Case Study | Crouching

Abraham has a diagnosis of cerebral palsy and presents with a very crouched gait. He is 11 years old. Abe is ambulatory and uses a reverse walker (Fig. 1) to assist him when at school and in the community. When at home, he ambulates without an assistive device (Fig. 2), but he often holds onto the walls when moving about.

Evaluation of Abe in weight bearing and during ambulation revealed that he presented with a crouched posture with his hips flexed, thighs internally rotated, knees flexed and up on his toes. His hind foot positioning was fairly normal with very little deviation of his hind foot into valgus and no sign of pronation. He still had a normal medial longitudinal arch and had not developed the typical midfoot collapse that you might see in an 11-year-old child with cerebral palsy. When I was assessing Abe’s passive range of motion in non-weight-bearing, I found that he had some notable tightness in his Achilles tendons. Abe could be passively stretched to a 90-degree ankle position with his hind foot in vertical and his knee extended as much as possible.

However, Abe’s very tight hamstrings are his biggest challenge. When I corrected Abe’s hind foot and dorsiflexed his ankle with him in a long-leg seated position, it was apparent that Abe lacks range of motion in his gastrocnemius and hamstrings. When I measured his knee flexion angle, Abe lacked approximately 23–25 degrees of full knee extension. To compound this, Abe also has tightness in his adductors and hip flexors.

He has been working with a school physical therapist on a stretching program. She has tried to impart the importance of Abe being responsible for managing some of his own care and taking an active role in stretching. His school therapist gave Abe some stretching exercises to do over the summer. The goal of the stretching exercises is primarily to stretch the hamstrings and adductors. If Abe gains range of motion over the summer, he will be able to stand more upright and be at eye level with his peers.

What really prevents Abe from standing with full knee extension is the knee flexion contracture. Abe has previously worn DAFO 4 supramalleolar braces that were fit by an orthotist at another facility. Abe had some dorsiflexion limitations that are difficult to control with a DAFO 4 (Fig. 3). Since he has tightness in his gastroc/soleus, I recommended a hinged DAFO 2 that blocks plantarflexion but allows free dorsiflexion. (DAFO 2s are not normally recommended for crouching in our literature, but Abe’s crouching is due to tightness.)

An evaluation of Abe’s muscle strength reveals that he does not show significant signs of weakness in his quadriceps or hip extensors. When Abe does ambulate, he is able to walk with as much knee extension as his hamstrings allow. My thought was to position Abe’s ankle at his end range of 90 degrees and allow him to have free dorsiflexion to stretch his gastrocnemius and soleus.

There was still this dilemma: I wanted to set Abe’s dorsiflexion angle for the DAFO 2 at 90 degrees, yet he has an approximate 25-degree knee flexion contracture. This will force Abe to walk up on his toes with the braces on, unless he has a heel wedge underneath his heels to give him full weight bearing throughout his entire foot. I suggested to his physical therapist that a heel wedge be added to his existing shoes. As his range of motion improved over the summer with his stretching program, I could decrease the shoe wedges in the fall to accommodate his improved ROM. The heel wedges would give Abe appropriate proprioceptive feedback that he currently lacks when he is up on his toes.

The plan was in place, and the community provided funds to get the wedges added to the shoes. I proceeded to cast Abe for bilateral DAFO 2s. During the casting process, I concentrated on correcting Abe’s ankle to his end range of motion of 90 degrees while maintaining his hind foot at vertical. As I mentioned, Abe’s hind foot positioning is fairly normal, but his Achilles tendons are tight. I cast Abe’s leg fairly high and specified a height for the finished braces so that I could maximize the leverage of his long legs in blocking the excessive plantar flexion. His forefoot was cast in a neutral position. The casts came out beautifully at the angles I anticipated in the finished braces.

I returned to Abe’s school to fit the braces with his physical therapist present. The braces fit well with minor adjustments to the toe plate due to excessive length. I had to do some minor flaring around the proximal edge of the 5th metatarsal heads. The braces fit into Abe’s existing Hatchback shoes. At first, the lifts were not added, to make sure the braces would fit into his shoes. Otherwise the family would have needed to purchase a new pair for him. As I suspected, Abe shifts his weight forward on the balls of his forefeet and walks on his toes without the lifts. If he didn’t compensate by walking up on his toes, Abe’s center of gravity would fall behind his knees due to his knee flexion contracture, causing him to fall backwards. The lifts on his shoes will accommodate the knee flexion contracture and allow weight bearing and proprioception throughout his entire foot. I took his shoes along with me to get the heel wedges added and planned to return to Abe’s home for final delivery of everything.

I went to Abe’s home to deliver the shoes, which had a 1½-in. heel wedge added to the shoes to accommodate the 25-degree knee flexion contracture. The wedge was thick at the heel with the full 1½ in. and tapered to the ball of the foot. I had the wedge inserted within the sole. Once Abe wore the DAFO 2 plantarflexion block braces, set at 90 degrees, in the wedged shoes, he was able to walk with his knees in as much extension as they allowed (Fig. 4). Yet his feet were in full contact with the ground. His aunt was present during the fitting; she commented on the improvement the braces and shoes were providing to his internal rotation. She remarked that Abe normally walks with significant in-toeing, but with the shoes and correction of the braces, his feet were in much better alignment. I reemphasized to his aunt the importance of Abe stretching regularly so that the lifts could be reduced in the fall.

Abe’s good foot alignment and quadricep muscle strength allow us to go outside of the normal range of options. Though a DAFO 2 wouldn’t be the first brace that comes to mind for the crouching patient, in his case that design goes straight to the root of the problem, allowing him to stretch beyond the range of a static brace.

My thanks to the family for participating in this video case study.

—Cindy Diener

[Stay tuned to hear Cindy’s followup assessment in the winter (December) Dafo Dynamics.—Ed.]


Cindy Diener, C.P.O., has a degree in prosthetics and orthotics from the University of Washington (1994). She has been with us for 13 years, working clinically for Cascade P&O and presenting at workshops and trade shows for Cascade DAFO.

Fig. 1. Abe walking in the walker, without a DAFO. Fig. 2. Abe walking completely on his own. Fig. 3. Abe in his previous orthotics, DAFO 4s. Fig. 4. Abe in his new DAFO 2s. As he gains proprioceptive feedback in his heels and stretches his hamstrings, we’ll decrease the heel wedges, currently 1½ inches.