Atypical Gait and Orthotics CSV Flashcards
What are the prerequisites of normal gait?
The prerequisites of normal gait include:
- Stability in Stance: Stability in stance ensures balance during weight-bearing
- Clearance in Swing: Clearance in swing prevents tripping
- Pre-Positioning of the Foot in Terminal Swing: Pre-positioning allows proper foot placement for the next step
- Adequate Step Length: Adequate step length ensures efficient stride
- Energy Conservation: Energy conservation minimizes fatigue during walking
What are common causes of gait deviations in pediatrics?
Gait deviations can result from:
- impaired motor control
- spasticity
- limited range of motion (ROM)
- decreased strength
- poor sensation
- bony deformities
- These factors disrupt the biomechanical and neuromuscular systems required for normal gait, leading to inefficient or abnormal walking patterns.
What are the three most common causes of in-toeing in pediatrics?
Femoral anteversion:
- Most common in children aged 3–10 years
- Characterized by feet pointing forward and patella turning medially.
- Typically resolves by age 8
Internal Tibial Torsion:
- Common in children aged 1–3 years
- Characterized by patella facing forward while the feet turn inward.
- Typically resolves by age 6
Metatarsus Adductus:
- Found in children under 1 year
- Evolving inward curvature of the foot
- These conditions are developmental and often self-correcting as the musculoskeletal system matures.
What are common characteristics of out-toeing in pediatrics?
Out-toeing can result from:
- External tibial torsion (common in older children or those with spina bifida).
- Planovalgus/Pes Planus (flatfoot): Often seen in early walkers and associated with calcaneal valgus and forefoot abduction.
- Femoral retroversion (common in obese children): Characterized by excessive hip external rotation and decreased hip internal rotation.
- Each condition affects alignment and joint mechanics, potentially increasing the risk of future complications like SCFE or degenerative arthritis.
What is limb length discrepancy (LLD), and what are 5 common causes?
Limb length discrepancy (LLD) occurs when one leg is shorter than the other, caused by
(1) Trauma
- Growth plate injuries
(2) Congenital conditions
- Hemihypertrophy
- Tib/fib hemimelia
- DDH
(3) Neuromuscular disorders
- CP
- Poliomyelitis
(4) Genetic syndromes
(5) Acquired conditions
- SCFE
- Tumors
- Benign bone cysts
- LLD impacts gait symmetry, leading to compensations like toe-walking on the shorter limb or circumduction on the longer limb.
What are compensatory patterns seen with limb length discrepancy?
short vs longer
Shortened Limb:
- Persistent plantarflexion (toe-walking)
- Supination to increase WB through the lateral border of the foot
Longer Limb:
- Circumduction during swing
- Pronation of the foot
- Excessive hip and/or knee flexion to accommodate
- These patterns attempt to equalize leg length during movement but may increase joint stress over time.
How is limb length discrepancy assessed?
Bony Assessment
- True leg length: ASIS to medial malleolus
- Galeazzi sign: femur or tibia
- Calcaneal eversion: Normal: 8 minus age
Muscular Assessment:
- Hip: flexion or adduction limitations
- Knee: Flexion or hyperextension
- Ankle: Limited dorsiflexion, Excessive supination or pronation
- Accurate assessment ensures targeted interventions to minimize compensations and prevent joint issues.
What are the causes, characteristics, and complications of idiopathic toe-walking (ITW)?
Idiopathic Toe-Walking (ITW) or “Bouncy” gait is characterized by:
- Sustained plantarflexion without heel strike, often appearing after age 2 without medical causes.
- Common gait features include
- Absent heel strike: foot flat or contact at metatarsal heads
- Sustained plantar flexion through stance OR hyperextended knees/forefoot pronation to obtain foot flat
- Decreased hip extension and push off at terminal stance
- Long-term ITW can lead to complications like:
- tight plantarflexors
- decreased ROM
- inefficient gait patterns
What treatments are recommended for idiopathic toe-walking?
Treatments include:
- Restore muscle balance (shortened muscles = over recruitment / lengthened muscles = under active)
- motor retraining (balance, functional movements)
- NMES
- orthotics
- stretching (contract-relax)
- serial casting
- strengthening exercises (dorsiflexors, glutes, abdominals)
- These interventions target muscle imbalances, restore normal gait patterns, and prevent long-term complications.
What are common gait deviations in children with cerebral palsy (CP)?
Common deviations include:
- Hemiplegic (weakness or paralysis on one side of the body)
- Equinus (toe-walking with plantarflexion)
- Planovalgus (collapsed arch)
- Crouch gait (excessive hip/knee flexion)
- Jump knee
- Stiff knee gait (limited knee motion during swing)
- These deviations arise from spasticity, muscle imbalances, or bony deformities and impact function and efficiency.
