Cerebral Palsy






- ankle foot orthosis

- knee ankle foot orthosis



- ground reaction AFO


Kaye walker 

- seat on it

- co-ordinates walking


Reciprocal Gait Orthoses




Short adducted leg - dislocated hip


Kyphosis - query secondary tight hamstrings




Decreased velocity 


Coronal Plane

- scissoring / tight adductors)

- asymmetrical arm swing / hemiplegia

- LLD / hip dislocation



- equinus / jump / crouch 


A.  Equinus

- ankle in equinus

- knee straight or in recurvatum

- hip extends full


B.  Jump

- equinus of ankle

- flexion of knees and hips, never extend fully


C.  Crouch

- ankle in dorsiflexion

- over lengthening of T Achilles

- have to flex knees and hips to regain centre of balance 


Lower Limb


R1 - do slowly

R2 - do quickly


Looking for a difference between the R1 and R2

- if reduced ROM on R2, have spasticity / dynamic element

- amenable to botox




1. Psoas

- FFD / Thomas test

- must test knee first

- do over edge of bed if FFD knee


2. Adductors

- scissored gait if bilateral

- apparent leg length inequality if unilateral

- Trendelenburg gait 

- decreased hip abduction


3. Hamstrings

- FFD at knee

- knee flexed at start of stance phase


Popliteal angle (hip flexed at 90°)

- straight is 0˚


Unable to sit up with legs straight

- decreased  SLR

- can't touch toes


4. Triceps Surae

- ankle equinus

- tiptoe gait


Silverskiold test 

- distinguish between the gastrocnemius and soleus

- test ankle DF range with knee flexed and extended

- if gastrocnemius tight, reduced DF with knee extended


On side


5. Iliotibial Tract


Obers' test 

- patient on side and flex knee with hip in neutral abduction then as flex knee further hip abducts 




6. Quadriceps

- stiff leg gait

- inability to flex knee with hip extended suggests tight rectus


Ely test (RF)

- child prone 

- when the knee is flexed the hip flexes suggesting tight RF


7.  Rotational profile




Increased / clonus / clasp knife






Primitive Reflexes



- child supine in arms, allow head to drop back 

- arms & legs stick out in extension

- disappears by 4 months



- arms and legs extend when child held prone

- appears at 5 months



- tone reduced & arms/legs flex when prone but increased tone & extended arms & legs with supine position


Upper Limbs 



- resting position

- contractures

- joint stability


Hand placement

- ability to place hand in space

- < 10 seconds



- ability to identify ojects in hand without looking


LLD Exam

Four Physical Outcomes


1.  Symmetrical Stance & Level Pelvis 


A.  LL Equality

- Components equal with no deformity


B.  Components equal with bilateral symmetrical deformity

- eg Bilateral varus knees


2.  Symmetrical Stance with Oblique Pelvis 


Uncompensated LLD


3.  Asymmetrical Stance & Level Pelvis 


A. Fully Compensated LLD

- Flexed contralateral knee 

- Equinus ipsilateral ankle


B. Sagittal deformity with ipsilateral sagittal compensation

- FFD knee with Equinus & hip flex OR

- Fixed Equinus with flex knee & hip OR

- FFD hip with equinus & flex knee


C.  Coronal deformity with contralateral coronal deformity

- Valgus of knee & contralat varus of knee


4. Asymmetrical Stance with Oblique Pelvis 


A.  Partly compensated LLD

- Partly flexed contralateral knee

- Partly equinus of ipsilateral ankle


B. Coronal hip deformity with sagittal compensation

- Fixed hip adduction with contralateral knee flexion / ipsilateral equinus

- Fixed hip abduction with ipsilateral knee flexion / contralat equinus


C.  Sagittal def c coronal compensation

- FFD knee c ipsilateral hip abduction

- Fixed equinus c ipsilateral hip ADD


Leg length Examination


1.  Look



- flexed knee


Signs hemihypertrophy

- NF
- haemangiomas / lipomas (Proteus, Klippel-Trenau-Weber, Beckwith)



