ORIGINAL ARTICLE
Management of Severe Crouch Gait in
Children and Adolescents With Cerebral Palsy
Benjamin Joseph, MCh Orth, MD, Kishore Reddy, MS Orth, Renjit A. Varghese, MS Orth,
Hitesh Shah, MS Orth, and Siddesh Nandi Doddabasappa, MS Orth
Background: Crouch gait in cerebral palsy is associated with
spasticity and contracture of the hamstrings and weakness of the
extensors of the hip and knee and ankle plantar flexors.
Different treatment options have been described in the literature
to deal with this difficult problem. We devised a different
protocol of treatment aimed at correction of the flexion
deformity of the knee, weakening of the hamstrings, and
augmenting the power of the knee and hip extension, which
we used on 17 children with severe crouch.
Methods: This surgery, performed in 2 stages, entailed short-
ening of the femur, plication of the patellar tendon, transfer of
the semitendinous to the back of the femur, and fractional
lengthening of the other hamstrings. The degree of fixed
deformity, the popliteal angle, quadriceps power, range of knee
motion, ambulatory status and the efficiency of gait, and the
position of the patella were evaluated before surgery and again
after a minimum 2-year follow-up.
Results: The gait improved and the power of the quadriceps and
the range of knee motion increased. The flexion deformity and
popliteal angle decreased significantly. Patella alta was corrected
and all fragmentation of the tibial tuberosity and fractures of the
patella healed. The Functional Mobility Scores and the ambula-
tory capacity increased in all the children. There was no evidence
of damage to the sciatic nerve in any patient.
Conclusions: The method of treatment of severe crouch gait
outlined in this study seems to be an effective and safe method of
dealing with this difficult problem.
Study Design: Level of evidence: IV.
Key Words: cerebral palsy, crouch gait, patella alta, femoral
shortening
(J Pediatr Orthop 2010;30:832–839)
T he various abnormalities noted in children with long-
standing crouch gait because of cerebral palsy include
spasticity of the hamstrings, altered lengths of the
hamstrings and quadriceps muscles,1 and weakness of
From the Paediatric Orthopaedic Service, Kasturba Medical College,
Manipal, Karnataka State, India.
None of the authors received financial support for this study.
Reprints: Benjamin Joseph, MCh Orth, MD, Department of Ortho-
paedics, Kasturba Medical College, Manipal 576 104, Karnataka,
India. E-mail: bjosephortho@yahoo.co.in.
Copyright r 2010 by Lippincott Williams & Wilkins
832 | www.pedorthopaedics.com
the hip and knee extensors and ankle plantar flexors.2 In
addition, joint contracture and adaptive changes, such as
patella alta3 have been reported to be frequently seen in
these children. To improve the gait pattern in children
with severe crouch, all these issues need to be addressed
and it has been suggested that a combination of soft tissue
and bone surgery followed by bracing may be required.4
We treated 17 children and adolescents with severe
crouch gait because of cerebral palsy with a combination
of procedures specifically aimed at: (1) correction of the
flexion deformity of the knee, (2) reduction in the power
of the hamstrings, and (3) augmenting the power of knee
and hip extension. We report the results of our interven-
tion in these patients who have all been followed for over
a minimum period of 2 years.
METHODS
Ambulant children with spastic cerebral palsy and a
crouch gait, seen at a single center, since 2002, were
identified. Seventeen children more than the age of 10 years
who met the following criteria were included in this study:
knee flexion greater than 30 degrees throughout the gait
cycle, fixed flexion deformity of the knee of any magnitude,
weakness of knee extension with patella alta and an
