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A simplified technique for determining foot progression angle in children 4 to 16 years of age
Abstracts
65
regard to age, left and right extremity. A 6m walkway was created and dynamic foot prints were obtained.The longitudinal axis of the foot in relation to the direction of gait measured. Based on a pilot study and the anatomical definition the longitudinal axis of the foot was defined to bisect the second toe and the center of the heel. The average of all left and all right foot prints was calculated. As a measure of convention, positive vainas describe external rotation of the lower extremity (out-toeing), negative values represent internal rotation (intoeing). A normal range of vafuas was established using the mean +/- 2 standard deviations. A univariant analysis was performed to analyze the correlation of individual variables of age, gender, handedness, arch development and rearfoot alignment.
Results: M.reetus femods
}<~leefiexl~ in I~me 113%
111% 109% 107% 105% 103% 101%
Children ages 4-5 were found to have an average out toeing of 2.8° (1 STD = 6.9°). The average foot progression angle increased with age to 7.3° at age 16 (1 sTY) = 4A°).Univariate analysis of these data found that age, tibia[ alignment, arch index, and the ratio of body weight to body height significantly affected foot progression angle. If, for children 4-16 years of age, two standard deviations fi'om the average of 4.2° out-toeing is taken as a normal range of variance, - 8° ( in-toeing ) to +16.4° (out-toeing) would be acceptable for these ages. The measurement technique is described in detail , and the normative values and age-specific results are described.
99%
97% 95% 0
16 32 98 64 80 S6 112 130 ~
Discussion: 0 8 16 24 32 40 48 5S f ~ 72 S0 08 96 ~ l St .... I Swing J
F i g u r e 1: T e s t of m. rectus femoris' length. Upper left: physical examination Upper right: SIMM-model Lower left: relative length of M. rectus femoris, as a function of knee angle. Lower right: relative length of M. rectus femorls, as a function &gait cycle.
DISCUSSION Although it is hard to obtain muscle silence during physical examination, especially in the cases of severe spasticity, it provides a baseline for the assessment of muscle length A good assessment is necessary to discriminatethe therapeutic alternativesto that address excessive involuntary or premature contractions (i.e. spasticity), versus those that address the shortened muscle tissue. Using muscle length instead of joint angles as a basis to understand the functional importance &physical examination, is especially useful for hi-articular muscles. REFERENCES 1. Gage James R, Gait Analysis in Cerebral palsy. Oxford t New York, 1991 2 Perry.L, Gait Analysis, Normal and pathological Function 1992 3 Kleissen RFM et al. Gait & Posture 8: 143-158, 1998. 4. Hoppenfeld, Stanley, Pysical examination of the spine and extremities. New York, 1976 5. Janda, Vladimir. Muskelfunktionsdiagnostik.Verlag ACCO Leuven/13elgian,1979.. 6. Kendall H.P.T, e a., Musles, testing and function 2e druk, Baltimore/London, 1971. 7. Delp Scottd. et.al. Computers in Biology and Medicine, 25, 1995, pp .21-34
A SIMPLIFIED TECHNIQUE FOR DETERMINNG FOOT PROGRESSION ANGLE IN CHILDREN 4 TO 16 YEARS OF AGE
Steffen Lrsel M.D] Lyle J. Micheli M.D.2 Claus Carstens M.D 1
Gait analysis is an important part in any thorough orthopaedic examination. In order to gain knowledge on the normal gait development of children we thought it was neccessary to obtain a large data base for that measure. The following questions were considered in the proceess: 1.) Is there a simple and reliable method to substitute or at least complement mere clinical observation? 2.) What are the primary factors influencing FPA? 3.) What can be considered the normal gait of a child using FPA as the representative parameter? FPA proved to be a low cost, valuable tool in clinical gait ardysis. A large normative data base was established and the influencing factors were identififed and discussed in detail.
