Early Knee Protocols Encourage Typical Motor Development in Young Patients

Mark Geil, PhD
Mark Geil

CHICAGO – In a study of seven children aged 3 to 5 years old, Mark Geil, PhD, associate professor of biomechanics at Georgia State University and O&P Business News Practitioner Advisory Council member found that when given an articulating knee, as opposed to the favored locked, fully-extended knee, children present with reduced clearance adaptations and — in turn — experience a more eased transition to walking.

“We expected clearance adaptations, but it is another piece of evidence in our hopefully growing body of evidence that will change this treatment protocol,” Geil said at the American Academy of Orthotists & Prosthetists Annual Meeting and Scientific Symposium. “These kids do very well on an articulating knee … we can debate this point for hours and there are still folks who look at our evidence and say to us, ‘No, the kids will fall over. They don’t have the stability or the hip motor control to accommodate an articulating knee.’ We disagree and are building the evidence to show that.”

At least one of the three clearance adaptations within the study – hip hiking, vaulting and circumduction – were present in all seven cases of the locked knee joint. In two cases, a child presented with more than one adaptation. When fitted with an articulating knee, only one child presented with a clearance adaptation. The same child presented with the same clearance adaptation while using a locked knee.

Geil’s focus is on the long-term implications for children who do not learn to walk with an articulating knee.

“If these kids do not have a knee when they are learning to walk, they develop clearance adaptations and these are some of those gait accommodations that stick with you for a long time,” he said. — by Jennifer Hoydicz

Knee Condition Accomodations
Source: Geil M.


Physical therapists, prosthetists and other practitioners that deal with gait deviations and their long-term consequences often emphasize the notion that building a strong base of appropriate gait mechanics is crucial in preventing injurious habit patterns such as clearance adaptations. This is not only associated with short-term benefit but has lifespan implications. Often, establishing this foundational motor control for gait is a difficult scenario to achieve as the current mindset stresses a different ideology. That is, hurry and provide a prosthesis and the user will ‘figure it out’. Or still a different notion that gait training and other therapies can be successfully administered in a downsized therapy program such as the classic eight sessions approved by many third party reimbursors if authorized at all. Years later, after many years of walking with inefficient and injurious habit gait deviations, there is a strong chance that comorbid overuse syndromes or joint degeneration can set in and complicate mobility, comfort and ultimately quality of life.

Geil’s study provides preliminary data making a case for the provision of articulated knees in pediatric cases when children are first learning to walk with a prosthesis. It would not be correct to assume that these children will walk without gait deviations or that they will not develop injurious overuse syndromes however it does look like a shift in the right direction. For practice, their data should give prosthetists ammunition for considering either knee condition (articulated or locked) as viable options as opposed to automatically choosing one in every case.

— Jason Highsmith, DPT, CP, FAAOP
Visiting assistant professor, University of South Florida, College of Medicine, School of Physical Therapy and Rehabilitation Services

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