Restoration of Heel–Toe Gait Patterns for the Prevention of Asymmetrical Hip Internal Rotation in Patients with Unilateral Spastic Cerebral Palsy

Abstract

Forward modelling has indicated hip internal rotation as a secondary physical effect to plantar flexion under load. It could therefore be of interest to focus the treatment for patients with unilateral spastic cerebral palsy on achieving a heel–toe gait pattern, to prevent development of asymmetrical hip internal rotation. The aim of this preliminary retrospective cohort investigation was to evaluate the effect of restoring heel–toe gait, through use of functional orthoses, on passive hip internal rotation. In this study, the affected foot was kept in an anatomically correct position, aligned to the leg and the gait direction. In case of gastrosoleus shortness, a heel raise was attached to compensate for the equinus and yet to provide heel–floor contact (mean equinus = −2.6 degrees of dorsiflexion). Differences in passive hip internal rotation between the two sides were clinically assessed while the hip was extended. Two groups were formed according to the achieved correction of their gait patterns through orthotic care: patients with a heel-toe gait (with anterograde rocking) who wore the orthosis typically for at least eight hours per day for at least a year, or patients with toe-walking (with retrograde rocking) in spite of wearing the orthosis who used the orthosis less in most cases. A Student’s t-test was used to compare the values of clinically assessed passive hip rotation (p < 0.05) between the groups and the effect size (Hedges’ g) was estimated. Of the 70 study participants, 56 (mean age 11.5 y, majority GMFCS 1, similar severity of pathology) achieved a heel-toe gait, while 14 remained as toe-walkers. While patients with heel–toe gait patterns showed an almost symmetrical passive hip internal rotation (difference +1.5 degrees, standard deviation 9.6 degrees), patients who kept toe-walking had an increased asymmetrical passive hip internal rotation (difference +10.4 degrees, standard deviation 7.5 degrees; p = 0.001, Hedges’s g = 0.931). Our clinical findings are in line with the indications from forward modelling that treating the biomechanical problem might prevent development of a secondary deformity. Further prospective studies are needed to verify the presented hypothesis.

Gait Deviations of the Uninvolved Limb and Their Significance in Unilateral Cerebral Palsy

“…Furthermore, particularly in the transversal plane (which underlines the relevance of transversal plane deviations for gait function and walking capability), despite distinct gait deviations at the pelvic level, the sound limb is able to compensate for excessive pelvic protraction and to maintain transversal kinematics within the range of the TD below the pelvic level and thus to ensure sufficient lever arm function [13][14][15]. In their analysis of anatomical and dynamic rotational alignment in unilateral CP, Riad et al describe comparable transversal kinematic characteristics of the uninvolved limb as found in our study [29].…”

“…Hence, many classification systems disregard coronal and transversal plane deviations, as well as compensatory adaption/strategy mechanisms of the sound limb (tertiary deviation) in unilaterally affected individuals [7,10]. However, transversal plane malalignment (particularly internal hip rotation of the involved limb) and compensatory deviations (pelvic protraction on the uninvolved side) are of importance for sagittal alignment (foot orientation), as these factors influence joint/muscle leverage (e.g., hip abductor weakness due to mal-rotation), and thus for sufficient propulsion in walking (e.g., altered plantarflexion moment due to mal-rotation) [11][12][13][14][15][16].…”

Altered Muscle Contributions are Required to Support the Stance Limb During Voluntary Toe-Walking

“…The restoration of a heel-to-toe gait pattern may improve the functionality and the gait efficiency of toe-walking patients while reducing the long-term risks associated with compensatory mechanisms ( Brunner et al, 2021 ). Several treatments aiming at restoring a heel-strike pattern are available ( Graham et al, 2016 ), ranging from conservative options, such as physical therapy ( Palmer et al, 2010 ), casting, and orthotic devices ( Totah et al, 2019 ), to the use local medication (Botulinum toxin-A) ( Strobl et al, 2015 ) and bone and soft tissue corrective surgeries ( McGinley et al, 2012 ).…”

The Management of Toe Walking in Children with Autism Spectrum Disorder: “Cast and Go”

“…Possible treatment strategies are described in the literature that include observation, physical therapy, serial casting, orthosis [ 20 ] or Achilles’ tendon (heel cord) lengthening surgery [ 21 ].…”