Patient
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Female, early 60’s
Generally healthy and been active in sport and ballet and dance all her life.
Walking was normal and brisk pre incident.
Incident
History of sciatica resulting from significant disc bulge
Had laminectomy 2 years ago to L5/S1
Since then has had numbness to the plantar foot and around the heel and slightly up into the Achilles - bilateral
Main concern:
Is in her current walking ability. Walking post surgery is problematical in that she is unable to initiate unilateral heel lift in gait.
Observations
1. In bilateral stance, she can initiate a slight jump (swinging her arms upwards) that allows her then to go up onto her toes. This involves a slight forward lean and use of the arms to generate power. Once there she can maintain it a while but does exhibit weakness by starting to go over laterally at the ankles.
This cannot be done unilateral
2. Once on her toes bilaterally, unilateral toe walking is possible but at huge energy expenditure, instability and use of the whole upper body in a manner resembling someone with marked co-ordination problems.
Conversely, heel walking gives her a sense of normal walking without the need for the exaggerated pelvic and hip function and marked torso and arm rotation
3. When walking she has to exaggeratedly rotate the pelvis and torso, slightly hitch the pelvis to generate unilateral forward propulsion as she cannot generate heel lift.
4. Slightly heeled foot wear makes no difference in ability to initiate unilateral stance.
5. Standing with knees slightly flexed, bilateral or unilateral, does not help in initiating heel raise
6. NWB dorsiflexion and plantar flexion power against resistance is normal but there is poor eversion and inversion power against resistance.
7. Has reduced calf bulk bilateral, especially soleus
8. She has been informed by a neurological consultant that nerve conduction tests show irrevocable degeneration of the nerves to the low leg, Achilles reflex is very poor to none existent bilateral.
Current considerastions
Am considering footwear adaptations that may allow some roll onto the ball of the foot to see if that helps. I feel something like the MBT with its negative heel is not appropriate for gait because postural stability is already compromised, however, at the back of my mind I do wonder if they might serve as an exercise function in stance only to see if anything could get the triceps waking up (badly put but been a long day!!).
Equally, I wondered if there is any material that could be used in the heel that would give adequate energy return that may help in unilateral heel raise. Trouble is I don’t know if it is unilateral carrying of body weight that inhibits further the initiation of heel lift or if it is just a neurological issue that cannot be overcome no matter what we do.
Thoughts and suggestions would be valued even if it is just a case of saying we can’t do anything.
Thanks
Ian
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