Effects of solid ankle-foot orthoses with individualized ankle angles on gait for children with cerebral palsy and equinus.

PURPOSE: For children with cerebral palsy (CP) and equinus, the conventional practice of setting the ankle angle in an ankle-foot orthosis (AA-AFO) at 90∘ may not adequately accommodate gastrocnemius length/stiffness. Therefore, this study compared the effects of statically-optimized solid AFOs with individualized AA-AFOs (iAA-AFOs) and conventionally-prescribed AFOs on gait for children with CP and equinus. METHODS: Ten children with CP and equinus (15 limbs with AFOs), and 15 typically-developing (TD) children participated. For the children with CP, solid AFOs with iAA-AFOs (range = 5∘-25∘ plantarflexion) were compared with their usual AFOs using three-dimensional gait analysis. TD children walked in shoes only. Peak values and Gait Variable Scores (GVS) for joint and segment variables were calculated for stance phase. Responses were categorized using 90% confidence intervals relative to TD data, for each affected leg. RESULTS: Net responses to iAA-AFOs were positive for 60% of limbs and negative for 40%. Knee variables (GVS and peak extension, flexion, and midstance moment) were most positively affected, and foot-floor angle and vertical ground reaction force were most negatively impacted. CONCLUSION: Individualized AFO prescription and iAA-AFOs can impact gait biomechanics for some children with equinus, compared to conventionally-prescribed AFOs. Optimizing dynamic alignment for walking may further improve outcomes.

Passive Muscular Insufficiency: The Etiology of Gastrocnemius Equinus.

The current understanding is that gastrocnemius equinus is caused by a pathologic tightening of the muscle leading to decreased ankle joint dorsiflexion. However, an alternative hypothesis is that it is a normal limitation of available muscle length. Passive muscular insufficiency of the gastrocnemius muscle acts on a pathologic foot, which is poorly prepared to accept the forces from the gastrocnemius-soleus complex. In this manner, a normal gastrocnemius muscle exerts abnormal forces across the foot. This alternative hypothesis leads to a different interpretation of the current research literature and a potential new area of biomechanical research.

Stair-shaped Achilles tendon lengthening in continuity - A new method to treat equinus deformity in patients with spastic cerebral palsy.

BACKGROUND: Equinus of the ankle is a common deformity in spastic cerebral palsy. Achilles tendon lengthening is one of the effective options for the treatment of equinus deformity. METHODS: In the study, a new stair-shaped Achilles tendon lengthening (ATL) procedure that preserves of the tendon continuity was performed in 28 tendons with equinus deformity (20 patients, mean age=10.5±2.6 years). The results were compared with a group of patients treated with the Z-lengthening procedure. During the latest follow-up visit, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scale score was much higher in the stair-shaped ATL group than in the Z-lengthening group (p<0.05). RESULTS: The two groups showed similar surgical correction angle after ATL(37.2±3.5° for stair-shaped ATL and 36.1±4.5° for Z-lengthening). During the latest follow-up visit, the correction angle in the Z-lengthening group decreased to 21.6±4.3°, which was lower than in the stair-shaped ATL group (29.0±3.1°; p<0.05). In addition, the data regarding the time required by each patient before being able to start rehabilitation and walking as well as gaining better stability for running indicated that the stair-shaped ATL group recovered significantly quicker than the Z-lengthening group. CONCLUSIONS: The stair-shaped ATL procedure resulted in a successful correction of the equinus deformity in spastic cerebral palsy, with the advantage of preserving a degree of continuity without a complete section of the tendon. This confers greater antigravity stability and quicker recovery in patients.

Validation of a weight bearing ankle equinus value in older adults with diabetes.