References l. Blank EE, MinalreP. Persistent medial deviation of the neck of the talus: a common cause of in-toeing in children. J Pediatr Orthop 1983;3:149 - 59. 2. Brinckmann P. Die Richtang der Fuglgngsachse beim Oehen. Z.Orthop 1981;119:45 - 8. 3. Craxford AD, Miuns RJ, Park C. Plantar pressures and gait parameters: a study of foot shape and limb rotation in children. J Pediatr Orthop 1984; 4 : 477 - 81 3a. Cavanagh PR, Rogers MM. The arch index: a useful measure from footprints. JBiomechanics 1987 ; 206 : 547- 51 4. Debrunner HU. Orthopgdisches Diagnostikum, 5 Aufi. Stuttgart : Thieme, 1987:206 - t7 5. Engel GM, Stab.eli LT. The natural history of torsion and other factores influencing gait in childhood. Clin O~hop 1974 ; 99 : 12 - 7 6. Giladi M , Milgrom C , Simkin A , Danon Y. Stress fractures : Identifiable risk factors. Am J Sports Meal I991 ; 19 : 647 - 52. 7. Luchini M , Stevens DB. Validity of torsional profile examination . J Pediatr Orthop 1983; 3 : 41 4. 8. Lysens RJ, Ostyn MS, Vanden Auweele Y , Lefevre J , Vuylsteke M , Renson L . The accident-prone and overuse-prone profiles of the young athlete. Am J Sports Med 1989 ; 17:612-9. 9. Milliron M, Loesel S, Michali LJ, Edington C. Comparison of methods for calculation of foot progression angle. Med Sci Sports Exere 1992 ; 24 : S 173. 10. Ogg HL .Measuring and evaluating the gait patterns of children. J Am Phys Assoc 1963 ; 43 : 717 - 20 11. Semtton DS, Robson R.The gait of 50 normal children- Physiotherapy 1968 ; 54 : 363 12. Staheli LT. In- toeing and out-toeing in children. J Faro Pratt 1983 ; 16 : 1005 - 11 13. Staheli LT. Report of the pediatric orthopedic subcommittee on torsional deformity . Orthop Trans 1980 ; 4 : 64 - 5. 14. Stahali LT, Corbet~ M , Wyss C , King H . Lower extremity rotational Problems in children. J Bone Joint Surg ( Am ) 1985 ; 67 : 39 - 47. 15. Yngve DA. Foot progression angle hi clubfeet. J Pediatr Orthnp 1990 ; 10 : 467 - 72.
Stiftung Orthop0.dische Universitfitsldinik Heidelberg i The Children's Hospital Harvard Medical School. Boston Mass. 2
Dr. reed. Steft~n L/~sel Stiftung OnhopSdische Universit~tsklinik Heidelberg Schlierbacher Landstr. 200a
69118 Heidelberg
Session 6 Functional Assessment II
Introduction Abnormalities of gait, such as in- toeing or out- toeing are one of the most common concerns of parents and restd.t in numerous visits to the pediatrician or orthopaedist. A large number of parameters determines a childrs gait. In addition to anatomical variations in the foot itself, rotational abnormalities of the lower extremity play a major role in the appearance of a child's gait. As previous studies have shown (7), clinical inspection and evaluation of the rotational profile of the lower exlremity shows lack of reproducability. The clinician is faced with the difficult decision wether the appearunce of the child's gait is normal or if it falls outside a normal range that has to be defined. Staheli et al. (5,I4) described and then amplified the torsional profile that describes the degree of hip, femoral and tibial torsion that results in a position of the foot during gait that is defined as the Foot Progression Angle.
Methodology: Foot progression angle was determined in 400 normal children ranging in age from 4-16 years using a new clinically available assessment technique. Both genders were examined with
AUTOMATIC DETECTION OF CLIMBING STAIRS IN DAILY LIVING - A VALIDATION STUDY R.C. van Lummel, E.A.S. Hairwassers, H.J. Busser. McRoberts B.V, Raamweg 43, The Hague. Introduction - One of the difficulties in clinical assessment is how to obtain accurate data in the 'real worldL Ambulatory monitoring enables monitoring of the ADL (activities of daily living) for 24 hours and more (Veltink et al., 1996, Busser et al., 1997, Bassmann et at., 1998, Uiterwaal et al., 1998). ADL monitoring presents a concept for evaluating function and dysfunction in dally living, in which the ability to climb stairs is a significant factor. The paper of Veltink (1996) discusses the feasibility of automatic detection of climbing stairs using accelerometry, however a detection
65
regard to age, left and right extremity. A 6m walkway was created and dynamic foot prints were obtained.The longitudinal axis of the foot in relation to the direction of gait measured. Based on a pilot study and the anatomical definition the longitudinal axis of the foot was defined to bisect the second toe and the center of the heel. The average of all left and all right foot prints was calculated. As a measure of convention, positive vainas describe external rotation of the lower extremity (out-toeing), negative values represent internal rotation (intoeing). A normal range of vafuas was established using the mean +/- 2 standard deviations. A univariant analysis was performed to analyze the correlation of individual variables of age, gender, handedness, arch development and rearfoot alignment.