extensor lag, evident contracture of the hamstring muscles,
and who had had no earlier surgery either on the knee or on
the calf.
The age of the children ranged between 10 and 17
years (mean: 12.47 y). Fourteen children had not had any
surgery before, 3 children had undergone adductor releases,
and none had undergone lengthening of the gastroc-soleus.
Fifteen children had a diplegic pattern of involvement
whereas 2 children had a triplegic pattern of involvement.
Ten of the children were girls, whereas 7 were boys.
We had no access to instrumented gait analysis and
the decision to operate, and the preoperative and post-
operative evaluations were based on the clinical assess-
ment outlined below. In every child, the knee was flexed
at least 30 degrees while standing erect; in some instances
the flexion was far greater than 30 degrees (Figs. 1A, B).
Video recordings confirmed that the knee flexion ex-
ceeded 30 degrees throughout the stance phase of gait in
all these children.
Fixed deformities of the knee, the popliteal angle,
the modified popliteal angle, the range of passive knee
movement, and lag in the quadriceps were measured with
J Pediatr Orthop  Volume 30, Number 8, December 2010
J Pediatr Orthop  Volume 30, Number 8, December 2010
FIGURE 1. A and B, The preoperative posture of an adolescent with spastic diplegic cerebral palsy who had not undergone any
earlier surgery is shown. The extreme degree of crouch is evident. He can barely walk 15 m.
the help of a goniometer. The power of the quadriceps
was assessed by manual muscle testing and also with the
help of a hand-held dynamometer (Chatillon DMG 250,
Jamar) by the make and break tests. The “make” test was
carried out with the child sitting with the legs hanging
over the edge of a couch. The dynamometer was held with
the force pad in contact with the shin 2 cm above the
ankle joint, and the child was asked to actively extend the
knee with as much force as possible. The force of knee
extension was read off from the dynamometer. The strength
of the quadriceps was then estimated by the “break” test.
The child was asked to actively hold the knee in as much
extension as possible and the force pad of the dynamometer
was held against the shin, 2 cm above the ankle. The
examiner exerted force on the tibia and the reading from the
dynamometer was recorded as soon as the knee began to
flex. The degree of spasticity of the hamstrings was assessed
by the modified Ashworth Scale.5 The gait pattern was
documented by direct visual observation, still photographs,
and video recording.
r 2010 Lippincott Williams & Wilkins
Management of Severe Crouch Gait
Lateral radiographs of the knee were taken with
the hip and knee flexed to 30 degrees and the position of
the patella was measured by the Insall-Salvati Index.6 The
Physiological Cost Index (PCI) was estimated after the
child walked 50 m at a self-determined speed as described
by Raja et al.7 The ambulatory capacity of the child was
rated on the Functional Mobility Scale for 5, 50, and
500 m (FMS-5, FMS-50, FMS-500)8 and with the Hoffer
et al’ grading.9 All these variables were measured again at
the end of 2 years after the last surgery.
Ten children were treated between April 2002 and
May 2005, and 7 children were treated after May 2005.
Children treated before 2005 did not have preoperative
dynamometric measurements of the power of the quad-
riceps and PCI estimation. The objective preoperative
assessments of children treated after 2005 and follow-up
assessments of all the children were done by the same
investigator.
The assessment of postoperative improvement of
gait was based on subjective clinical impression of the
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Joseph et al J Pediatr Orthop  Volume 30, Number 8, December 2010