BACKGROUND: Accurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion < 30°) in unimpaired cohorts, and secondly to investigate any clinical effects this degree of ankle dorsiflexion restriction has on forefoot plantar pressure variables in older adults with diabetes. METHODS: Ankle dorsiflexion was measured using a Lunge test with the knee extended in young adults without diabetes (YA) and older adults with diabetes (DA). In-shoe and barefoot plantar pressure was recorded for the DA group. Spearman's correlation was calculated to determine any association between the presence of ankle equinus and plantar pressure variables in the DA group. DA group differences in people with and without an equinus were examined. RESULTS: A weight bearing equinus of < 30°, assessed in a lunge using an inclinometer placed on the anterior tibia, falls within the restricted range in young unimpaired cohorts. In the DA group this degree of ankle restriction had a fair and significant association with elevated barefoot forefoot peak pressure (r = 0.274, p = 0.005) and pressure-time integrals (r = 0.321, p = .001). The DA equinus group had significantly higher barefoot peak pressure (mean kPa (SD): 787.1 (246.7) vs 652.0 (304.5), p = 0.025) and pressure-time integrals (mean kPa (SD): 97.8 (41.6) vs 80.4 (30.5), p = 0.017) than the DA non equinus group. CONCLUSIONS: We support a preliminary weight bearing ankle equinus value of < 30°. This value represents a restricted range in young adults and is correlated with increased forefoot plantar pressure variables in older adults with diabetes. Mean population weight bearing ankle dorsiflexion data presented here for older adults with diabetes, will allow use of the more functional Lunge test with knee extended in research and clinical practice.

Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons.

BACKGROUND: Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons. METHODS: We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy. RESULTS: Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy. CONCLUSIONS: An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population. LEVEL OF EVIDENCE: Level III-retrospective cohort.

Conservative treatment for equinus deformity in children with cerebral palsy using an adjustable splint-assisted ankle-foot orthosis.

BACKGROUND: A novel splint, the assisting ankle-foot orthoses (AFO), was developed to provide adjustable sustained stretching to improve conservative treatment for equinus deformities in children with cerebral palsy (CP). The treatment effect was validated by follow-up visits. METHODS: This study involved subjects between 2 and 12 years old, including 28 CP children treated with splint-assisted AFO correction, 30 CP children treated with static AFO correction, and 30 normal children with typical development (TD). Quantitative pedobarographic measurements were taken to evaluate the effect of splint-assisted AFO correction. The heel/forefoot ratio was introduced to indicate the degree of the equinus deformity during treatment. RESULTS: The results showed that the heel/forefoot ratios were 1.41 ±â€Š0.26 for the TD children; 0.65 ±â€Š0.41, 1.02 ±â€Š0.44, and 1.24 ±â€Š0.51 for the splint-assisted AFO correction before and after 6-month and 12-month treatments; 0.59 ±â€Š0.37, 0.67 ±â€Š0.44, and 0.66 ±â€Š0.42 for the static AFO correction before and after 6-month and 12-month treatments. CONCLUSIONS: This study suggests that correction with the adjustable splint-assisted AFO is an effective treatment for equinus deformity in CP Children.

A pilot investigation into the relationship between static diagnosis of ankle equinus and dynamic ankle and foot dorsiflexion during stance phase of gait: Time to revisit theory?

BACKGROUND: Although the clinical assessment of ankle dorsiflexion has traditionally been measured utilising various goniometric means, the validity of this static examination has never been investigated. Since any impairment in ankle flexibility is likely to result in injuries, it is imperative that the correct examination technique is conducted. HYPOTHESIS/PURPOSE: To determine whether a clinical diagnosis of ankle equinus, or limited ankle dorsiflexion, correlates with a decreased dorsiflexion range of movement of the foot and ankle during gait. METHODS: Twenty participants with a clinical diagnosis of ankle equinus underwent optoelectronic motion capture utilising the Rizzoli foot model. Participants were divided into two groups, Group A with <-5° of dorsiflexion and Group B with -5° to 0° of ankle dorsiflexion. RESULTS: Participants in Group B had a mean dynamic ankle dorsiflexion angle of 13.9°, while those in Group A had a mean dorsiflexion angle of 4.4°, resulting in a significant difference (p=0.004) between the two groups. Likewise, foot mean dynamic dorsiflexion angle of Group B was 17.13° and Group A 8.6° (p=0.006). CONCLUSION: There is no relationship between a static diagnosis of ankle dorsiflexion at 0° with dorsiflexion during gait. On the other hand, those subjects with less than -5° of dorsiflexion during static examination did exhibit reduced ankle range of motion during gait.

Real-time feedback of dynamic foot pressure index for gait training of toe-walking children with spastic diplegia.