What is equinus gait in children with CP, and how is it treated?
Equinus gait: Abnormal foot position relative to the tibia
- Involves sustained plantarflexion during stance and toe-walking, often with knee hyperextension.
Treatment:
- Hinged or solid AFOs, and exercises targeting gastroc-soleus strengthening and flexibility.
- Interventions reduce spasticity and restore functional alignment during gait.
What are the benefits of orthotics in pediatric gait management?
Orthotics improve function, support development, enhance ROM, provide proprioceptive feedback, and prevent deformity progression.
- By simulating muscle actions or stabilizing joints, orthotics optimize movement patterns and reduce energy expenditure during gait.
What is planovalgus gait, and how does it present in children with CP?
Planovalgus: Equinus of the hindfoot and pronation of the forefoot and midfoot.
- Gastroc-soleus weakness
- Collapse medially (reduce stability and efficiency in gait)
- Unable to push off at terminal stance
- Compensated by:
- Calcaneal/hindfoot valgus, forefoot abduction, and medial arch collapse. It is commonly associated with crouch gait and results from gastroc-soleus weakness and overactive hamstrings.
- PLANOVALGUS/PES PLANUS (flatfoot) - think out-toeing
What is crouch gait, and what are its characteristics?
Crouch gait is characterized by excessive hip flexion, knee flexion, and ankle dorsiflexion.
- It is common in spastic diplegia and quadriplegia
- Short stride length, poor efficiency
- Due to:
- Overactive hamstrings in stance,
- Weak quads
- Weak plantar flexor
- This gait pattern increases energy expenditure and places stress on the joints
- Often requiring orthotic support (Solid ankle AFO or Ground reaction AFO)
What is stiff knee gait, and what causes it in children with CP?
Stiff knee gait is characterized by increased knee extension throughout swing.
- Often caused by overactive rectus
- Compensations:
- Hip circumduction
- Vaulting (plantar flexion with abduction during swing)
- Post pelvic tilt or external rotation to prevent toe drag
- The reduced knee flexion impairs foot clearance and swing efficiency, leading to compensatory strategies like hip circumduction.
What are the characteristics of toe-walking in children with CP?
Toe-walking in CP involves:
- plantarflexion throughout stance
- knee hyperextension in mid-late stance
- possible knee pain in adolescence
- This pattern is often due to spasticity in the gastroc-soleus, resulting in inefficient gait mechanics and increased joint stress.
What is recurvatum gait, and how is it managed?
Recurvatum gait is characterized by knee hyperextension during stance due to gastroc-soleus spasticity or weakness.
Management: AFOs set in 3-5 degrees of dorsiflexion to prevent hyperextension and promote proper alignment.
- Preventing knee hyperextension reduces stress on the posterior knee structures and improves gait mechanics.
Why are orthotics commonly used in pediatric gait management?
- Orthotics address primary impairments like spasticity, weakness, and instability.
- They simulate muscle function, improve alignment, and provide stability during gait.
- By enhancing function and supporting development, orthotics promote mobility and reduce energy expenditure.
What is orthotic tuning, and why is it important?
- Orthotic tuning is the process of fine adjustments to the AFO to optimize its performance in gait.
- It involves analyzing kinematics and kinetics to align the device with the patient’s biomechanics.
- Proper tuning ensures the orthosis meets functional goals, such as stability, efficiency, and comfort.
What are solid ankle AFOs, and when are they used?
Solid ankle AFOs are used for moderate to severe hypertonia, distal stability, and gait control.
- They provide maximum support by restricting ankle motion, improving knee stability, and preventing deformities in children with spasticity or weakness.
What are posterior leaf spring AFOs, and what conditions are they used for?
Posterior leaf spring AFOs assist with dorsiflexion during swing and manage foot drop.
- By allowing some ankle motion, they support mild foot drop while promoting a more natural gait pattern.
What are ground reaction AFOs, and when are they indicated?
Ground reaction AFOs are used for crouch gait, weak quads, or lower-level paraplegia.
They provide stability by controlling knee flexion and improving push-off.
- These AFOs promote energy-efficient gait by leveraging ground reaction forces to support weak muscles.
What are articulating ankle AFOs, and what are their key features?
Articulating AFOs allow controlled ankle motion with adjustable joints for dorsiflexion assist or plantarflexion resistance.
They are used for mild foot drop, genu recurvatum, or moderate medial-lateral instability.
- These orthoses support dynamic movements while maintaining joint stability, improving function in ambulatory children.
What are the benefits of custom orthoses for pediatric patients?
Custom orthoses ensure proper anatomical alignment, accommodate deformities, and meet the unique needs of growing children.
- Customization optimizes fit and function, addressing individual impairments and activity demands while promoting comfort and adherence.
