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Tibialis Anterior Rupture

Discussion in 'General Issues and Discussion Forum' started by Rick K., Sep 5, 2011.

  1. Rick K.

    Rick K. Active Member


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    Had a 75 y.o. man come in one month post injury after he jumped off truck tailgate and couldn't walk. Eval by vascular surgeon (daughter is his nurse) and orthopods without any firm diagnosis. Patient complained of "my foot slaps the floor, but not when I start to walk." Also related he now had a know on the front of his lower leg. He's in fairly good shape for 75 - or he wouldn't be jumping off truck tailgates.

    Exam showed a firm nodule at distal anteromedial leg without pain and no TA tendon visible on attempted dorsiflexion as compared to right foot. Forefoot in eversion to rearfoot. Foot doesn't slap floor initially when walking, but progressively contacts floor more forcefully after a few minutes of walking. Has not resulted in any falls.

    Due to the patient's age and the time frame from injury to presentation, I would be reluctant to suggest surgical repair. Was going to place him in an AFO initially to try and maintain foot position and help gait, but patient wanted to wait and see.

    Suggestions?
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. Peter

    Peter Well-Known Member

    seems a logical solution. Consider a rizolli (no casting to do, less in-shoe difficulties)
     
  4. I would go with an the AFO straight away even if something simple rather than waiting for the patient to fall or start to get problems in hip flexors etc.
     
  5. RobinP

    RobinP Well-Known Member

    My money is on the AFO. Rizzoli also a good suggestion although some people are not keen on the shoe adaptation required and it is a good deal more pricey thatn an off the shelf AFO.

    Pt needs to know that he endagers himself not following your treatment plan. he might be spritely for a 70 year old but he won't be so spritely if he fractures his neck of femur following a trip on a kerb stone

    Robin
     
  6. Mark2

    Mark2 Member

    Would a walking boot with a rocker bottom do a similar job to an AFO?
    Mark.
     
  7. BAMBLE1976

    BAMBLE1976 Active Member

    Hi

    The walking boot would be insuffiecient if there is no dorsiflexion power present. He will need some form of AFO i.e. Drop foot splint or similar.

    Barry
     
  8. RobinP

    RobinP Well-Known Member

    Mark,

    Looking at the forces, it is unlikely that the resistance to the plantarflexion moments offered by a walking boot would be outweighed by the external plantarflexion moment created by the mass of a rocker sole times the distance from the talo crural joint axis to the location of the rocker sole.

    I would imagine that it might make the situation worse. We need a David Smith style drawing here to demonstrate the forces I think!

    Robin
     
  9. Rick:

    An AFO of some sort for this gentleman is a must to prevent tripping, prevent a steppage gait pattern and to allow more normal ambulation. As an immediate demonstration for a patient of how an AFO would work at help making gait more efficient in my clinic, I will sometimes use 1" cloth adhesive tape to attach the dorsal midfoot of the shoe to their pants leg (loop tape around midfoot of shoe then loop tape around proximal tibia to form a "tape sling" that prevents plantarflexion) to hold the ankle from plantarflexing past 90 degrees. I then have them walk in my office hallway to allow them to feel the difference that this simple "tape sling" helps with their gait. I have used this "AFO simulation technique" a number of times with my patients over the past few decades to convince them of the importance of preventing the steppage gait pattern that comes with foot-drop deformities.

    Hope this helps.
     
  10. efuller

    efuller MVP

    Mechanical analysis of anterior tibial absence/weakness:
    You want your treatment to apply a dorsiflexion moment at the ankle. So, a force applied to the bottom of the foot somewhere distal to the ankle joint axis is needed. So, the device, AFO or Boot, will have an equal and opposite reaction of the foot applying a downward force on the boot. The device will tend to slide down the leg unless there is a force from the leg to keep the device from sliding. This is the tough part in making an AFO. If you have a really skinny leg there is not much to grab on to. The most common way is to have a strap that will create a frictional force at the device/ leg interface.

    The force needed to dorsiflex the ankle is usually not that high. So, the frictional force doesn't need to be that high. If you use a walker, which will tend to be heavier than an AFO, the frictional force will need to be a bit higher. If the patient, still has some plantar flexion power in their gastroc soleus, and they choose to use it, then you will tend to get more sliding.

    So, if someone walks in with a drop foot... You look in your closet and all you see is a walker, it might work. It might not be the best solution. The shape of the leg will matter....

    Understanding Phyzzzzics helps in understanding treatments.

    Eric
     
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