 |
The orthotic management of crouch gait patterns from tight hamstrings is a subject of great debate among orthotists and rehab clinicians. The key to managing crouch gait is understanding that there is more to it than treatments that center around the question of what to do at the ankle to control the knee.
Do you fix the ankle, or do you accommodate and allow motion?
Hamstring tightness, or their lack of range of motion (ROM), is what brings about this question or dilemma. As clinicians, we have a real opportunity to make a difference here. For example, let's take a kiddo with spastic cerebral palsy who has a gait pattern of 30 degrees of crouched or flexed knees and a plantigrade foot at 15 degrees of dorsiflexion. If we lock motion out at the ankle and try to give a knee-extension moment, then, because of the lack of range at the knee, we will simply be moving the patient's center of gravity (COG) posterior of the base of support (BOS). The knees do not straighten or have the range to accept the extension moment forces, so the resulting gait pattern becomes compensatory because the patient will lean forward to get the COG back in the BOS and will ambulate on his or her toes. We have thus made walking worse and more difficult. So what do we do? Do we accommodate by simply allowing the crouch pattern? This allows the patient to ambulate, but as the child grows, the hamstrings will tend to get tighter, forcing the legs closer to the ground as the bones elongate on already shortened tendons.
Rise Against the Wind
Winston Churchill once said, "Kites rise highest against the wind, not with it." As practitioners, let's look at the knees and address or fight against the increasing tightness and decreased ROM first.
Let's build a foundation. The key is increasing ROM. We can use static progressive options or, with the rise in spasticity-management clinics, use dynamic splinting as well. Fighting against hamstring tightness allows more options for developing ambulation protocols. We can now use AFOs set in dorsiflexion with the goal being a progressive correction toward the 90-degree angle as the ROM at the knee is increased. There is even a design available that provides dorsiflexion resistance to allow the crouched position but resist it. The resistance can be adjusted as the ROM increases.The take-home message here is that we need to tackle the issue head on, and the issue at hand is the aggressive management of the tightness at the knee that can lead to a better and more successful outcome for ankle and knee position. The key is that the patient can maintain a foot-flat plantigrade position in stance and therefore be stable while he or she is transitioned with increased ROM at the knees and then incrementally changed in ambulation. Compliance increases as well because as the ROM increases, so does the patient's height. The knees get straighter, allowing the patient to stand at normal height rather than creeping closer and closer to the ground from increased tightness. Generally speaking, this will result in heightened self-confidence, which, in turn, will result in increased patient compliance.
Why is this issue so important? Besides the deformational forces applied to the developing joints in a crouched ambulatory gait pattern, simply stand up right now with this article in your hand and walk across the room in a crouched-knee pattern. How far can you go before your quadriceps start to burn in agony? How long can you stand in this position before pain sets in? Napoleon Bonaparte once said, "Ability is of little account without opportunity." As clinicians, let's give these patients the opportunity to ambulate farther and more efficiently with knees that are in the best possible position.
Keith M. Smith CO, LO, FAAOP, is the president of the American Academy of Orthotists and Prosthetists (the Academy). He practices at Orthotic & Prosthetic Lab, St. Louis, Missouri, where he specializes in the care of patients with neuropathic and orthopedic disorders. He can be reached at
