Crouch gait in an 8-year-old with spastic diplegia: strength, length or both?
Layla is an 8-year-old girl with bilateral spastic cerebral palsy (diplegia) born at 28 weeks, GMFCS level II, who walks independently at home and school. She has a crouch gait with about 20 degrees of knee flexion at initial contact, a popliteal angle of 50 degrees bilaterally, a Thomas test showing a 15-degree fixed flexion deformity, and ankle dorsiflexion of 5 degrees with the knee extended but 15 degrees with the knee flexed. She can jump 5 cm and cannot hop on one leg. She trips when running and has had two falls at school this term. She attends mainstream school and wants to play football at break. Her parents ask you to stretch her hamstrings hard every day to stop her getting worse, and they have been offered a 4-week intensive suit therapy programme costing OMR 900.
1. Analyse the contributors to her crouch gait and decide what to prioritise. What is your view on daily hard hamstring stretching?
Read the worked answer
Crouch is multifactorial, and treating one element will fail. Ankle dorsiflexion of 5 degrees with the knee extended but 15 degrees with the knee flexed isolates the gastrocnemius as the tight plantar flexor, not the soleus. The popliteal angle of 50 degrees and the 15-degree Thomas test indicate hamstring and hip flexor tightness that pull the knee and hip into flexion.
But length is not the whole story. She cannot hop and jumps only 5 cm - plantar flexors, hip extensors and knee extensors are weak, and the crouch may partly be a strategy to gain stability with weak push-off. The tripping and two falls point to dorsiflexion timing and balance problems as well.
Priority: strengthen hip and knee extensors and plantar flexors, improve single-leg control and heel strike, and stretch the gastrocnemius with the knee extended. Hamstring stretching can continue gently but is not the main lever.
On daily hard hamstring stretching: the evidence that aggressive stretching prevents contracture or changes gait is weak, it can be uncomfortable, and over-lengthening hamstrings in a child who already lacks push-off may worsen function. It also crowds out time that would be better spent on strengthening and practice. Explain this to the parents using her own goals - football at break - rather than dismissing their concern.
2. Prescribe a strengthening, balance and stretching programme with dose, progression and family/school integration, and state how you will monitor it.
Read the worked answer
Strength (2-3 times weekly, 2-4 sets of 8-12 with good form; add 5-10% load when 12 repetitions are easy): sit-to-stand from a low bench, step-ups of 10-15 cm, heel raises progressing from double to single leg, bridging, standing hip extension and abduction. Add low-level plyometrics when she can hop - pogo jumps, then hopping in place.
Balance and motor control: heel-toe walking, walking while carrying a beanbag, turning tasks, an obstacle course, and single-leg stance at a bench. Progress by reducing hand support and adding a cognitive task.
Length: gastrocnemius stretch with the knee straight, 30 seconds x 3, once daily; gentle hamstring stretch within comfort; consider a night resting ankle orthosis if dorsiflexion with the knee extended falls below neutral.
Family and school: a 10-minute home programme on 4 days, taught to parents with a picture sheet; graded football at break from 5 to 20 minutes with rests; a rest bench and permission to sit out when tired.
Monitoring: 10 m walk speed, 6-minute walk, video gait at 6 and 12 weeks, and a falls log. Refer for orthotic assessment if heel contact does not improve, since an ankle-foot orthosis may be more effective than stretching alone.
3. How will you counsel the family about the OMR 900 suit therapy, and what would prompt orthopaedic or gait-laboratory referral?
Read the worked answer
Suit therapy counselling: explain that the evidence for intensive suit or suit-assisted programmes is low quality; reported gains are not clearly greater than those from the same dose of intensive walking, strengthening and practice, which she would receive from an intensive block without the device. It is unlikely to harm her, but the money buys intensity, not a proven device. Present it as a family decision requiring informed consent rather than a recommendation, and state plainly that any benefit will be lost without an ongoing home and school programme afterwards. Offer an intensive block of evidence-based practice as the alternative.
Orthopaedic or gait-laboratory referral triggers: popliteal angle increasing beyond about 60 degrees; a fixed knee flexion contracture at initial contact that is worsening; ankle dorsiflexion with the knee extended falling below neutral despite stretching; a decline in walking or gross motor function not explained by growth; or a fixed equinus. Request three-dimensional gait analysis alongside orthopaedic review, because isolated tendon lengthening in a crouch gait can worsen the lever arm and function. Also refer for orthotic and seating review, and reassess at each growth spurt, since contracture risk rises then.