Replies to questions about a case
Paula Martinek
Description
Collection
Title:
Replies to questions about a case
Creator:
Paula Martinek
Date:
12/10/2008
Text:
Hello all, these are the replies on my patient. I have not seen her back in the office as of yet, she has been ill. My main idea right at the moment is to start simple. I don't think she is able to handle her foot being dorsiflexed to neutral. Something about her not being able to plantarflex is throwing off some kind of synergy. I may adjust the stop to allow plantarflexion, gradually increasing it to stretch out the achilles along with a simple heel lift on the brace side to prevent a hyperextension moment at the knee. Or as someone suggested, put ROM brace on the patient with the knee set in flexion to see how she ambulates. I can let you know how it works out meanwhile here are some responses that I got. I don't have all of them due to my accidental deleting things off my e-mail that I would rather have kept. I can make a brace, apparently can't work a computer.
Original post: To give you a little more detail: in gait she starts with> the right leg and drags left leg to, not through. She seems> to be unable to flex the knee and hip of left leg, so she is> not swinging the left side through. She keeps the left foot> in about 7 degrees of plantarflexion, so that she is bearing> weight on the ball of the foot in stance. She can swing> right leg through, still plantarflexed on the left. If she> concentrates she can get her heel to the floor while> standing, thus bringing ankle to nearly neutral. Her foot> can be brought to neutral while sitting and with knee in> extension and sitting. There is no heel rise in the AFO.> When she is wearing the AFO she can't drag the foot> through in swing phase. She steps with the right and then> it seems as if her left foot gets 'stuck' and she> can't move. As far as muscle strength, hamstring> strength is poor, along with hip flexion on left side. Quad> strength on left is fair. Dorsiflexion is poor. So besides> having weak hamstrings her knee is tightening up with> weightbearing making it almost impossible to flex the left> knee.> It's the fact that her left leg is getting> 'stuck' with the left AFO on that is odd to me. I> would imagine the brace would allow clearance and facilitate> swing phase, but the opposite seems to be happening. I have> to assume that in bringing the foot to neutral is stretching> the achilles and the gastroc muscle too much, thus adding to> the spasticity of the knee and the hip.
Responses:
As for the sticking of the left side, I am assuming this is at pre-swing? If so, have you considered that the weight of the orthosis may be overloading the ability of poor hip flexors to initiate the swing through? I learned long ago that just because we are clearing the foot with an afo doesnt mean we get clearance. Hip flexion is equally as important, as are hamstrings and quads. I think you should be looking more proximal for your problem. Your assumption of spasticity of the gastroc group doesn't seem right to me. How is the gastroc group going to impact the hip flexors, or knee for that matter? If this is a CVA (sorry, can't remember the Dx) are you dealing with extensor tone patterns that overpower any intervention you propose? If extensor patterns are the issue, makes sense when seated, plantarflexion deminishes. However your report that while seated and knee extended, foot also comes back tonormal is not consistent with my experience of extensor tone patterns. Stranger things have happened with this neurological trauma.Anyway, based on what you are telling us, you might be out of luck in helping this patient with an orthosis. That does happen. However one last thought. If quads are fair, and patient presents with 7 degrees of plantar flexion, maybe consider a floor reaction AFO with ankle at about 3 degrees of plantarflexion. This would provide a posterior force vector at the knee giving her stability. Problem may still be weight of orthosis preventing the initiation of swing
These are my thoughts on possible reasons for what you areseeing.1. Physiologic: There is some powerful extension synergypattern that is making swing on the L challenging. Pt istrying to plantarflex into the Ox and essentially isgetting her foot stuck on the ground. Added to that, theGlutes and Quads may be active?2. Biomechanical: Pt has shortened her R side step lengthbecause L leg is functionally shorter, and 'functionaltibial progression' of the L is inhibited. This makes itmore difficult for the Pt to balistically swing the L legas would be required in someone with weak hip flexors. (noheel rise in the AFO is evidence of this.)3. Friction: Because there is no heel rise in the AFO, thePt is not able to overcome 'friction' caused by the groundcontact with the entire shoe between the L foot and thefloor to clear the foot from the ground.4. balance and confidence. The new gait pattern means Ptnow feels unstable transfering weight from the L to the Rleg and is not comfortable shifting body weight to R andlifting the L without fear of falling.5. Some combination of all 4 of the above or other factors.
What is her diagnosis? When dealing with a neuromuscular disease she is dealing with the inability to fire her muscles in normal sequence. This would account for her freezing her left foot when she cannot plantarflex. In certain CP patients this happens causing them not to be able to move the extremity forward. You might want to try a little experiment by positioning her knees in about 15 degrees of flexion with rom knee joints and then watch how she ambulates. This position is the early phase of a crouch gait. If she seems to be able to bring the extremities forward without locking out the left leg then you are dealing with reciprocal interruption which usually is not well controlled by an AFO set to neutral. When working with crouch gait and setting up their orthosis we constantly battle for a fine balance to get them to ambulate bring one foot in front of the other. In most cases a walker with wheels is used to provide support and balance and rarely do they walk without some circumduction. The AFO is usually set up with joints either dual action or dorsi assist and many times setup as a floor reaction trimline. I hope this helps.
