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Causes of Intoeing Gait in Children with Cerebral Palsy
Susan A. Rethlefsen, PT1; Bitte S. Healy, MS, PT1; Tishya A.L. Wren, PhD1; David L. Skaggs, MD1; Robert M. Kay, MD1
1 Childrens Orthopaedic Center, Childrens Hospital Los Angeles, 4650 Sunset Boulevard, M/S 69, Los Angeles, CA 90027. E-mail address for S.A. Rethlefsen: srethlefsen@chla.usc.edu
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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive 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.
Investigation performed at Childrens Hospital Los Angeles, Los Angeles, California

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Oct 01;88(10):2175-2180. doi: 10.2106/JBJS.E.01280
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Background: Intoeing is a frequent gait problem in children with cerebral palsy. It is essential to determine the cause(s) of intoeing when surgical intervention is being planned. The purpose of this study was to evaluate the prevalence of various causes of intoeing in children with cerebral palsy and to determine whether the causes differ between children with bilateral and those with unilateral involvement.

Methods: The cause of intoeing gait was examined retrospectively, with use of gait analysis, in 412 children with cerebral palsy (587 involved sides). The causes were evaluated separately for the children with bilateral involvement (diplegia or quadriplegia) and those with hemiplegia.

Results: Overall, the most common causes of intoeing were internal hip rotation (322 of 587 sides) and internal tibial torsion (296 of 587 sides). Pes varus contributed to intoeing of thirty-five of the eighty-two involved limbs of the patients with hemiplegia and of forty-two of the 505 limbs of the patients with diplegia or quadriplegia. Multiple causes of intoeing were noted in 215 of the 587 involved limbs, including 176 of the 505 limbs of the patients with bilateral involvement and thirty-nine of the eighty-two involved limbs of the patients with hemiplegia. The most common causes of intoeing in the subjects with bilateral involvement were internal hip rotation (288 of 505), internal tibial torsion (261 of 505), and internal pelvic rotation (ninety-two of 505). The most common causes in the hemiplegic children were internal tibial torsion (thirty-five of eighty-two), pes varus (thirty-five of eighty-two), internal hip rotation (thirty-four of eighty-two), and metatarsus adductus (twenty of eighty-two).

Conclusions: More than one-third of children with cerebral palsy have multiple causes of intoeing. Pes varus commonly contributes to intoeing by children with hemiplegic cerebral palsy but rarely contributes to intoeing by those with diplegia or quadriplegia. These findings should be carefully considered prior to surgical correction of the intoeing gait of these patients.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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