Results: M.reetus femods
}<~leefiexl~ in I~me 113%
111% 109% 107% 105% 103% 101%
Children ages 4-5 were found to have an average out toeing of 2.8° (1 STD = 6.9°). The average foot progression angle increased with age to 7.3° at age 16 (1 sTY) = 4A°).Univariate analysis of these data found that age, tibia[ alignment, arch index, and the ratio of body weight to body height significantly affected foot progression angle. If, for children 4-16 years of age, two standard deviations fi'om the average of 4.2° out-toeing is taken as a normal range of variance, - 8° ( in-toeing ) to +16.4° (out-toeing) would be acceptable for these ages. The measurement technique is described in detail , and the normative values and age-specific results are described.
99%
97% 95% 0
16 32 98 64 80 S6 112 130 ~
Discussion: 0 8 16 24 32 40 48 5S f ~ 72 S0 08 96 ~ l St .... I Swing J
F i g u r e 1: T e s t of m. rectus femoris' length. Upper left: physical examination Upper right: SIMM-model Lower left: relative length of M. rectus femoris, as a function of knee angle. Lower right: relative length of M. rectus femorls, as a function &gait cycle.
DISCUSSION Although it is hard to obtain muscle silence during physical examination, especially in the cases of severe spasticity, it provides a baseline for the assessment of muscle length A good assessment is necessary to discriminatethe therapeutic alternativesto that address excessive involuntary or premature contractions (i.e. spasticity), versus those that address the shortened muscle tissue. Using muscle length instead of joint angles as a basis to understand the functional importance &physical examination, is especially useful for hi-articular muscles. REFERENCES 1. Gage James R, Gait Analysis in Cerebral palsy. Oxford t New York, 1991 2 Perry.L, Gait Analysis, Normal and pathological Function 1992 3 Kleissen RFM et al. Gait & Posture 8: 143-158, 1998. 4. Hoppenfeld, Stanley, Pysical examination of the spine and extremities. New York, 1976 5. Janda, Vladimir. Muskelfunktionsdiagnostik.Verlag ACCO Leuven/13elgian,1979.. 6. Kendall H.P.T, e a., Musles, testing and function 2e druk, Baltimore/London, 1971. 7. Delp Scottd. et.al. Computers in Biology and Medicine, 25, 1995, pp .21-34
A SIMPLIFIED TECHNIQUE FOR DETERMINNG FOOT PROGRESSION ANGLE IN CHILDREN 4 TO 16 YEARS OF AGE
Steffen Lrsel M.D] Lyle J. Micheli M.D.2 Claus Carstens M.D 1
Gait analysis is an important part in any thorough orthopaedic examination. In order to gain knowledge on the normal gait development of children we thought it was neccessary to obtain a large data base for that measure. The following questions were considered in the proceess: 1.) Is there a simple and reliable method to substitute or at least complement mere clinical observation? 2.) What are the primary factors influencing FPA? 3.) What can be considered the normal gait of a child using FPA as the representative parameter? FPA proved to be a low cost, valuable tool in clinical gait ardysis. A large normative data base was established and the influencing factors were identififed and discussed in detail.
