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Complex ankle equinus case

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kahuna, Jul 7, 2008.

  1. Kahuna

    Kahuna Active Member


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    Hi there

    This is my first post, and I really need it!

    I have a pt of 70 who has legs anatomically the same length (measured from sternum and ASIS).

    When she walks, a severe pelvic twist (under physio mgmt) makes her (L) leg barely touch the ground, which the (R) leg is heavily overloaded.

    I am torn between a heel raise as part of an orthotic for the (L) side, but don't want to reinforce poor pelvic issues as there is not really a leg length differential to correct.

    To complicate matters further, she has an ankle equinus (even when lying prone with knee flexed) on the (R) leg - so it could be argued that a heel lift is needed there to help dorsiflexion.

    I'm concerned that too many heel lift issues (if used bilat) will make her feel like she's walking out the rear of her shoes and make her more unstable... but something clearly needs to be done.

    Anyone got any experience pls?

    Thx
     
  2. Re: Ankle equinus compexities !

    Give her a walking stick
     
  3. drsarbes

    drsarbes Well-Known Member

    Re: Ankle equinus compexities !

    Hi Pete:

    Simon may have a point, but just for completeness sake:

    What is her complaint?
    Duration?
    Neuro and Ortho History?

    Sternum to ASIS......OK. How about ASIS to medial malleolus?

    Diagnosis first, treatment second.

    Steve
     
  4. Kahuna

    Kahuna Active Member

    Re: Ankle equinus compexities !

    Thanks for the reply Steve

    Sorry for the confusion... I meant that both sternum to med malleolus and
    ASIS to med malleolus measurements showed leg length equality.

    Her complaint is (R ) fibula and (R) ITB pain, which moves up to (R) pelvic girdle, SIJ and coccyx.

    The notable history is that she never had a gait pattern (L) leg missing the ground (and (R) leg overloading until (1997) when a (R) leg DVT was misdiagnosed as sciatica for 3 months.

    Once the vascular surgeons made the call and cleared the DVT, she has had the walking inequality.

    Thanks folks
    Pete
     
  5. drsarbes

    drsarbes Well-Known Member

    Re: Ankle equinus compexities !

    "The notable history is that she never had a gait pattern (L) leg missing the ground (and (R) leg overloading until (1997) when a (R) leg DVT was misdiagnosed as sciatica for 3 months."

    Ok. Sounds as though her underlying etiology stems from her surgery.
    How soon after the procedure did she witness gait changes? Did her surgeon tell her theere were complications? Have you talked with him (or her)?

    Did you do a neurological exam? Deep tendon reflexes present and normal?
    Dermatome asymmetries?
    Muscle strength?

    I'm still not clear as to her gait pattern. Is it possible to post a video of her?

    Just from what you have told us, I would say she had a complication of her thrombectomy (if that's what she in fact had done) and more than not nerve damage. Do you know if she had spinal anesthesia? Any evidence of a post stroke syndrome?

    Steve
     
  6. Kahuna

    Kahuna Active Member

    Re: Ankle equinus complexities !

    "Did you do a neurological exam? Deep tendon reflexes present and normal?
    Dermatome asymmetries?
    Muscle strength?"

    All neurological tests were normal, but muscle strength diminished on (R ) foot dorsiflexion/eversion/inversion so that she can only mobilise without any operator resistance. when I physcially hold the (R) foot all muscle power is lost.

    I've put a call out for her surgeon to respond to me with Q's about the DVT management as she doesn't recall/explain well - which may be a post CVAsyndrome as you suggested. She certainly feels that no complications have been previousky reported to her.

    I'll try and get her back in for gait video... but basic summary is that the (L) leg acts like a functionally short limb, ie, supine foot, early heel-off... the (R) leg acts like longer limb, ie, p/w lower medial arch & overpronation (also due to equinus).
    (r) hip is higher than (l) but legs are same length.
    (L) shoulder is higher than (R) shoulder due to scoliosis
    (L) eye is slightly higher than (R) eye and cervical neck area is sore bilat.

    Thanks for your continued interest Steve
     
  7. Stanley

    Stanley Well-Known Member

    Re: Ankle equinus compexities !

    Pete,

    Sounds like there is a contracture of the right gastroc-soleus as a result from the surgery.
    The resulting equinus would make the leg function longer, but measurements from the ASIS to the medial malleolus and the sternum to the ASIS would be normal.
    If there is scarring of the muscle and or tendon, then this could be helped by soft tissue work (cross friction massage, etc. ) If you can't get the leg to loosen fully, then a heel lift for the equinus, and an equal amount of heel lift on the opposite side with an equivalent sole lift would balance the body.

    Regards,

    Stanley
     
  8. drsarbes

    drsarbes Well-Known Member

    "All neurological tests were normal, but muscle strength diminished on (R ) foot dorsiflexion/eversion/inversion so that she can only mobilise without any operator resistance. when I physcially hold the (R) foot all muscle power is lost."

    So all muscle groups on the right are poor to fair. Correct? And she has normal DTR?
    I assume her upper extremity is normal.
    You mention scoliosis in your last post. Does her scoliosis predate her surgery?


    disuse atrophy could cause the decreased muscle strength you observe without a neuro component. Stan may be correct, if she has damage to her gastroc-soleus complex from her DVT/Surgery she may have developed a more regional disuse due to her gait pattern.

    Other than the above explanation, I cannot think of any other LOCALIZED cause of her gait pattern. All others are more central in etiology (i.e., post CVA, scoliosis, UMNL, MS, etc......)

    Steve
     
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