authors’, the parents’, and the patient’s subjective

perception and viewing of video recordings. The shortest
follow-up was 24 months, whereas the longest follow-up
was 72 months. Intraobserver and interobserver reprodu-
cibility of the evaluation of knee deformity, dynamo-
metric measurements, and radiographic measurements
were tested with 2 repeated measurements of 10 knees and
differences were evaluated by the paired t test. Changes
between the preoperative and postoperative status of each
variable was evaluated with the Wilcoxon sign-rank test.
A P value of less than 0.05 was regarded as being
significant.

The Surgical Protocol

All the 17 children underwent multiple surgical
procedures and they were done in 2 sessions, 6 weeks
apart. Apart from operating on the knee, if surgery at the
hip or ankle and foot was deemed necessary, these
operations were also undertaken in one of these sessions.

Technique of Surgery For the Knee and

Postoperative Care
With the patient lying in the supine position, the
distal third of the femur was exposed through a lateral
incision. An osteotomy of the femur was performed in the
distal third of the shaft and the proximal fragment was
brought out of the wound as the knee was passively
extended. The extent of overlap of the fragments that
occurred was noted and much of the femur was resected
from the proximal fragment. The length of the resected
bone was usually between 2.5 and 3.5 cm; on one occasion
in an adolescent with very severe deformity, 5 cm had to
be resected. It was ensured that the same length of bone
was resected from both sides to avoid limb length
inequality. The shortened femur was fixed with a plate
and screws (Fig. 2). Care was taken to ensure that full
extension of the knee was obtained before the fragments
were fixed. In 15 cases, full extension of the knee was
achieved by femoral shortening alone. In 2 instances,
some residual flexion of the knee was present even after
shortening of the femur; the distal fragment was tilted
anteriorly, sufficient (B15 degrees) to obtain full knee
extension and the fragments were fixed in this position.
The patella alta was then corrected by shortening
the patellar tendon. The technique differed in skeletally
mature and immature children. In skeletally mature
children, the patellar tendon was split longitudinally into
3 slips. The outer 2 slips were detached from the tibial
tuberosity, pulled distally, and buried under triangular
flaps of the periosteum raised from the medial and lateral
surfaces of the tibia just distal to the tibial tuberosity
(Fig. 3). In skeletally immature children, the lateral slips
were detached from the lower pole of the patella, pulled
proximally, and sutured to the anterior surface of the
patella. In all the children, the central slip was not
detached from either the proximal or distal attachment
but was pulled proximally and the redundant fold was
sutured onto the anterior surface of the patella. The limb
FIGURE 2. The femur is fixed with a plate and screws after
shortening. This radiograph, taken 12 weeks after surgery,
shows sound union at the site of shortening.
was immobilized in a long leg cast for 6 weeks with the
knee in extension.
When indicated, additional surgery was performed
at the same sitting; this included release of the adductors
(n = 2), intramuscular release of the psoas at the pelvic
brim (n = 3), and proximal rectus femoris release (n = 2).
These procedures were undertaken in patients with
clinically evident contractures of the respective muscles;
release of the iliopsoas and the rectus were done to
minimize the risk of anterior pelvic tilt after our
intervention that entailed weakening of the hamstrings.
The second-stage surgery was performed with the
child lying in the prone position 6 weeks after the first
stage. Fractional lengthening of the biceps femoris and
the semimembranous aponeurosis was done at 2 levels
and the gracilis tendon was divided. The semitendinous
was divided close to its insertion and transferred to the
back of the femur. The tendon was anchored to itself after
passing it through a periosteal tunnel made close to the
medial supracondylar ridge. The limb was immobilized in
a long leg cast for a further period of 6 weeks. After cast
removal, physiotherapy was begun to strengthen the
quadriceps and to restore knee motion. Once radio-
graphic confirmation of sound union of the femoral
osteotomy was noted, weight bearing was permitted; no
form of bracing was used thereafter, except in 1 patient
who had a rigid equinovarus deformity of the left foot. He
used an ankle-foot orthosis after undergoing a triple

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J Pediatr Orthop  Volume 30, Number 8, December 2010 Management of Severe Crouch Gait

Patellar
tendon Patella Central slip
split into pulled pulled up &
three & the distally sutured to
lateral slips patella
detached
from tibial
attachment
(central slip Lateral slips
left intact) Flaps of pulled down
periosteum & buried under
raised periosteal flaps

FIGURE 3. Line figure showing the technique of patellar tendon advancement in skeletally mature adolescents with patella alta
and crouch gait.

fusion on that limb after the knee had been operated on
(Figs. 4A, B). The patients underwent supervised physio-
therapy and gait training for 2 weeks after cast removal.
Thereafter they were instructed to continue quadriceps
strengthening and hamstring stretching exercises at home.
RESULTS
The reproducibility of measurement of all the
variables assessed in these patients was good with no
variable showing significant difference between 2 repeated
measurements. In all the 17 children, the gait pattern
improved dramatically with substantial reduction of the
crouch posture (Figs. 5A, B). Flexion deformity of the
knee, the popliteal angle, and the modified popliteal angle
decreased significantly. The range of knee movement and
the Insall-Salvati Index increased significantly from the
preoperative status to final follow-up (Table 1). The
power of the quadriceps improved in every instance and
the extensor lag reduced (Fig. 6). There was no significant
reduction in the spasticity of the hamstrings measured on
the Ashworth Scale. The FMS-5, FMS-50, and FMS-500
scores improved from 3, 1, and 1, respectively to 5, 3, and
3, respectively. Three household ambulators remained as