What is the process for creating custom orthoses?
The process includes evaluation and casting, fabrication, fitting and delivery, and tuning the orthosis.
- This ensures that the orthosis aligns with the patient’s biomechanics, supports development, and optimizes performance during gait.
What are derotation straps, and what are they used for?
Derotation straps are external supports used to control excessive internal or external rotation of the lower extremities.
- They provide stability and alignment during gait, particularly in children with rotational deformities or spasticity.
What are supramalleolar orthoses (SMOs), and when are they indicated?
Supramalleolar Orthoses (SMOs) are used for moderate to severe pronation, low tone, or delayed walkers.
- They provide medial-lateral stability while allowing for functional mobility, ideal for children with flatfoot or mild neuromuscular impairments.
What are stretching splints, and how are they used in pediatric orthotics?
Stretching splints are worn overnight or during rest to maintain muscle length and improve ROM.
- They reduce contractures and spasticity in conditions like CP, promoting better joint alignment and function.
What are the key differences between pediatric and adult orthotic management?
Pediatric orthotic management considers growth, higher activity levels, and developmental needs, requiring a multidisciplinary approach.
- Children’s changing anatomy and functional demands necessitate frequent adjustments to ensure optimal outcomes.
What are gait plates, and what is their purpose?
Gait plates are orthotic devices that encourage proper foot alignment and function during gait.
- They are often used in children with toe-walking or excessive pronation to correct abnormal mechanics and improve efficiency.
What are Theratogs, and how are they used in pediatric gait training?
Theratogs are wearable systems designed to provide postural and sensory feedback, supporting improved alignment and motor control.
- They are especially beneficial for children with neuromuscular disorders, enhancing proprioception and functional movement patterns.
What are the long-term complications of untreated idiopathic toe-walking (ITW)?
Complications include tight plantarflexors, decreased ankle ROM, foot deformities, knee pain, and inefficient gait patterns.
- Early intervention prevents these issues and promotes normal gait development.
What role does neurology play in evaluating idiopathic toe-walking?
Neurological evaluation identifies red flags like tethered cord syndrome, hereditary spastic paraplegia, or CP that could underlie toe-walking.
- This ensures appropriate diagnosis and treatment, ruling out serious neurological conditions.
What are some surgical options for managing idiopathic toe-walking?
Surgical lengthening of the Achilles tendon or gastrocnemius may be performed in severe cases to improve ROM and alignment.
- Surgery is a last resort when conservative treatments fail, addressing persistent contractures or deformities.
What are Cascade DAFO orthotics, and when are they used?
Cascade DAFOs are dynamic AFOs designed for children with mild to moderate spasticity, weakness, or pronation issues.
- These flexible orthotics promote active movement while providing necessary support and alignment.
What resources are available for selecting pediatric orthotics?
Resources include manufacturers like Surestep, Cascade DAFO, and Kid Sole, as well as clinical guidelines from organizations like APTA.
- These resources provide evidence-based recommendations and product options to match individual patient needs.
What are the characteristics of hemiplegic gait in children with CP?
Hemiplegic gait presents in progressive patterns:
(1) foot drop during swing with normal plantarflexion;
(2) sustained plantarflexion and knee hyperextension during stance;
(3) limited knee movement in swing; and
(4) hip flexor and adductor tightness reducing hip extension.
- These patterns result from spasticity and weakness, requiring tailored interventions like orthotics and therapy.
What is jump knee gait, and what causes it in children with CP?
Jump knee gait is characterized by excessive knee extension during swing due to overactive rectus femoris.
- The compensatory pattern involves vaulting or hip circumduction to clear the foot, often necessitating orthotic or therapeutic intervention.
What is the difference between idiopathic toe-walking and spastic diplegic gait?
Idiopathic toe-walking typically lacks an underlying neurological condition
Spastic diplegic gait involves abnormal tone, spasticity, and ROM limitations.
- Differentiation guides appropriate interventions, with idiopathic cases often treated conservatively and spastic diplegia requiring multidisciplinary care.
What are unique features of SWASH orthoses?
SWASH (Standing, Walking, and Sitting Hip orthoses) provide hip stability by limiting excessive abduction or adduction during movement.
- They are particularly effective for children with spasticity or at risk of hip dislocations.
How do ankle-foot orthoses (AFOs) differ in their functions?
Solid AFOs: Provide maximum stability and restrict motion.
Articulating AFOs: Allow controlled motion with adjustable stops.
Posterior Leaf Spring AFOs: Assist with dorsiflexion during swing.
Ground Reaction AFOs: Control knee flexion in crouch gait.
- The choice depends on the child’s specific gait deviations, strength, and stability needs.
What is the role of NMES in treating idiopathic toe-walking?