Thank you for your responses and Happy holidays.
Paula martinek, LPO
Original post: To give you a little more detail: in gait she starts with> the right leg and drags left leg to, not through. She seems> to be unable to flex the knee and hip of left leg, so she is> not swinging the left side through. She keeps the left foot> in about 7 degrees of plantarflexion, so that she is bearing> weight on the ball of the foot in stance. She can swing> right leg through, still plantarflexed on the left. If she> concentrates she can get her heel to the floor while> standing, thus bringing ankle to nearly neutral. Her foot> can be brought to neutral while sitting and with knee in> extension and sitting. There is no heel rise in the AFO.> When she is wearing the AFO she can't drag the foot> through in swing phase. She steps with the right and then> it seems as if her left foot gets 'stuck' and she> can't move. As far as muscle strength, hamstring> strength is poor, along with hip flexion on left side. Quad> strength on left is fair. Dorsiflexion is poor. So besides> having weak hamstrings her knee is tightening up with> weightbearing making it almost impossible to flex the left> knee.> It's the fact that her left leg is getting> 'stuck' with the left AFO on that is odd to me. I> would imagine the brace would allow clearance and facilitate> swing phase, but the opposite seems to be happening. I have> to assume that in bringing the foot to neutral is stretching> the achilles and the gastroc muscle too much, thus adding to> the spasticity of the knee and the hip.
Responses:
As for the sticking of the left side, I am assuming this is at pre-swing? If so, have you considered that the weight of the orthosis may be overloading the ability of poor hip flexors to initiate the swing through? I learned long ago that just because we are clearing the foot with an afo doesnt mean we get clearance. Hip flexion is equally as important, as are hamstrings and quads. I think you should be looking more proximal for your problem. Your assumption of spasticity of the gastroc group doesn't seem right to me. How is the gastroc group going to impact the hip flexors, or knee for that matter? If this is a CVA (sorry, can't remember the Dx) are you dealing with extensor tone patterns that overpower any intervention you propose? If extensor patterns are the issue, makes sense when seated, plantarflexion deminishes. However your report that while seated and knee extended, foot also comes back tonormal is not consistent with my experience of extensor tone patterns. Stranger things have happened with this neurological trauma.Anyway, based on what you are telling us, you might be out of luck in helping this patient with an orthosis. That does happen. However one last thought. If quads are fair, and patient presents with 7 degrees of plantar flexion, maybe consider a floor reaction AFO with ankle at about 3 degrees of plantarflexion. This would provide a posterior force vector at the knee giving her stability. Problem may still be weight of orthosis preventing the initiation of swing
These are my thoughts on possible reasons for what you areseeing.1. Physiologic: There is some powerful extension synergypattern that is making swing on the L challenging. Pt istrying to plantarflex into the Ox and essentially isgetting her foot stuck on the ground. Added to that, theGlutes and Quads may be active?2. Biomechanical: Pt has shortened her R side step lengthbecause L leg is functionally shorter, and 'functionaltibial progression' of the L is inhibited. This makes itmore difficult for the Pt to balistically swing the L legas would be required in someone with weak hip flexors. (noheel rise in the AFO is evidence of this.)3. Friction: Because there is no heel rise in the AFO, thePt is not able to overcome 'friction' caused by the groundcontact with the entire shoe between the L foot and thefloor to clear the foot from the ground.4. balance and confidence. The new gait pattern means Ptnow feels unstable transfering weight from the L to the Rleg and is not comfortable shifting body weight to R andlifting the L without fear of falling.5. Some combination of all 4 of the above or other factors.
What is her diagnosis? When dealing with a neuromuscular disease she is dealing with the inability to fire her muscles in normal sequence. This would account for her freezing her left foot when she cannot plantarflex. In certain CP patients this happens causing them not to be able to move the extremity forward. You might want to try a little experiment by positioning her knees in about 15 degrees of flexion with rom knee joints and then watch how she ambulates. This position is the early phase of a crouch gait. If she seems to be able to bring the extremities forward without locking out the left leg then you are dealing with reciprocal interruption which usually is not well controlled by an AFO set to neutral. When working with crouch gait and setting up their orthosis we constantly battle for a fine balance to get them to ambulate bring one foot in front of the other. In most cases a walker with wheels is used to provide support and balance and rarely do they walk without some circumduction. The AFO is usually set up with joints either dual action or dorsi assist and many times setup as a floor reaction trimline. I hope this helps.
Thank you for your responses and Happy holidays.
Paula martinek, LPO
Citation
Paula Martinek, “Replies to questions about a case,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/229911.