FIGURE 4. A and B, The preoperative appearances of the lower limbs of an adolescent with cerebral palsy are shown (A). Apart
from severe crouch there is an equinovarus deformity of the left foot. The foot deformity was treated with a triple arthrodesis. This
patient used an ankle-foot orthosis on the left foot postoperatively (B). The excellent alignment of the knees is also evident.

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Joseph et al J Pediatr Orthop  Volume 30, Number 8, December 2010

FIGURE 5. A and B, The posture of the adolescent, shown in Figure 1, 4 months after surgery is markedly improved. He stands
and walks without crouch; excessive lumbar lordosis is not present and he has become a community ambulator. Four years later
he continues to be a community ambulator.

TABLE 1. Preoperative and Final Follow-up Values of Variables Measured in 17 Children With Crouch Gait
Preoperative At Final Follow-up
Variable Median IQR (Range) Median IQR (Range) P
Flexion deformity of the knee (degrees) 22 20, 34 (12-40) 2 0, 7.5 (0-12) <0.05
Popliteal angle (degrees) 61 53, 75 (50-78) 31 20, 40 (28-46) <0.05
Modified popliteal angle (degrees) 52 40, 61.5 (30-70) 20 16.5, 23.5 (12-28) <0.05
Quadriceps power (manual muscle testing-MRC grade) 3 3, 3 (2-4) 4 4, 4 (3-4) <0.05
Quadriceps power (kg) dynamometric “make” test* 6.2 4.5, 6.8 (4.5-7.9) 10.77 9.1, 11.3 (4.5-13.6) <0.05
Quadriceps power (kg) dynamometric “break” test* 2.3 2.3, 3.4 (2.3-4.5) 4.5 4.5, 5.3 (2.3-6.8) <0.05
Range of motion of the knee (degrees) 118 110, 121 (106-136) 136 130, 140 (128-142) <0.05
Insall-Salvati Index (ratio) 0.7 0.7, 0.8 (0.7-0.8) 1.45 1.02, 1.7 (1-1.9) <0.05
IQR indicates interquartile ranges.
*These measurements were made only on 7 children treated after 2005.

