Pediatric Radiology (2019) 49:1587–1594

https://doi.org/10.1007/s00247-019-04519-w

MUSCULOSKELETAL IMAGING

Cerebral palsy — beyond hip deformities

Jeffrey P. Otjen 1 & Ted C. Sousa 2 & Jennifer M. Bauer 2 & Mahesh Thapa 1

Received: 4 July 2019 / Revised: 29 July 2019 / Accepted: 28 August 2019 / Published online: 24 October 2019
# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Cerebral palsy is a neurologic condition with myriad musculoskeletal and articular manifestations. While every patient is unique
with innumerable variations in presentation, symptoms and treatments, there are broad themes and recognizable patterns of
development. Many of these findings spill over to other neurodevelopmental disorders, and lessons learned from children with
cerebral palsy translate well to multiple neurologic conditions. This review focuses on the more common manifestations involv-
ing the spine, knee, foot and ankle, with an emphasis on collecting and describing imaging features, along with clinical and
radiologic pearls and pitfalls.

Keywords Cerebral palsy . Children . Feet . Lower extremity . Musculoskeletal . Radiography . Spine

Introduction significant foot deformities. Spasticity is the most common

Cerebral palsy is a central nervous system abnormality that
affects 1–5 per 1,000 live births [1, 2]. The most common risk
factors are prematurity and low birth weight, but any prenatal
or perinatal insult can have this affect [2], including traumatic,
hypoxic, infectious and genetic. Although the underlying en-
cephalopathy is static, the downstream muscular abnormality
can cause a variety of progressive musculoskeletal and gait
disturbances [3–5]. There is heterogeneous presentation with a
variable degree of muscle weakness, spasticity, contractures
and impaired sensation. Cerebral palsy is anatomically cate-
gorized with respect to the affected area, for example diplegia
(affecting two limbs, usually legs, symmetrically), quadriple-
gia (synonymous with tetraplegia — affecting all four limbs)
and hemiplegia (affecting one side). Individuals can also be
grouped using the Gross Motor Functional Classification
System (GMFCS), which focuses on functional impairment
[6]. GMFCS can be more prognostic with regard to develop-
ment of deformities such as scoliosis, hip dysplasia and
* Mahesh Thapa
thapamd@uw.edu
1
Department of Radiology, Seattle Children’s Hospital,
University of Washington, Mail Stop MA.7.220,
4800 Sand Point Way NE, Seattle, WA 98105, USA
2
Department of Orthopedic Surgery,
Seattle Children’s Hospital, University of Washington,
Seattle, WA, USA
tone abnormality, often develops over time, and most com-
monly affects the paraspinal muscles, hip flexors and adduc-
tors, hamstrings and calf musculature [2], though upper ex-
tremities are also frequently affected.
Radiographic evaluation and monitoring are important parts
of the management of these children. This review covers com-
mon skeletal abnormalities of the spine, knees and feet associ-
ated with cerebral palsy, excluding the large topic of hip abnor-
malities. Because the manifestations of cerebral palsy are fre-
quently shared across other neuromuscular disorders such as
myelomeningocele, spinal muscular atrophy, Charcot–Marie–
Tooth and the muscular dystrophies [7], an understanding of the
pathology, imaging and treatment is widely applicable.
Spine
Ideally spine radiographs should be in a standing or upright
position and acquired in similar position to prior examinations
to optimize comparability.
In contrast to the S-shape of idiopathic scoliosis, cerebral-
palsy-related neuromuscular scoliosis tends to have a broad C-
shape and is more frequently left convex [8] (Fig. 1). Scoliosis
is more common in males with cerebral palsy (in contrast to
idiopathic scoliosis), with an overall prevalence of 15–61%,
and the degree of curvature varies highly [2] but can be severe.
Curve progression can be increased by the onset of pubertal
growth spurt, deteriorating neurologic function or decreased
1588 Pediatr Radiol (2019) 49:1587–1594