PURPOSE: The aim of this study was to determine whether and how real-time feedback of dynamic foot pressure index (DFPI) could be used to correct toe-walking gait in spastic diplegic children with dynamic equinus. METHODS: Thirteen spastic diplegic children with dynamic equinus were asked to wear a monitoring device to record their ambulation during daily gait, conventional training gait, and feedback training gait. Parameters based on their DFPI and stride duration were compared among the three test conditions. RESULTS: The results with feedback training were significantly better for all DFPI parameters in comparison to patients' daily gait and showed significant improvements in DFPI for toe-walking gait and percentage of normal gait in comparison to conventional training methods. Moreover, stride duration under two training gaits was longer than patient's daily gait, but there was no significant difference between the two training gaits. CONCLUSIONS: Although the stride duration for the two training gaits was similar, gait training with real-time feedback of DFPI did produce noticeably superior results by increasing heel-loading impulse of toe-walking gait and percentage of normal gait in comparison to convention training methods. However, its effectiveness was still impacted by the motion limitations of diplegic children. Implications for Rehabilitation The DFPI-based gait training feedback system introduced in this study was shown to be more effective at toe-walking gait rehabilitation training over conventional training methods. The feedback system accomplished superior improvement in correcting toe-walking gait, but its effectiveness in an increasing heel-loading impulse in normal gait was still limited by the motion limitations of diplegic children. Stride duration of normal gait and toe-walking gait was similar under conventional and feedback gait training.

Randomized Controlled Trial on Effectiveness of Intermittent Serial Casting on Spastic Equinus Foot in Children with Cerebral Palsy After Botulinum Toxin-A Treatment.

OBJECTIVE: Physical therapy (PT) and botulinum toxin-A (BTX-A) injections are widely used in the treatment of spastic equinus foot due to cerebral palsy. The aim of this study was to show effects of intermittent serial casting (SC) in addition to standard treatment on spasticity, passive range of motion (PROM), and gait. DESIGN: Fifty-one ambulatory patients, treated by BTX-A to plantar flexor muscles, were randomly assigned to casting or control groups in a 2:1 ratio. Both groups received PT for 3 weeks. Casting group additionally received intermittent SC during 3 consecutive weekends. Assessments included Modified Ashworth Scale (MAS), Tardieu Scale, Observational Gait Scale (OGS), and Physician Global Assessment at baseline and posttreatment weeks 4 and 12. RESULTS: Significant improvements in PROM, MAS, Tardieu Scale, and OGS were recorded in both groups (P < 0.001 for all). Average changes in MAS, PROM, angle of catch, spasticity angle, and OGS of the casting group were significantly higher than those of the controls at week 4 (P = 0.006, P = 0.002, P < 0.001, P = 0.005, P = 0.011), and 12 (P = 0.013, P < 0.001, P < 0.001, P = 0.011, P < 0.001). Follow-up Physician Global Assessment also favored casting group (P < 0.001 for both). CONCLUSIONS: Combining intermittent SC with BTX-A injections and PT might provide additional benefits for spastic equinus foot. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) identify treatment options for spastic equinus goot in children with cerebral palsy; (2) explain different approaches of serial casting with an additional model of intermittent casting; and (3) describe the potential benefits of combined treatment modalities, including intermittent serial casting, for spastic equinus foot in children with cerebral palsy. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The relationship between foot posture index, ankle equinus, body mass index and intermetatarsal neuroma.