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J Pediatr Orthop  Volume 30, Number 8, December 2010
FIGURE 6. Active knee extension without any evident
extensor lag is seen in an adolescent who has undergone
surgery.
household ambulators; 2 functional ambulators and 10
household ambulators became community ambulators
after surgery. Two children who were community ambu-
lators to begin with, remained as community ambulators.
Of the 7 children operated after 2005, 3 could not walk
50 m at a stretch to measure the PCI preoperatively. They
were able to walk 50 m from 3 months after surgery and
their PCI values which were 4, 6, and 8 beats/m,
respectively at this point reduced to 3.5, 3.25, and 3
FIGURE 7. A and B, Before surgery, patella alta, fracture-separation of the patella, and fragmentation of the tibial tuberosity are
seen (A). After surgery, the patella alta has been corrected and the fracture of the patella and the fragmentation of the tibial
tuberosity have healed spontaneously (B).
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Management of Severe Crouch Gait
beats/m within 9 months of surgery. There was modest
improvement in the PCI values in 3 of the other 4 children
(preoperative range 1.3 to 2.6 beats/m; postoperative range
0.6 to 2 beats/m).
Before surgery, all the 17 children had patella alta of
varying degrees and in addition, they all had either
fracture-separation of the patella or fragmentation of the
tibial apophysis or both but none complained of anterior
knee pain. In every instance, these abnormalities of the
patella and the tibial tuberosity healed completely within
3 months of surgery (Figs. 7A, B).
There were no wound complications and no
instances of nerve traction symptoms. Mild recurvatum
of the knee of 5 and 6 degrees was noted in 2 instances at
final follow-up; there was no evidence of anterior tibial
growth plate arrest in these patients.
DISCUSSION
The strategies used in our patients included correc-
tion of the flexion deformity, weakening of the ham-
strings, and augmenting the power of the knee and hip
extension. We believe that a combination of all these
factors were crucial to the very satisfactory results we
achieved in children with severe crouch gait. The
seemingly radical approach seems to be justified, as we
did not encounter instances of major overcorrection.
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Joseph et al
Correction of Flexion Deformity of the Knee
In these children with severe long-standing crouch,
it is unlikely that complete correction of the flexion
deformity would have been achieved by mere release of
the hamstrings. In the past, we have combined release of
the hamstrings with a supracondylar extension osteotomy
recommended by some researchers.10,11 We refrained
from attempting correction of the deformity in this
manner in these children because on an earlier occasion,
permanent injury to the common peroneal nerve has
occurred. This worrisome complication has been well
documented in the literature,12 and may well be more
frequent than recognized.13 Rodda et al4 noted 2
instances of paresthesia in the distribution of the common
peroneal nerve in patients with flexion deformities of 22
and 28 degrees, respectively among the 10 patients that
they reported. It is pertinent to note that several of our
patients had deformities in this range (Table 1). We opted
to shorten the femur to avoid stretching of the sciatic
nerve. In all our patients, complete correction of the
flexion deformity was achieved during surgery. The same
surgical approach was adopted for all degrees of fixed
flexion deformity, although the amount of shortening
required was greater with increasing severity of deformity
and some tilt of the distal fragment into extension was
required in the 2 most severe cases.
Another interesting outcome of femoral shortening
noted in the study was an actual increase in the range of
motion of the knee from a median value of 118 to 136
degrees (Table 1). A supracondylar extension osteotomy
would have altered the arc of motion with an increase in
knee extension equal to the angle of the wedge removed
but there would have been a concomitant reduction in
knee flexion. A loss of knee flexion can be disabling in
communities such as ours in which squatting and sitting
on the floor is a way of life.
It has been suggested that in long-standing crouch,
contracture of the posterior capsule of the knee may also
occur.14,15 However, as shortening of the femur in the
supracondylar region corrected the flexion deformity
without having to tilt the distal fragment into extension
in all but 2 patients, it suggests that in the majority of
instances capsular contracture is not present. Even if mild
residual deformity because of capsular contracture
persisted after surgery as described here, it could probably
be corrected safely by serial casting without risk of stretch
on the nerve that has been rendered lax by the femoral
shortening.
Weakening the Hamstrings
As one of the primary causes of crouch is spastic
overactivity of the hamstring muscles it is imperative that
they are sufficiently weakened to correct the muscle
imbalance and also to reduce the risk of recurrence. We
believe that a combination of femoral shortening and
aponeurotic lengthening of the semimembranous and the
biceps femoris will sufficiently weaken these muscles by
reducing the resting length of the muscle fibers. In
addition, the knee flexor function of the semitendinous
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J Pediatr Orthop  Volume 30, Number 8, December 2010
is removed as the tendon is transferred to the back of the
femur. A similar approach has been reported by
Uyttendaele et al.16 We opted to anchor the transferred
tendon to the medial side of the distal femur rather than
the lateral side as advocated by Sutherland et al17 who
were attempting to deal with internal rotation gait. The
