This 1987 landmark study by Winters, Gage, and Hicks used computerized kinematics and dynamic EMG to classify spastic hemiplegic gait. 46 patients were grouped into four patterns based on the level of proximal involvement. The classification directly guides which joints need surgical or orthotic treatment.
Before this classification, treatment of spastic hemiplegic gait was empirical — surgeons routinely lengthened the Achilles tendon in any patient who walked on their toes, regardless of whether the heel cord was actually tight.
Winters showed that Group I patients dorsiflex normally in stance, meaning the calf is not shortened. Lengthening the Achilles in these patients removes what little plantar flexor power they have and worsens gait. The correct treatment is a leaf-spring AFO to manage swing-phase drop foot.
When you see a child with hemiplegic CP in clinic, classify the gait before recommending surgery: check stance-phase dorsiflexion first. If it is preserved, do not touch the Achilles. If the knee arc is less than 45° or the hip arc less than 35°, treatment must address those joints too.
This paper established the principle that gait analysis should drive surgical decision-making in cerebral palsy — a concept that remains the foundation of modern CP orthopedic practice.
This 1987 landmark study by Winters, Gage, and Hicks used computerized kinematics and dynamic EMG to classify spastic hemiplegic gait. 46 patients were grouped into four patterns based on the level of proximal involvement. The classification directly guides which joints need surgical or orthotic treatment.
Before this classification, treatment of spastic hemiplegic gait was empirical — surgeons routinely lengthened the Achilles tendon in any patient who walked on their toes, regardless of whether the heel cord was actually tight.
Winters showed that Group I patients dorsiflex normally in stance, meaning the calf is not shortened. Lengthening the Achilles in these patients removes what little plantar flexor power they have and worsens gait. The correct treatment is a leaf-spring AFO to manage swing-phase drop foot.
When you see a child with hemiplegic CP in clinic, classify the gait before recommending surgery: check stance-phase dorsiflexion first. If it is preserved, do not touch the Achilles. If the knee arc is less than 45° or the hip arc less than 35°, treatment must address those joints too.
This paper established the principle that gait analysis should drive surgical decision-making in cerebral palsy — a concept that remains the foundation of modern CP orthopedic practice.