BACKGROUND: The main purpose of this study was to investigate the presence of an association between intermetatarsal neuroma and foot type, as measured by the Foot Posture Index. The study also examined whether there was a relationship between foot type and the interspace affected with intermetatarsal neuroma, and whether ankle equinus or body mass index had an effect. METHODS: In total, 100 participants were recruited from The University of Western Australia's Podiatry Clinic, 68 of whom were diagnosed with inter-metatarsal neuroma from 2009 to 2015. There were 32 control participants recruited from 2014 to 2015. The age of subjects was recorded, as were weight and height, which were used to calculate body mass index. The foot posture index and ankle dorsiflexion were measured using standard technique. Independent t-tests and Kruskal-Wallis tests were used to compare differences in foot posture index, body mass index and ankle dorsiflexion between the inter-metatarsal neuroma and control groups. Multivariable logistic regression was also used to model relationships for outcome. RESULTS: The 68 intermetatarsal neuroma subjects had a mean age of 52 years (range 20 to 74 years) and comprised of 56 females and 12 males. The 32 control subjects had a mean age of 49 years (range 24 to 67 years) with 26 females and six males. There were no significant differences between the control and the intermetatarsal neuroma groups with respect to the mean foot posture index scores of the left and right foot (p = 0.21 and 0.87, respectively). Additionally no significant differences were detected between the affected intermetatarsal neuroma interspace and foot posture index (p = 0.27 and 0.47, respectively). There was no significant difference in mean body mass index between the intermetatarsal neuroma (26.9 ± 5.7) and control groups (26.5 ± 4.1) (p = 0.72). There was, however, a significant difference in mean ankle dorsiflexion between the intermetatarsal neuroma and control groups (p < 0.001 for both feet). Logistic regression models, adjusted for age, sex, foot posture index and body mass index estimated that the odds of having an intermetatarsal neuroma in the right foot increased by 61% (OR 1.61; 95% CI 1.32-1.96) with each one degree reduction of ankle dorsiflexion, and in the left foot by 43% (OR 1.43; 95% CI 1.22-1.69). CONCLUSION: No relationships were found between foot posture index and body mass index with intermetatarsal neuroma, or between foot posture index and the interspaces affected. However, a strong association was demonstrated between the presence of intermetatarsal neuroma and a restriction of ankle dorsiflexion.

A cohort study of tibialis anterior tendon shortening in combination with calf muscle lengthening in spastic equinus in cerebral palsy.

The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (±5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15°, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p=0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP.

Ortesis pasiva tobillo-pie de uso nocturno en la prevención del pie equino en la parálisis cerebral / Nocturnal use of an ankle-foot orthosis in the prevention of equinuus in cerebral palsy

Introducción. El equinismo, que es la deformidad más frecuente en los pacientes con parálisis cerebral, aumenta la inestabilidad, dificulta la marcha y la adaptación a la silla de ruedas. La corrección del equinismo beneficia al niño deambulador, facilita la adecuada colocación del pie en el reposapiés de la silla de ruedas y la posibilidad de usar un calzado convencional en el niño que no tiene capacidad de marcha. El objetivo de este estudio es valorar si el uso nocturno de ortesis de tobillo-pie en ortoposición permite prevenir o diferir la aparición de equinismo y así evitar o retrasar la cirugía de alargamiento tendinoso. Material y método. Se ha realizado un estudio observacional descriptivo retrospectivo, revisando el historial clínico de pacientes diagnosticados de parálisis cerebral, tratados mediante ortesis de tobillo-pie nocturnas en la Unidad de Rehabilitación Infantil del Hospital Virgen Macarena. Resultados. De los 90 pacientes tratados con la ortesis de tobillo-pie nocturna, el 88,9% consiguió el rango de flexión dorsal necesario para la deambulación (≥ 10°) o la correcta adaptación a la silla de ruedas y al calzado (≥ 0°). Únicamente en 9 pacientes (10% de los casos) no se alcanzaron los objetivos pretendidos. Conclusión. El tratamiento preventivo con ortesis rígidas constituye una opción de primera línea en el tratamiento de la parálisis cerebral. El uso reglado y mantenido de las ortesis de tobillo-pie nocturnas puede retrasar la aparición del equinismo en la parálisis cerebral y permite diferir o evitar la cirugía con un beneficio funcional evidente (AU)