Fig. 1 Extreme scoliosis. Anteroposterior supine spine radiograph in a

10-year-old girl with cerebral palsy shows extreme scoliosis. Note the C-
shape and the rotatory component, with the lumbar spine in near lateral
projection. Hip dysplasia is also present

ambulation. More severely affected cerebral palsy patients, as

measured by the GMFCS, tend to suffer from more spinal
deformity progression than those less affected because of the
degree of abnormal motor coordination [9]. Once skeletally
mature, larger curves progress more rapidly than smaller ones,
and curves tend to be more severe in non-ambulatory children. Fig. 2 Pelvic obliquity. Anteroposterior upright spine radiograph in a 17-
Although C-shape spinal curves are more frequently seen in year-old boy with cerebral palsy shows pelvic obliquity and shortening of
the distance between ribs and the relatively elevated right iliac crest
cerebral palsy, a child with enough head control might posi-
tion his or her head over her pelvis and develop a compensa-
deformity and restricted lung function and drive a decision
tory spinal curve, leading to a more S-shape curvature (Fig. 2).
for surgery. These larger curves, particularly with pelvic obliq-
Lateral spinal radiographs should be evaluated for excessive
uity, can also cause discomfort while sitting in a chair for long
thoracic kyphosis and lumbar lordosis.
periods or inability to remain in an upright position to interact
Radiographs can also measure the angle of pelvic obliquity,
with the environment, and these problems are other important
a contributor to these processes, as the angle a line across the
iliac crests makes with respect to horizontal on an upright film
(Fig. 2). Severe pelvic obliquity can be a cause of difficulty
sitting and soft-tissue pressure injury. A short distance be-
tween the lower ribs and the iliac crests or frank impaction
between these structures also denotes more severe deformity
and a potential source of pain. Bending or traction films can
help to determine the current flexibility as well as the amount
of surgical correction likely to be needed (Fig. 3), and both
curve reduction and any change in rotational component or
“unwinding” of the spine should be noted.
Young patients prior to triradiate cartilage closure and those
with surgical contraindications can be treated with soft bracing
and seating support, which can slow but not stop curve pro-
gression [10] and is less effective than the bracing commonly
used in idiopathic scoliosis. A decision for spinal fusion is
complex and multifactorial. The magnitude of the curve is
Fig. 3 Traction films. Supine neutral (a) and traction (b) anteroposterior
an important aspect because curves over 50° are likely to
spine radiographs in a 5-year-old girl (the same patient as in Fig. 1). Note
continue to progress no matter the patient’s age. Larger curves the lessening of the curve with traction (b). A mild rotatory component
might cause respiratory compromise from chest wall does not significantly change
Pediatr Radiol (2019) 49:1587–1594 1589

surgical indications. The median surgical curve magnitude

range for neuromuscular scoliosis is 70–80° [11].
For skeletally mature patients, definitive fusion prevents
further curve progression. Fusion hardware frequently extends
to the high thoracic region in its cranial extent. The caudal
extent might include pelvic fixation because this is the best
way to control pelvic obliquity, but a surgical decision might
be made to stop in the lumbar spine instead, based on curve
characteristic and clinical status [1, 8, 10, 12].
Severe scoliosis or rapidly progressive scoliosis before ap-
proaching the age of triradiate cartilage closure can require
surgical intervention and growing spinal rods might be used
[10] (Fig. 4). As with growing constructs placed in other pa-
tient populations, complications such as infection, hardware
fracture or loosening are seen, and more commonly so in this
population [10] (Fig. 5).
Fig. 5 Hardware complications. Lateral spine radiograph in a 12-year-old
Low back pain can inhibit ambulation and degrade quality boy shows a complication of hardware placement, with a fractured and
of life, and is common in children with cerebral palsy [13]. displace inferior rod
Children with cerebral palsy are also at risk for increased
lumbar lordosis (Fig. 6), leading to increased shear stress on Knee
the posterior elements of the lower lumbar spine and potential
pars defects and spondylolisthesis [2, 13]. Hamstring spasticity is associated with flexion contrac-
As a final note, non-orthopedic issues such as constipation tures, the most common knee abnormality seen in cerebral
could be present and cause pain. While radiographs cannot palsy. This leads to a characteristic “crouch knee” defor-
diagnose constipation and radiographic stool burden is not mity while standing (Fig. 7) and can cause difficulties
associated with constipation [14, 15], trends in degree of stool with sitting if fixed greater than 90°. Chronic knee flexion
burden in a child clinically diagnosed with constipation might causes over-stretching of the quadriceps muscles and knee
be a helpful guide to manage therapy. When considering the extensor mechanism, which leads to patella alta. This is
cause of pain and discomfort in a non-verbal child with cere- seen in 58–72% of children with spastic cerebral palsy
bral palsy, constipation should be ruled out prior to ascribing
the pain to scoliosis.

Fig. 6 Lumbar lordosis. Lateral standing lumbar spine radiograph in a

Fig. 4 Expandable rods. Anteroposterior upright spine radiograph in a 6- 20-year-old woman with cerebral palsy and low back pain shows
year-old girl after placement of posterior expandable growing rods exaggerated lordosis, but no current spondylolisthesis
1590 Pediatr Radiol (2019) 49:1587–1594

Fig. 7 Crouch knee deformity.