fact that very mild recurvatum was noted in just 2
patients suggests that the hamstrings have not been
weakened so much as to create imbalance in the opposite
direction as with the classical Egger transfer.18
Augmenting the Power of the Knee and Hip
Extension
Unless the quadriceps muscle is strong enough to
act against the gravity, the child will continue to crouch
even if the deformity is fully corrected and the hamstrings
have been weakened. Plication of the patellar tendon
effectively corrected the patella alta and this clearly
resulted in evident improvement in the strength of the
quadriceps muscle very early in the rehabilitation period.
The technique of patellar tendon plication that we
describe is easy to perform and does not require any
anchorage of the patella with sutures or wires14 or internal
fixation of the tibial tubercle after advancement.19,20 The
method of burying the strips of the patellar tendon under
the periosteum of the tibia is almost identical to that
described recently by Novacheck et al.14 The risk of loss of
continuity of the quadriceps, if the anchorage fails, is
avoided by leaving the central third of the tendon attached
to the tibial tuberosity and the patella.
In most of the children, the patella seemed to have
been brought down excessively as the postoperative values
of the Insall-Salvati Index were above normal. This was
partly because often the patella itself became more
elongated as the fracture-separation healed (Figs. 4A, B),
thereby influencing the patella to patellar tendon length
ratio. None of the patients complained of anterior knee
pain at final follow-up.
The transferred semitendinous may help in pulling
the femur backwards, and thus provide additional hip
extensor power during the stance phase, although we have
no proof that this does occur, as we did not measure hip
extensor power before and after surgery. Even if the
transferred tendon does not actively facilitate the hip and
knee extension we hope that it may at least act as a
tenodesis.
Effectiveness of the Treatment Approach
Our approach to dealing with severe crouch in
cerebral palsy differs from that reported by other
surgeons. Beals15 advocated a combination of hamstring
lengthening, posterior capsulotomy of the knee, and
patellar tendon advancement, whereas Stout et al,10 and
Novacheck et al14 recommended distal femoral extension
osteotomy combined with patellar tendon advancement.
Rodda et al4 reported a combination of distal femoral
extension osteotomy, hamstring release, and postopera-
tive bracing with a rear-entry floor reaction orthosis.
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J Pediatr Orthop  Volume 30, Number 8, December 2010
We opted to shorten the femur to correct the
disparity in length between the contracted hamstrings and
the skeleton, and thereby correcting the flexion deformity.
It may be argued that an extension osteotomy is a more
appropriate approach but our results, which have
remained good even in the children whom we have
followed to 6 years, show that shortening the femur is an
acceptable option. We believe that femoral shortening is
the preferred option in children with major flexion
deformity as it effectively reduces that risk of nerve
damage.
We are unaware of any published report of the
combination of femoral shortening, patellar tendon
advancement, hamstring release and transfer for the
treatment of severe crouch gait in cerebral palsy.
However, a similar approach has been alluded to in the
review of Aiona and Sussman13 and in the presentation of
Selber et al.21
Some of the published studies report improvement
in the status of the patients on the basis of instrumented
gait analysis, which we did not have access to. As the
outcome variables in these studies differ from those used
in this study, it is difficult to compare our results with
these earlier reports. However, our clinical evaluation
data suggest that the results in our patients have been
quite satisfactory; the deformity was corrected, knee
extensor power improved, the range of motion increased,
and the patients walked more. In addition, none of our
patients required postoperative bracing to maintain knee
extension, which we believe is a distinct advantage.
Finally, we immobilized the limbs in plaster for 3
months because we did not use any additional method of
fixation of the patellar tendon after advancement and the
semitendinous tendon after transfer, apart from sutures,
to the periosteum. Despite this, the patients were
ambulating well within 3 weeks and we could not show
any adverse effects of immobilization.
Limitations of This Study
We did not use the Gross Motor Function
Classification Scale to document the preoperative status
of the children. This was because none of our patients
possessed a walking aid or a wheelchair before surgery; to
allocate them to a Gross Motor Function Classification
Scale level based on the projected use of a walking aid or
wheelchair would have been conjectural and inappropri-
ate. We opted to use the FMS and the Hoffer et al’s
grading to assess the improvement of the ambulatory
status after surgery.
As we did not have instrumented gait analysis we
could not quantify improvement of the pattern of gait
and, consequently, could not compare our results with
other studies. The impression of the improvement of gait
was partly based on the subjective criteria of surgeons and
therapists involved in the treatment and this introduces
bias. However, we considered the gait to have improved
only if our impressions concurred with those of the
parents and the children.
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Management of Severe Crouch Gait
In the absence of gait analysis it is difficult to
determine conclusively if any of our patients have
developed anterior pelvic tilt, an undesirable outcome of
excessive weakening of the hamstrings, and consequently
the hip extensors.
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