gastrocnemius length be-
cause of the improvement of the
genu recurvatum. Therefore, we sug-
gest that measurement of the dy-
namic soleus muscle length, rather
than the dynamic gastrocnemius
length, is useful in evaluating the dy-
namic spasticity of calf muscle when
the patients show tip toeing and genu
recurvatum. This is because the so-
leus crosses only a single joint and is
not affected by the motion of the
knee joint.

Figure 2: Knee and ankle flexion angle and gastrocnemius and soleus muscle CONCLUSION
length graph in nine limbs in eight children with spastic cerebral palsy. The
horizontal axis is the gait cycle (%). All values were increased after the block Gastrocnemius length and soleus
except the gastrocnemius length. Dashed line, curve after the block; solid line, length are useful variables in evalua-
curve before the block. tion of the antispastic effect of botu-

October 2002 Change in Muscle Length After Injection 763

 linum toxin on patients with CP. In
cases of associated genu recurvatum,
the dynamic gastrocnemius length
must be substituted by the dynamic
soleus length or other gait variables,
including the measurement of knee
and ankle angles.
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Email: fribtera.walter@mgh.harvard.edu
Am. J. Phys. Med. Rehabil.
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