Right side (a) and posterior (b)
photographs of a 9-year-old girl
with tetraplegic cerebral palsy
with asymmetrical limb
involvement. Note the crouch
stance caused by flexion at the
hips and knees. The feet show
planovalgus, with right-greater-
than-left hindfoot and ankle
equinus with a heel lift, or toe
walk

[2]. Although there are many variations on technique to
measure patella alta, the most common is the Insall–
Salvati ratio: the craniocaudal length of the patellar tendon
to that of the patella, with normal less than 1.2–1.5 [2, 16].
Radiographs might additionally show fragmentation at the
lower patella or tibial tuberosity resembling Sinding–
Larsen–Johansson or Osgood–Schlatter disease, respec-
tively (Fig. 8).
Variable combinations of spasticity, weakness and muscle
control can lead to other alignment problems, such as genu
recurvatum from abnormal quadriceps and gastric-soleus
complex muscles [2, 17]. Genu varus or valgus might also
be seen, frequently caused by abnormal femoral version or
instability at the ankle or subtalar joints.
Foot and ankle

As many as 93% of children with cerebral palsy have foot or

Fig. 8 Lower patella fragmentation. Lateral knee radiograph in a 15-year-
old boy with cerebral palsy shows an elongated, high patella (patella alta)
with fragmentation at its inferior pole. There is mild thickening of the
patellar tendon
ankle abnormalities [18]. Numerous radiographic measure-
ments have been developed to describe foot alignment and
deformities, the most widely used based on a three-segment
(hindfoot, midfoot and forefoot) and two-column (medial and
lateral) biomechanical model, and these have been applied to
children with cerebral palsy [19, 20].
Chronic relative overactivity and spasticity of the
gastrocnemius-soleus frequently lead to hindfoot equinus
deformity (plantar flexion of the calcaneus) (Fig. 9).
Clinically this often manifests as toe walking, or heel lift
in children with spastic calf muscles (Fig. 7). Equinus can
be seen in conjunction with valgus or varus hindfoot, de-
pending on the relation of the anterior calcaneus to the
talus [2]. If the calcaneal head is positioned under the talus,
varus hindfoot results, but more commonly it is pulled
from under the talus, and valgus hindfoot is seen.
Equinovalgus is more common in children with diplegia
and quadriplegia, whereas children with hemiplegia more
Pediatr Radiol (2019) 49:1587–1594
Fig. 9 Hindfoot equinus deformity. Lateral standing foot radiograph in a
15-year-old girl with cerebral palsy shows hindfoot equinus with a
plantar-flexed anterior calcaneus and heel lift. Also note the severe
forefoot inversion as evidenced by the ladder-like arrangement of the
metatarsals
commonly have equinovarus deformity [21]. Midfoot and
forefoot cavus and planus deformities are also associated
with these alignment problems, usually equinoplanovalgus
and equinocavovarus, though other alignment combina-
tions can occur if the segments that are normally coupled
are decoupled [20]. Abnormal midfoot abduction/
adduction and pronation/supination alignment also
Fig. 10 Vertical talus. Lateral foot
radiographs while standing (a)
and in maximum plantar flexion
(b) in a 5-year-old boy with rigid
flat feet. Radiographs show a
talus in equinus position, with
anterior talus plantar-flexed, and
abnormal dorsal displacement of
the navicular, which does not
reduce with maximum
plantarflexion, consistent with a
vertical talus
Fig. 11 Oblique talus. Lateral foot radiographs with simulated standing
(a) and in maximum plantar flexion (b) in a 20-month-old boy with flat
feet. The position of the navicular must be inferred from the position of
1591
contribute to overall foot deformity, as does great toe
malalignment (e.g., hallux valgus).
Inability to dorsiflex an ankle equinus to neutral position
despite bracing and medical management are indications for
surgery [21]. Once foot or ankle realignment surgery has been
deemed necessary, a combination of tendon lengthening/trans-
ferring, osteotomies, bone grafts, and arthrodeses might be
employed [3]. Prior to orthopedic surgery, medical manage-
ment of tone with botulinum toxin and baclofen or neurosur-
gery with selective dorsal rhizotomies (or baclofen pumps) are
frequent therapies [20].
Congenital vertical talus or oblique talus can be seen in
the setting of cerebral palsy, arthrogryposis and other neu-
rologic abnormalities. This is an equinus position of the
talus with standing or simulated standing, resulting in ab-
normal talonavicular alignment, the navicular dorsally
subluxed with respect to the talar head [22]. With maximal
plantar flexion this relationship is irreducible (vertical ta-
lus; Fig. 10) or reducible (oblique talus; Fig. 11). In young
children, the navicular might not be ossified and its posi-
tion must be inferred from the position of the lateral cune-
iform and 2nd metatarsal base because these midfoot bones
would be in plane with the navicular [23].
the midfoot, which remains in line with the navicular. In contrast to the
boy in Fig. 10, with maximum plantarflexion the (unossified) navicular
reduces to a normal position at the talar head
1592 Pediatr Radiol (2019) 49:1587–1594