- trauma, infection


Aids / Shoes

- heel inserts / raises


2.  Gait




Compensate well 

- Walk on toes short leg usually / equinus

- Flexion long knee uncommon as energy++




Compensate less well

- Walk with bilateral heel-toe gait

- Vaults over long leg

- Excess Sagittal head motion


3.  Measure LLD

A.  Functional LLD

- on blocks

- heels flat, nil knee FFD (if able)

- correct pelvic tilt

- should correct scoliosis



- if can make pelvis stable

- ASIS equal

- blocks are a quantitative measure of functional LLD


B.  Apparent LLD


Lying on bed

- measure from xiphisternum to medial malleolus

- no correction for contractures


C. Real / True LLD


Must correct for deformity in coronal and sagittal plane



- hip adduction / abduction contracture

- hip FFD

- knee FFD



1.  Hip FFD

- pillow under both thighs

2.  Knee FFD

- pillow under both knees

3.  Hip adduction contracture won't correct to neutral

- measure each leg crossed over the other

4.  Hip abduction contracture won't correct to neutral

- place both legs in similar position


If there is a contracture, perform the above measures

- then meaure the intercalated segments

- from ASIS to medial joint line

- medial joint line to medial malleolus


4.  Identify site of shortening



- must not forget can have small foot / old calcaneal fracture / wasted buttock

- hips and knees flexed

- side by side

- look for tibial / femoral shortening


If shortening above knee, find out if shortened above greater trochanter

- i.e. hip deformity


Bryant's triangle

- line perpendicular to GT and ASIS

- distance between

- quantify in fingerbreadths


Nelaton's line

- line from ischial tuberosity to ASIS

- GT should be on or below line


Klisics line

- GT to ASIS

- should aim to umbilicus

- will be more parallel


5.  Other


Examine Knee stability

- can have problems lengthening femur if ACL deficient

- i.e. fibula hemimelia

Ligamentous Laxity

Wynne Davies Ligamentous Laxity JBJS 1970


Original Paper


2486 individuals examined

- aged 1 week to 18 years

- at birth - no child lax jointed by criteria

- 2 years - 45% of normal children lax jointed

- 6 years - only 5% of normal children had lax joints

- 12 years - <1% of normal children had lax joints




If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive


1. Thumb touching forearm on flexing wrist

2. Fingers parallel to forearm with wrist extension

3. Elbows extend past 180°

4. Knees extend past 180°

5. Foot dorsiflex past 45°


Ligamentous Laxity Thumb to ForearmLigamentous Laxity Elbow HyperextensionLigamentous Laxity Knee HyperextensionLigamentous Laxity Hands to Floor.







Pes Cavus

Goal Of Examination


1.  Identify possible aetiology

- NM axis

- RA

- trauma

- clubfoot / arthrogryposis


2.  Define the deformity & its flexibility

- fixed / flexible forefoot

- fixed / flexible hind foot

- fixed / flexible lesser toes




Aids / shoes




Stork Legs

Lesser toes clawing


Hands (dorsal wasting intrinsics (CMT 1), rheumatoid hands)


Medial Side


High Medial arch

Plantar flexed first ray

Claw first toe




Hindfoot varus

Calf muscle bulk



- scoliosis

- cutaneous manifestations spinal dysraphism


Double heel raise 

- Heel swings into varus or remains in valgus

- does the medial arch restore

- bilateral suggests neurological


Single heel raise

- Must put patient close to wall

- otherwise will cheat by pushing up or leaning forward against wall 


Coleman Block Test

- block under lateral foot

- allow first ray to touch ground

- Assess hindfoot

- If hindfoot varus flexible, heel corrects

- Elimination of forefoot deformity will correct hindfoot deformity if hindfoot flexible


Lateral side


Exclude calcaneo-cavus




Stiff ankle 


Marionette Gait / High stepping

- Fixed equinus (weak Tib ant)(back knee gait)