Neuromuscular electrical stimulation (NMES) strengthens weakened muscles (e.g., dorsiflexors) and enhances neuromuscular control during gait.
- NMES complements other interventions by targeting specific impairments contributing to toe-walking.
What are the clinical benefits of kinesiotaping in gait management?
Kinesiotaping provides proprioceptive feedback, supports weak muscles, and reduces spasticity.
- It is a non-invasive adjunct to improve alignment and movement quality during gait training.
What are some key considerations for fitting pediatric orthoses?
Consider growth potential, activity level, comfort, and compatibility with footwear.
- Proper fitting ensures optimal function, adherence, and adaptability to the child’s changing needs.
What types of orthotic devices are recommended for children with crouch gait?
Ground Reaction AFOs (GRAFOs) and solid ankle AFOs are recommended.
- These devices support knee extension and stability, reducing the energy cost of crouch gait.
What is the importance of energy conservation in pediatric gait?
Energy conservation minimizes fatigue, allowing children to participate more in functional activities and play.
- Gait deviations that increase energy expenditure reduce endurance and overall mobility, emphasizing the need for efficient interventions.
What is the Galeazzi sign, and how is it used in limb length discrepancy assessment?
The Galeazzi sign involves comparing knee heights in a supine position to detect tibia or femur shortening.
- This quick assessment identifies discrepancies that may affect gait and posture.
Why is a multidisciplinary approach important in pediatric orthotic management?
A multidisciplinary approach ensures comprehensive care, addressing musculoskeletal, neurological, and developmental needs.
- Collaboration among physical therapists, orthotists, and physicians optimizes outcomes for complex gait deviations.
What are the long-term risks of femoral retroversion in children?
Femoral retroversion, characterized by excessive external rotation and decreased internal rotation of the hip, increases the risk of SCFE (slipped capital femoral epiphysis), degenerative arthritis, and stress fractures.
- Early identification and management help reduce the likelihood of joint damage and long-term complications.
What are common sensory-based treatments for idiopathic toe-walking?
Sensory-based treatments often include desensitization techniques, proprioceptive input, and sensory integration therapy.
- These approaches address underlying sensory processing deficits that may contribute to atypical gait patterns.
How does tethered cord syndrome affect gait?
Tethered cord syndrome can cause lower extremity weakness, spasticity, and sensory changes, leading to gait deviations such as toe-walking or crouch gait.
- Early recognition and intervention prevent further neurological complications and improve functional outcomes.
What are key features of Charcot-Marie-Tooth disease that affect gait?
Charcot-Marie-Tooth disease often results in foot drop, steppage gait, and high arches (pes cavus) due to progressive peripheral neuropathy.
- Orthotic support, such as AFOs, can improve gait efficiency and prevent secondary complications.
What are the key steps in stretching programs for children with gait deviations?
Stretching programs focus on increasing ROM through contract-relax techniques, dynamic stretches, and caregiver-assisted stretching (e.g., hamstrings, adductors, dorsiflexors).
- Regular stretching prevents contractures and maintains joint flexibility, supporting functional mobility.
What is the significance of knee pain in adolescents with CP-related toe-walking?
Knee pain often results from prolonged hyperextension during mid-late stance, placing excessive stress on posterior knee structures.
- Addressing spasticity and providing proper orthotic support reduce pain and protect joint integrity.
What are Cascade DAFO Jump Start Bunny and Kangaroo orthotics designed for?
These orthotics are designed for children with mild to moderate spasticity or pronation issues, promoting functional mobility while offering lightweight support.
- They combine flexibility with stability to encourage natural movement patterns.
What is the role of proprioceptive feedback in gait management?
Proprioceptive feedback improves body awareness, alignment, and motor control, enhancing gait efficiency and stability.
- Interventions like Theratogs and kinesiotaping provide sensory input to guide proper movement patterns.
What is the function of a WalkAide system in pediatric gait training?
The WalkAide system provides functional electrical stimulation to the dorsiflexors during swing phase, correcting foot drop.
- It restores a more natural gait pattern by activating muscles at appropriate times during the gait cycle.
How does calcaneal eversion change with age, and why is this significant?
Calcaneal eversion typically decreases by one degree for each year of age until neutral alignment is achieved.
- Monitoring this progression ensures that flatfoot or pronation issues are addressed before they affect gait mechanics.
Why is surgical intervention rarely the first choice in pediatric gait management?
Surgery is avoided initially to prioritize less invasive treatments like orthotics, therapy, and NMES.
- Conservative management supports growth and minimizes risks, reserving surgery for severe, persistent cases.
What is the importance of patient and caregiver education in pediatric gait management?
Education ensures that caregivers understand how to support therapeutic interventions, use orthotics correctly, and perform home exercises.
- Empowered caregivers play a vital role in achieving long-term functional improvements for the child.