Fig. 12 Coleman block test.

Dorsoplantar foot radiographs in
two 9-year-old girls, each with
cerebral palsy and undergoing the
modified Coleman block test. a, b
The first girl shows hindfoot
varus with little change in
alignment between standing on
flat ground (a) and standing with
lateral foot on the block (b). c, d
The second girl shows milder
hindfoot varus with flat standing,
demonstrating superimposed
talus and calcaneus (c), which
does reduce on the Coleman
block (d). In the latter case, a less
extensive surgical correction
could be considered

Radiographic evaluation of foot alignment in the cavovarus obtained in the child’s typical standing position, followed by
foot can often be augmented by use of the modified Coleman standing with the lateral foot on a 2- to 4-cm-thick block,
block test. In this test, dorsoplantar and lateral images are allowing for the first ray and medial foot to hang off the block
Pediatr Radiol (2019) 49:1587–1594 1593

Fig. 13 Varying lateral views. Lateral radiographs illustrate different therefore the ankle must be in valgus. b Dedicated ankle radiograph
views obtained at the ankle. a Radiograph shows cavovarus hindfoot, shows normalization of this relationship and allows for better scrutiny
but also the physes of the distal tibia and fibula are at the same level, of the talar dome
which should not happen when viewing a normally aligned ankle, and

(Fig. 12). While the predictive utility of this test is debated [24,
25], if the hindfoot alignment corrects, then surgical correction
of the forefoot alone can be considered (with cuneiform
dorsiflexion osteotomy). If the hindfoot is rigid, then surgery
must include both forefoot and hindfoot (with calcaneal slide
osteotomy to take hindfoot out of varus position).
Obtaining standardized weight-bearing radiographic
views of the foot and ankle can be challenging because
of altered anatomy and physical limitations in these chil-
dren. For example, cavovarus foot alignment is frequently
seen with valgus ankle alignment, possibly as a compen-
satory mechanism to bring the extremity into a more neu-
tral overall alignment. Weight-bearing lateral foot radio-
graphs might show the physis of the fibula at or above the
level of the tibial physis. Outside of infancy (where a high
fibular physis might be normal) this relationship indicates
the image was not obtained lateral with respect to the
ankle but rather lateral with respect to the foot (Fig. 13),
and dedicated ankle radiographs should be recommended
to evaluate for ankle valgus that might require treatment,
and to better profile the talar dome. The best method to
evaluate for ankle valgus, however, is on anteroposterior
view of the ankle. The angle between a vertically oriented
line along the distal tibial shaft and a horizontally oriented
line along the talar dome should be close to 90°; 10° or
less of ankle valgus is often well tolerated (Fig. 14). In
addition, the lateral distal tibial epiphysis is asymmetrical-
ly smaller and the distal fibula appears shorter (high fib-
ular station) [26].
Conclusion
Cerebral palsy is a common condition that manifests in
n u m e r o u s w a y s o n t h e m u s c ul o s k el e t a l s y s t e m .
Recognizable patterns of malformations develop, and

Fig. 14 Evaluating for ankle

valgus. a Anteroposterior
radiography of a 10-year-old boy
with cerebral palsy demonstrates
ankle valgus. b On the same
image, the increased tibio-talar
angle is shown by lines drawn
across the top of the talar dome
and along the long axis of the
tibia, smaller lateral distal tibial
epiphysis and high fibular station
1594
imaging is valuable for monitoring, treatment planning
and follow-up. Having familiarity with and the ability to
describe these radiologic manifestations allows for better
communication with care teams and helps to make radi-
ologists valuable resources for clinical providers.
Acknowledgments We would like to thank the musculoskeletal radiolo-
gists and orthopedic surgery department at Seattle Children’s Hospital.
Compliance with ethical standards
Conflicts of interest None
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