References l. Blank EE, MinalreP. Persistent medial deviation of the neck of the talus: a common cause of in-toeing in children. J Pediatr Orthop 1983;3:149 - 59. 2. Brinckmann P. Die Richtang der Fuglgngsachse beim Oehen. Z.Orthop 1981;119:45 - 8. 3. Craxford AD, Miuns RJ, Park C. Plantar pressures and gait parameters: a study of foot shape and limb rotation in children. J Pediatr Orthop 1984; 4 : 477 - 81 3a. Cavanagh PR, Rogers MM. The arch index: a useful measure from footprints. JBiomechanics 1987 ; 206 : 547- 51 4. Debrunner HU. Orthopgdisches Diagnostikum, 5 Aufi. Stuttgart : Thieme, 1987:206 - t7 5. Engel GM, Stab.eli LT. The natural history of torsion and other factores influencing gait in childhood. Clin O~hop 1974 ; 99 : 12 - 7 6. Giladi M , Milgrom C , Simkin A , Danon Y. Stress fractures : Identifiable risk factors. Am J Sports Meal I991 ; 19 : 647 - 52. 7. Luchini M , Stevens DB. Validity of torsional profile examination . J Pediatr Orthop 1983; 3 : 41 4. 8. Lysens RJ, Ostyn MS, Vanden Auweele Y , Lefevre J , Vuylsteke M , Renson L . The accident-prone and overuse-prone profiles of the young athlete. Am J Sports Med 1989 ; 17:612-9. 9. Milliron M, Loesel S, Michali LJ, Edington C. Comparison of methods for calculation of foot progression angle. Med Sci Sports Exere 1992 ; 24 : S 173. 10. Ogg HL .Measuring and evaluating the gait patterns of children. J Am Phys Assoc 1963 ; 43 : 717 - 20 11. Semtton DS, Robson R.The gait of 50 normal children- Physiotherapy 1968 ; 54 : 363 12. Staheli LT. In- toeing and out-toeing in children. J Faro Pratt 1983 ; 16 : 1005 - 11 13. Staheli LT. Report of the pediatric orthopedic subcommittee on torsional deformity . Orthop Trans 1980 ; 4 : 64 - 5. 14. Stahali LT, Corbet~ M , Wyss C , King H . Lower extremity rotational Problems in children. J Bone Joint Surg ( Am ) 1985 ; 67 : 39 - 47. 15. Yngve DA. Foot progression angle hi clubfeet. J Pediatr Orthnp 1990 ; 10 : 467 - 72.
Stiftung Orthop0.dische Universitfitsldinik Heidelberg i The Children's Hospital Harvard Medical School. Boston Mass. 2
Dr. reed. Steft~n L/~sel Stiftung OnhopSdische Universit~tsklinik Heidelberg Schlierbacher Landstr. 200a
69118 Heidelberg
Session 6 Functional Assessment II
Introduction Abnormalities of gait, such as in- toeing or out- toeing are one of the most common concerns of parents and restd.t in numerous visits to the pediatrician or orthopaedist. A large number of parameters determines a childrs gait. In addition to anatomical variations in the foot itself, rotational abnormalities of the lower extremity play a major role in the appearance of a child's gait. As previous studies have shown (7), clinical inspection and evaluation of the rotational profile of the lower exlremity shows lack of reproducability. The clinician is faced with the difficult decision wether the appearunce of the child's gait is normal or if it falls outside a normal range that has to be defined. Staheli et al. (5,I4) described and then amplified the torsional profile that describes the degree of hip, femoral and tibial torsion that results in a position of the foot during gait that is defined as the Foot Progression Angle.
Methodology: Foot progression angle was determined in 400 normal children ranging in age from 4-16 years using a new clinically available assessment technique. Both genders were examined with
AUTOMATIC DETECTION OF CLIMBING STAIRS IN DAILY LIVING - A VALIDATION STUDY R.C. van Lummel, E.A.S. Hairwassers, H.J. Busser. McRoberts B.V, Raamweg 43, The Hague. Introduction - One of the difficulties in clinical assessment is how to obtain accurate data in the 'real worldL Ambulatory monitoring enables monitoring of the ADL (activities of daily living) for 24 hours and more (Veltink et al., 1996, Busser et al., 1997, Bassmann et at., 1998, Uiterwaal et al., 1998). ADL monitoring presents a concept for evaluating function and dysfunction in dally living, in which the ability to climb stairs is a significant factor. The paper of Veltink (1996) discusses the feasibility of automatic detection of climbing stairs using accelerometry, however a detection