Clinical assessment and

treatment of lower limb

deformities in Cerebral
Palsy patients
Cerebral Palsy

static encephalopathy: a non-progressive, permanent injury

to the brain caused by damage, defectiveness, or illness. CP
can affect childhood motor development, speech, cognition,
and sensation. Although the brain injury in CP is static, the
peripheral manifestations (for example, contractures and
bone deformities) of CP are often not static.
Classification
GMFCS
Lower Limb Deformities
 HIP:
1. Mild hip subluxation to Dislcation.
2. Flexion Deformities.
3. Adduction Deformities.
4. Femoral anteversion and increase Neck-Shaft angle.
 KNEE:
1. Flexion Deformities
2. Recurvatum of the knee.
3. Valgus Knee.
4. Patella Alta.
Lower Limb Deformities

 FOOT:
1. Equinus Deformity.
2. Varus and Valgus Deformities.
3. Calcaneus Deformities.
4. Forefoot Adduction Deformities.
5. Hallux Valgus Deformities.
6. Claw Toes.
 Rotational Deformities:
May occur at multiple levels, most common internal hip
rotation followed by internal tibial torsion.
Clinical assessment

 Every patient should be approached individually.

 Developmental evaluation.
 Gait assessment.
Clinical assessment

 Observe the posture, Functional abilities and areas of

involvement.
 Muscle weakness or pain, athetosis or ataxia, scoliosis,
and bony malalignment should be noted.
 Test for spasticity—The “catch” test shows a velocity-
dependent difference in muscle tightness, in which a
quick passive motion elicits a rapid tightening of the
muscles used in walking.
 ROM of Hip, Knee, Ankle and Foot.
Clinical assessment of the Hip

 Crouched gait,scissoring, In-toeing.

 ROM.
 Rotational deformities.
 Flexion Contracture by Thomas’ test.
 Differentiate between Adduction def and pseudoadduction
def (Flexion-Internal Rotation of the hip).
 Difficult to test for subluxation and dislocation.
Clinical assessment of the Knee

 Knee Flexion deformity keep the knee from fully extending at

the end of swing phase of gait.
 Hamstring strength, spasticity, and knee contracture are
assessed with the patient prone and supine.
 The patient can be examined for medial hamstring spasticity
in the supine position.
 Rectus Femoris spasticity OR Ely’s test.
 Testing for Quadriceps strength, spasticity and contracture.
Ankle and Foot assessment

 Foot posture.
 Abnormal weight bearing areas.
 Deformities.
 ROM.
 Confusion test: for tibialis anterior.
 Tibialis posterior: assessed by tightness when hindfoot is
positioned in valgus.
 SilfverSkiold test.
Radiological assessment
 Hip assessment:
 Reimer’s index
 Acetabular index.
 Sourcil type.
 Femoral version.
 Neck-shaft angle.
 For Follow up of hip
subluxation or
dislocation which
occurs mostly at age
2-4 yrs.
Management
 Non-Surgical : consist of
Physical therapy: gait trainers, walkers, or crutches, prevention of
contracture through bracing, stretching and standing programs.
Occupational therapy.
Splinting or serial casting to reduce or prevent contractures.
Bracing.
Anti-spasticity medications: Oral centrally acting Baclofen and
Diazepam, Peripherally acting Dantrolene.
Intrathecal Baclofen
Botulinum toxin (BTX-A).
Management
Surgical:
 Indications: When deformities decrease function, cause pain,
or interfere with ADLs, and significant fixed contractures
exist.
 Use of single-event multi-level surgery is advised.
 Operative treatment divided into:
1. Correct static or dynamic def.
2. Balance muscle power.
3. Reduce spasticity.
4. Stabilize uncontrollable joints.
Management

 Ranges from:
1. Lengthening of muscle-tendon procedures. Flexible static and dynamic
def.
2. Capsulotomies.
3. Osteotomies  Rigid deformities.
4. Neurectomy by mechanical or chemical methods.
5. Arthrodesis  Foot. Pathological changes to joint
as a result of long-standing
6. Resection Arthroplasties  Hip. def.

7. Joint Replacement in carefully selected patients

Selective Dorsal Rhizotomy (SDR)

 Selectively severing Dorsal nerve rootlets between L1-S1.

 Indications:
1. Ambulatory patients.
2. Age 3-8 yrs with Diplegic CP.
3. Good selective motor control.
4. Minimal cognitive impairment.
 Complications: Scoliosis, Spondylolisthesis, Bowel/Bladder
incontinence, Dysesthesia, and increasing weakness.
Hip Subluxation and Dislocations
 Hip at Risk:
1. Clinically: Flexion contracture > 20°, Abduction < 30°.
2. Radiographically: Increased Neck-Shaft angle and Femoral
anteversion, acetabular dysplasia and abnormal Reimer’s
index.
 Treatment:
1. Aggressive physical therapy and Abduction Splinting.
2. Tenotomy of adductor longus, anterior half of adductor
brevis and gracilis followed by physical therapy and night
abduction splints.
Hip Subluxation and Dislocations

