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All,

I have a patient with right-sided hemiparesis following meningitis and CVI as a child. Due to the developmental delay on this side, she also has an LLD with associated scoliosis.

Her barefoot gait is of a spastic dropfoot (in essence) with ground contact occuring first on the forefoot with the toes going into extreme plantarflexion, making barefoot walking extremely painful as the toes curl right under the forefoot. The heel does not appear to make ground contact and the ankle is unstable into inversion / eversion, causing tib post dysfunction (which is her problem and pain).

My quandry is how to cast her and wether an AFO would be any better than an orthotic (perhaps plus shoe modifications). Just to explain, she has no control over the spasticity and could go into spasm at any point during the casting procedure.

Has anyone been here before? Perhaps custom-made is not the way to go, thereby avoiding the casting procedure altogether?

Any help would be appreciated!

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nicpod1

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Nic, there is almost no chance of finding a prefabricated AFO that will meet her needs. The casting procedure doesn't take that long... I'd take a chance, because the plaster's not thick enough to do her much damage. The worst you'll get is a bad impression. In my experience of these sorts of patients, foot orthoses are frequently redundant, as most of the foot is not brought into contact with the ground, hence you're not really controlling much.
You are correct though.. an AFO by itself will probably be less effective unless you do either shoe mods or a build-up on the actual orthosis to compensate for the LLD.

Are there any muscles actually working that you want to preserve the function of?

Richard

Tough case. It appears that she needs some sort of AFO, I doubt that a FO will be enough.

Can she be ranged to ankle neutral (despite spasm)? If so, attempt casting in a semi-weight bearing postion (sitting). I would first try a MAFO, or perhaps a TRAFO (tone reducing AFO) if toes still go into spastic flexion(won't help if the toe flexion is due to passive insufficiency- if so stretch long flexors). If the spasm/equinus is too much, consider physiotherapy, botox blocks, medication for spasm (I don't handle this and refer out)- then cast for MAFO.

If this doesn't seem feasable, perhaps a double upright AFO with heel lift to accomadate the equinus provided it is her short side.

Found a good article for you on TRAFO's:

http://www.oandp.org/jpo/library/1993_01_001.asp

Not enough info.

What is passive range of motion? Does this elicit spasm? What is active available motion?
What happens when you try to assess muscle strength? Does this elicit pain or spasm? I'm not quite sure what you mean by spastic dropfoot.
What are the reflexes? Hyper?

Regards,
Eric Fuller

Thanks for your replies - I will look at the links on the TRAFO.

More info for Eric:

1) Spastic dropfoot - she walks with a similar motion to a drop foot (i.e. dorsiflexors do not create foot clearance of the ground), but it is held in spasm, not flacidity, by the digital plantarflexors going into spasm (I don't know how else to best describe this gait). Inversion is also being caused by tib ant.

2) She has no resriction in joint movement, as far as can be ascertained, other than that caused by muscles going into spasm.

3) Merely touching the foot (myself), causes a spastic reaction. When sitting, the foot continually goes into spasm, as does her right arm, and she has to push her foot down with her other foot to try to prevent this. The motion of the spasm is dorsiflexion by tibialis anterior only (no EHL or FDL activity), thereby, there is also inversion of the rearfoot in this motion and dorsiflexion of the 1st met, but her toes are going into plantarflexion at the same time)

4) No pain is elicited when resisting these movements.

5) She is one 2 types of muscle relaxants and has had botox in leg and arm

6) She does have enough range at the ankle to cast for an AFO, but she can't maintain that position as the spasticity goes on and off, but perhaps I could stimulate the tib. ant. by touch during that casting to try and keep it there. In this position though, the toes would be plantarflexed right down, rearfoot inverted and 1st ray dorsiflexed, which wouldn't be great!

What I'm trying to achieve though is control of pronation / supination to alleviated tib post dysfunction.

thanks for the help!

P.S. Reflexes are of an upper motor lesion

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nicpod1

Dear Nicpod

From a biomechanical point of view I would consider what I ned to do to normalise the gait.

The right leg is short and there is foot drop with spasm in the FDL (I assume)?
Is it all the toes including hallux or just lesser toes. Is the FDL or other muscular spasm or tonicity causing the foot drop or is the ant tib weak. This is important to know if designing an intervention.

What is needed is to address the LLD (if it is significant) some intervention to extend the toes (this will probably involve surgery) and reduce or eliminate the foot drop. A FFO can't achieve this. A built up rocker shoe might balance the lld and foot drop but may tend to hyperextend the knee. A SAFO from Dorset Orthopaedics and a modified shoe might work. As Eric said It all depends on the quality of RoM of the ankle. To know how to design an AFO with the correct stiffness it will be necessary to know much more data about the kinetics and kinematics of the gait. Maybe you would like to allow some ankle plantarflexion at toe off for instance. How will you know how stiff the AFO should be.

I think this would be a difficult case without much more data available to you and is bound to be multi disiplinary.

Cheers Dave Smith

I think I understand. She has a spastic posterior group that plantar flexes the ankle during swing so she has to have knee and hip flexion to clear the swing foot.

So, why do think she has posterior tibial dysfunction if there is no pain on testing the posterior tibial muscle?

If she has spasm in the chair, chances are good that she will have spasm wearing an AFO. Sounds uncomfortable. You also mentioned that she hits forefoot first and has inversion/eversion instability. Is it inversion or eversion? To prevent sudden motion in either direction you could use one of those stirrup (Aircast) type devices. These allow ankle motion. The problem sounds like its coming from the spasticity. That's going to be difficult to treat with a foot related device.

Regards,

Eric

Thanks everyone for all your advice about this patient. I thought long and hard about what to do and ended up casting for a foot orthotic!

My reasoning:

1) Have never done any of the AFOs recommended and did not really want to experimeny on this young, privately paying girl!
2) Managed to get hold of consultant referral, which, typically, was lost until the casting appt! Consultant had also asked for an orthotic, so took this on board!
3) Re-evaluation (which was difficult as unshod walking was not possible due to pain of toes curling under foot) of her condition suggested that primarily, ground contact was forefoot first, with tib ant in spasm, causing a large forefoot varus, which then caused an eversion motion from the front of the foot carrying through to the rearfoot as the heel came closer to the ground, which tib post was trying to resist and which was causing lateral ankle compression and pain. This was also the shorter leg, so eversion continued for some time as heel never quite made ground contact.

Therefore:

1) Casted 'au natural' with foot going into spasm!
2) Asked lab to ignore digits; add large forefoot varus wedge and heel lift, plus deep heel cup and medial flange.
3) Further LLD correction to be done on shoe if patient positive towards this suggestion.

Outcome unknown at present as still at the lab, but will let you know progress and am open to intense criticism if you like!!!!!

Safetys off..................!

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nicpod1