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Achilles Tendon Length and Medial Gastrocnemius Architecture in Children With Cerebral Palsy and Equinus Gait

Wren, Tishya A. L. PhD* † ‡ § ∥; Cheatwood, Allison P. MS* §; Rethlefsen, Susan A. PT*; Hara, Reiko MA*; Perez, Francisco J. BA; Kay, Robert M. MD* ‡

Journal of Pediatric Orthopaedics: July-August 2010 - Volume 30 - Issue 5 - p 479-484
doi: 10.1097/BPO.0b013e3181e00c80
Cerebral Palsy

Background The aim of this study was to examine both the tendon and muscle components of the medial gastrocnemius muscle-tendon unit in children with cerebral palsy (CP) and equinus gait, with or without contracture. We also examined a small number of children who had undergone prior surgical lengthening of the triceps surae to address equinus contracture.

Methods Ultrasound was used to measure Achilles tendon length and muscle-tendon architectural parameters in children of ages 5 to 12 years. Muscle and tendon parameters were compared among 4 groups: Control group (N=40 limbs from 21 typically developing children), Static Equinus group (N=23 limbs from 15 children with CP and equinus contracture), Dynamic Equinus group (N=12 limbs from 7 children with CP and equinus gait without contracture), and Prior Surgery group (N=10 limbs from 6 children with CP who had prior gastrocnemius recession or tendo-achilles lengthening). The groups were compared using analysis of variance and Scheffe post hoc tests.

Results The CP groups had longer Achilles tendons and shorter muscle bellies than the Control group (P<0.001). Normalized tendon length was also longer in the Prior Surgery group compared with the Static Equinus group (P<0.001). The Prior Surgery group had larger pennation angles than the CP groups (P≤0.009) and tended to have shorter muscle fascicle lengths (P≤0.005 compared with Control and Static Equinus, P=0.08 compared with Dynamic Equinus). Similar results were observed for pennation angles and normalized muscle fascicle lengths throughout the range of motion.

Conclusions Children with spastic CP and equinus gait have longer-than-normal Achilles tendons and shorter-than-normal muscle bellies. These characteristics are observed even in children with dynamic equinus, before contracture has developed. Surgery further lengthens the tendon, restoring dorsiflexion but not normal muscle-tendon architecture. These architectural features likely affect function, possibly contributing to functional deficits such as plantarflexor weakness after surgery.

Level of Evidence Level II, prospective comparative study.

*Children's Orthopaedic Center

Department of Radiology, Children's Hospital Los Angeles

Departments of Orthopaedics

§Biomedical Engineering

Radiology, University of Southern California, CA

Funding for this study was provided by the United Cerebral Palsy Research and Educational Foundation grant number R-767-04.

Reprints: Tishya A. L. Wren, PhD, Children's Hospital Los Angeles, 4650 Sunset Blvd., ♯69, Los Angeles, CA 90027. E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.