Tip toe & heel walk




Examine Sole

- callosities over metatarsal head



- tenderness

- thickening CPN



- range AKJ

- range STJ

- Silverskiold

- active v passive


Motor examination

- T. Ach strong / plantarflexion

- T. Ant weak / dorsiflexion and inversion

- T. Post strong / plantarflexion and inversion

- PB weak / eversion


First MT

- is plantar flexion correctable


Claw toes 

- correctible


Neurological Exam


Abdominal Reflexes


Decreased or absent DTR

- CMT 1


Sensory decrease in 25%

Rotational Deformity Exam



In-toeing is normal up til 8 - 10 years

- combination ITT / PFA

- anteversion decreases, ETT increases


Causes Intoeing



- usually symmetrical

- unilateral consider CP



- usually asymmetrical



- metatarsus adductus


- metatarsus primus varus

- skewfoot


Causes out-toeing



- usually unilateral

- consider NM cause i.e. CP, SB






Staheli's Torsional Profile




Squinting patella

- rotation above patella, in femur


Foot Progression angle

- Us 10° out (0°-30°) 





- curved lateral border

- heel bisector should pass through second MT


Thigh- Foot Angle TFA

- knees flexed

- Reconstruct foot

- Usually 15° (0°-30°) ER


Transmalleolar Axis (TMA)

- knees flexed

- Usually 0 - 30° ER


Hip Internal Rotation

- Usually < 65° 

- > 70° = FAV


Gage's trochanteric angle

- GT most prominent laterally

- angle of tibia from verticle


Hip External Rotation

- Usually 40° (20-60°)

- Greater in young child

- Note IR + ER should  = 90°



Scoliosis Exam

Aims of Examination


1.  Identify cause


- Marfan's / Neurofibromatosis / Skeletal Dysplasia


2.  Balance & body asymmetry


3.  Exclude LLD as cause

- correct with blocks or sit patient


4.  Forward flexion / Adams forward bending

- look for rotation / rib hump


5.  Assess flexibility if considering surgery


Typical curve


The right shoulder is raised

The right scapula is prominent

The loin creases are asymmetrical

The pelvis is level

There is flattening of the normal thoracic kyphosis

There is a normal lumbar lordosis

On forward bending, there is a (mild/moderate/severe) (well rounded/angular) rib hump and a mild left lumbar fullness





- height / breasts / pubic hair



- cafe-au-lait spots

- axillary freckling (look in axilla)

- neurofibromas



- Lisch nodule (NF)

- blue sclera (OI)

- cloudy cornea (mucopoly)

- dislocated lens (Marfan's)

- optic glioma



- Abnormal teeth (OI)

- high-arched palate (Marfan's)

- large tongue (Achondroplastic)



- pectus carinatum or excavatum

- protruberant sternum with sharp manubriosternal angle



- hemihypertrophy

- dolichostenomelia (long limbs)

- arachnodactyly (thumb in palm)

- clubfoot - often first sign of dysraphism

- cavovarus foot






Thoracic kyphosis

- exaggerated, normal or reduced / hypokyphotic


Lumbar lordosis

- exaggerated, normal or reduced


Protruberant abdomen





- right or left


Balanced or Unbalanced 

- alignment of C7 over gluteal cleft (ask for plumb bob)


Shoulder height


Scapular symmetry


Loin creases / lumbar fullness


Flattened heart-shaped buttocks



- level or not (pant line or PSIS)


Spinal dysraphism

- hyperpigmentation / hairy patch / dimple / lipoma / tail


Leg length 

- if abnormal use blocks & reassess curve


Adam's test 

- hands together & bend forwards to touch floor

- mild/mod/severe rib hump

- well rounded or angular

- satisfactory unroll





- hamstring tightness



- Reflexes UL / LL / Abdominal / Babinski

- Sensation

- Power UL/LL


Scoliosis + No Abdominal reflexes & No Axillary sensation 

 Syrinx till proven otherwise


Abdominal reflexes disappear during teens




"This is a PA spine radiograph of a __ old skeletally mat/immature Risser __ male/ female with Scoliosis"


"There is a R/L typical/atypical curve thoracic/lumbar curve ±  a R/L T/TL/L lower curve"


"The spine is/isn't balanced, the pelvis is/isn't level & the curve has a rotational component"


"The curve appears to be Idiopathic / Congenital / NF ? NM


Don't mention which is 1°/ 2° or postural or structural