This Article Full Text Full Text (PDF) Letters to the Editor: Submit a response Alert me when this article is cited Alert me when Letters to the Editor are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baddar, A. Articles by Abel, M. F. Search for Related Content PubMed PubMed Citation Articles by Baddar, A. Articles by Abel, M. F. Social Bookmarking                   What's this?

Ankle and Knee Coupling in Patients with Spastic Diplegia: Effects of Gastrocnemius-Soleus Lengthening

Investigation performed at the Motion Analysis and Motor Performance Laboratory, Kluge Children's Rehabilitation Center and Research Institute, University of Virginia, Charlottesville, Virginia

Adrian Baddar, MD
Kevin Granata, PhD
David V. Carmines, PhD
John S. Blanco, MD
Department of Orthopaedic Surgery, P.O. Box 800159, University of Virginia, Charlottesville, VA 22908

Diane L. Damiano, PT, PhD
Human Performance Laboratory, Barnes Jewish Hospital, 4555 Forest Park Parkway, St. Louis, MO 63108

Mark F. Abel, MD
Kluge Children's Rehabilitation Center and Research Institute, 2270 Ivy Road, Charlottesville, VA 22903

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Orthopaedic Research and Education Fund. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Empirical observations of subjects with an equinus gait have suggested that there is coupled motion between the ankle and knee such that, during single-limb stance, the ankle moves into equinus as the knee extends. Since the gastrocnemius-soleus muscle-tendon unit spans both joints, we hypothesized that this muscle-tendon unit may be responsible for the coupling and that lengthening of the gastrocnemius-soleus muscle alone would result in greater ankle dorsiflexion as well as greater knee extension in single-limb stance, effectively uncoupling these joints. The concept that gastrocnemius-soleus lengthening may promote knee extension is counter to the popular notion that crouch gait may result if the hamstrings are not lengthened concomitantly.

Methods: A retrospective review identified thirty-four subjects with specific kinematic characteristics of equinus gait, and their gait was compared with that of normal children. Of the thirty-four subjects, eleven (twenty-two limbs) subsequently underwent isolated midcalf lengthening of the gastrocnemius and soleus muscles with use of a recession technique. Gait analysis including joint kinematics and joint kinetics, electromyography, and physical examination were performed to test the hypothesis.

Results: We found that, unlike the normal subjects, the patients with an equinus gait pattern had a positive correlation (r = 0.7) between ankle and knee motion during single-limb stance. As hypothesized, ankle plantar flexion occurred while the knee moved into extension during single-limb stance. Calculations of the lengths of the gastrocnemius-soleus muscle-tendon units showed them to be short throughout the gait cycle (p < 0.0001). After gastrocnemius-soleus recession, peak ankle dorsiflexion (p < 0.001) and peak ankle power (p < 0.001) shifted to occur later in stance than they did in the preoperative gait cycle. Furthermore, the magnitude of peak power increased (p < 0.001) in late stance despite the added length of the gastrocnemius-soleus muscle-tendon unit. The electromyographic amplitude of the gastrocnemius-soleus was reduced during loading (p < 0.02), and this finding, together with the kinetic changes, suggested that muscle tension was reduced. Changes at the knee were less pronounced but included greater knee extension at foot contact (p < 0.01). No increase in the knee flexion angle or extension moment occurred in midstance after the surgery.

Conclusions: Patients with an equinus gait pattern function with a shortened gastrocnemius-soleus muscle-tendon unit, and this results in coupled motion between the ankle and knee during single-limb stance. Lengthening, with use of a recession technique, shifted ankle power generation and dorsiflexion to a later time in stance with no tendency to increase midstance knee flexion. Knee extension did increase at foot contact, but excessive midstance knee flexion persisted and was likely due to concomitant contracture of the hamstrings.

CiteULike    Connotea    Del.icio.us    Facebook    Technorati    Twitter    What's this?

This article has been cited by other articles:

				M. S. Kocher and J. F. Sarwark What's New in Pediatric Orthopaedics J. Bone Joint Surg. Am., June 1, 2004; 86(6): 1337 - 1346. [Full Text] [PDF]

Stanford University Libraries' HighWire Press (TM) assists in the publication of JBJS Online.
Copyright © 2002 by The Journal of Bone and Joint Surgery, Inc. Online ISSN: 1535-1386.
The Journal of Bone and Joint Surgery®, JBJS®, JB&JS®, and eJBJS® are registered in the U.S. Patent and Trademark Office.