Which functional impairments are the main contributors to pelvic anterior tilt during gait in individuals with cerebral palsy?

•Excessive pelvic tilt ROM is associated with increased knee flexion at initial contact but reduced knee ROM.•Clinically, mainly increased proximal spasticity as tested by Tardieu is associated with increased pelvic tilt ROM.•In contrast, mean pelvic tilt is mainly associated with strength imbalance between knee extensors to flexors.•Mean pelvic tilt in gait is associated with reduced hip extension and increased pelvic obliquity ROM and trunk obliquity ROM.

While past investigations focused on describing pelvic motion patterns in the frontal and transversal plane, the sagittal plane “double bump” pattern commonly found in children with cerebral palsy was only rarely investigated, especially concerning the underlying pathology.375 ambulatory (GMFCS I-III) patients with bilateral spastic cerebral palsy were included in this study. Gait and clinical data (ROM, strength, spasticity) were classified in two different ways: (a) into two groups of normal and enhanced mean anterior pelvic tilt and (b) into two groups of moderate and excessive ROM in pelvic tilt.The results reveal that increased mean pelvic tilt is mainly associated with gait features of reduced hip extension and increased pelvic and trunk obliquity ROM but with increased knee ROM. In the clinical exam this corresponds to a smaller passive knee extension deficit and reduced knee flexor strength. It seems that flexors to extensors strength imbalance at the knee is a major feature why mean pelvic position is tilted anterior whereas maximum passive hip extension is of minor importance.Contrarily, excessive sagittal pelvic ROM is associated with increased knee flexion at initial contact and reduced knee ROM. Furthermore, Duncan-Ely- and Tardieu-tests show both increased values in this group with excessive pelvic range of motion indicating for spastic rectus femoris activation.The results of our study indicate that the two gait variables are influenced by different specific mechanisms which are now described for the first time. Since the pelvis plays a central role during gait, these findings should be considered when planning single event multilevel surgery in patients with cerebral palsy.