3. Hip subluxation:
Soft tissue procedures in younger children.
Or in addition to soft tissue procedures Proximal femoral
osteotomy with or without pelvic osteotomy.
4. Hip Dislocation:
Relocation procedures, resection arthroplasty (Castle), hip
arthrodesis, THR.
 Relocation procedures criteria, Unilateral; moderately
mature intellectually; sitting potential if not walking;
minimal or corrected pelvic obliquity. (Drummond et al.)
Hip Subluxation and Dislocations

 THR criteria:
Intelligent, Independent, ambulator with mild soft tissue
contractures.
 Increasing anteversion and inclination and use of
cemented femur stem recommended.
Hip Flexion Deformities

 Determine whether increased hip flexion is the primary

deformity or is secondary to knee, ankle contractures.
 From 15-30º psoas lengthening through intramuscular
recession.
 More than 30º  more extensive release of Sartorius,
rectus femoris, tensor fascia lata, anterior fibers of
Gluteus medius and minimus in addition to iliopsoas.
Hip Adduction Deformities

 Mild contractures  adductor tenotomy.

 Sever contractures  release of gracilis and anterior half
of adductor brevis.
 Followed by program of physical therapy and abduction
bracing.
 Should be done bilaterally to prevent a windswept pelvis.
Knee flexion deformity (Crouched Gait)

 Indications of hamstring lengthening:

1. SLR < 70º. Or
2. Popliteal angle < 135º.
3. Absence of significant bony deformity.

 Begin with Z-plasty of gracilis and semitendinosus,

fractional lengthening of semimembranosus.
 If further correction is desired  fractional lengthening of
Biceps femoris.
Knee flexion deformity

 Combined Hamstring lengthening and posterior capsular

release with or without quadriceps shortening.
 Used in significant fixed knee contractures.
 Distal Femoral extension Osteotomy: stiff rigid def.
Knee recurvatum
 If Rectus femoris is tight  Lengthening or
release in non-ambulators, transferred
posteriorly in ambulators
 Ankle equinus  correction either
operatively or non-operatively.
 Excessive Iatrogenic Hamstring weakness 
Difficult to treat.
 Significant recurvatum  Bilateral long-leg
braces with pelvic band and knee locked in
20º flexion and ankle stops at 5º dorsiflexion.
 Flexion osteotomy is not advised.
Knee Valgus

 Hip Adduction and internal rotation  Correction.

 Tight iliotibial band  Resection.
Rotational Deformities (In-toeing Gait)

 Most common cause include internal femoral rotation

followed by internal tibial torsion.
 Derotational Osteotomy done at the same time of soft
tissue procedures.
Equinus deformities
 First to start physical therapy stretching and bracing for
surgical correction to be deferred for fixed deformities or for
child beyond 6 yrs of age.
 Options include:
1. Gastrocnemius recession.
2. Soleus recession.
3. Open Achilles lengthening to be restored for sever deformities
that do not correct with recession.
 Indications: ankle can’t be brought to neutral in ambulators,
difficulty with foot hygiene, foot wear or standing position in
non-ambulators.
Equinovarus Deformities

 Split transfer of either Tibialis anterior or posterior according to the

cause of Varus deformity.
 For flexible deformity.
 For Rigid deformity soft tissue procedures in addition to calcaneal
(Dwyer) osteotomy.
Equinovalgus Deformities

 Non-surgical:
 Bracing with supra-malleolar orthosis or AFO, Physical therapy and
BTX-A injections.
 Surgical:
 Calcaneal osteotomy
Moderate deformity: Calcaneal lengthening with Peroneus Brevis
lengthening.
Sever deformity: medial calcaneal sliding osteotomy, medial closing
wedge osteotomy Of the cuneiform, opening wedge osteotomy of
cuboid, and Achilles tendon lengthening.
Sever of Rigid: Subtalar arthrodesis.
Planovalgus deformities

 Non-surgical: Supramalleolar Orthosis or AFO

 Surgical:
Moderate to severe deformities: calcaneal lengthening
osteotomy, peroneus brevis lengthening, with tightening of
medial TN capsule and/or PTT.
Or Medial calcaneal sliding osteotomy, plantar flexion closing
wedge osteotomy of the cuneiform, opening wedge
osteotomy of the cuboid bone.

Sever or Rigid deformities: Subtalar Arthrodesis.

Calcaneus deformity

 Rare mostly due to overlengthening or repeated

lengthening of Achilles tendon.

Transfer of TA tendon or peroneal tendons to calcaneus.

With poor success.
Forefoot Adduction Deformity

 Caused by tight Abductor Hallucis

 Flexible: resection of a segment of muscle and tendon.
 Rigid or difficulty in shoe-wear: MT osteotomy and K-wire
fixation, OR medial column opening wedge osteotomy,
lateral column closed wedge osteotomy.
Hallux Valgus deformity

 Toe straps added to AFO or night-time splint.

 Sever deformity: Fusion of 1st MTP.
 If Valgus interphalangeus is present: Proximal phalanx
(Akin) osteotomy.
 No role for soft tissue balancing procedures.