Introduction. Equinus, the most common deformity in patients with cerebral palsy, increases instability and impairs gait and adaptation to a wheelchair. Correction of equinus benefits walking children and aids proper placement of the foot on the footrest of a wheelchair. It also allows the possibility of using conventional footwear in children with no ability to walk. The aim of this study was to assess whether the use of an ankle-foot orthosis at night, keeping the foot in orthoposition, can prevent or delay the onset of equinus and thus prevent or delay tendon lengthening surgery. Material and methods. We performed a retrospective observational study based on a chart review of 90 patients diagnosed with cerebral palsy treated with a nocturnal ankle-foot orthosis in the Children's Rehabilitation Unit at Hospital Virgen Macarena in Spain. Results. Of the 90 patients treated with nocturnal ankle-foot orthosis, 88.9% achieved the dorsiflexion necessary for ambulation (≥ 10°) or adequate adaptation to a wheelchair and footwear (≥ 0°). Only 9 patients (10%) did not achieve the intended objectives with the use of the splint. Conclusion. Preventive treatment with a rigid ankle-foot orthosis is a widely accepted practice that constitutes a first-line option in the treatment of cerebral palsy. Systematic and persistent use of a nocturnal ankle-foot orthosis can delay the onset of equinus in cerebral palsy and can delay or avoid surgery, with a clear functional benefit (AU)

Anterior transfer of tibialis posterior tendon for treating drop foot: Technique of enforcing tendon implantation to improve success rate.

UNLABELLED: An absolutely convincing technique of anterior transfer of the tibialis posterior (TP) tendon for treating drop foot has not been developed. Thirty-seven consecutive adult patients with drop foot owing to deep peroneal nerve injury were treated with bone-to-bone TP tendon transfer. The TP tendon with a small bony attachment was procured from the undersurface of the navicula and then transferred through a tunnel of the interosseous membrane. The navicular attachment was implanted in the tunnel of the navicula or intermediate cuneiform. Cancellous bone graft procured from the distal tibial metaphysis was packed into the tunnel inlet. Side-to-side tendon suturing was performed between the TP tendon and tibialis anterior tendon. Thirty-one patients were followed for a mean of 2.8 years (range, 1.2-4.8 years), and all achieved satisfactory outcome for the ankle. All patients achieved a normal gait after one year and at the latest follow-up. CONCLUSIONS: The described technique may provide a high success rate. This surgical technique is not complex, and complications are few.

Post-activation depression of the lower extremities in stroke patients with spasticity and spastic equinovarus deformity.

This study aimed to investigate changes of post-activation depression in two groups of patients with or without spastic equinovarus deformity (SED). Paired and independent t-tests were used to compare post-activation depression within and between the groups, respectively. There was a significant positive correlation between diminished post-activation depression and spasticity severity. The soleus and tibialis anterior (TA) post-activation depression values were significantly decreased on the affected sides of patients with SED compared to those without. In patients without SED, the soleus post-activation depression was significantly decreased on the affected side; however, TA post-activation depression was higher on the affected side. Both the soleus and TA become active, but the onset time may be different. The imbalanced muscle tone between the soleus and TA in the early stage after stroke may be related to equinus deformity.

Post-activation depression of the lower extremities in stroke patients with spasticity and spastic equinovarus deformity / Depressão pós-ativação das extremidades inferiores de pacientes com acidente vascular cerebral que apresentam espasticidade e deformidade equinovarus por espasticidade

This study aimed to investigate changes of post-activation depression in two groups of patients with or without spastic equinovarus deformity (SED). Paired and independent t-tests were used to compare post-activation depression within and between the groups, respectively. There was a significant positive correlation between diminished post-activation depression and spasticity severity. The soleus and tibialis anterior (TA) post-activation depression values were significantly decreased on the affected sides of patients with SED compared to those without. In patients without SED, the soleus post-activation depression was significantly decreased on the affected side; however, TA post-activation depression was higher on the affected side. Both the soleus and TA become active, but the onset time may be different. The imbalanced muscle tone between the soleus and TA in the early stage after stroke may be related to equinus deformity.

O principal objetivo deste estudo é a investigação da depressão pós-ativação em pacientes com deformidade equinovarus espástica (DEE). Os pacientes foram divididos em dois grupos. Student-t testes pareados e independentes foram utilizados para comparar a depressão pós-ativação intra- e inter-grupos, respectivamente. Houve uma correlação positiva significativa entre a diminuição da depressão pós-ativação e a gravidade da espasticidade. A depressão pós-ativação dos músculos sóleo e tibial anterior (TA) estavam significativamente diminuídas no lado afetado dos pacientes com SEE em relação aos membros sem SEE. Em pacientes sem SEE, a depressão pós-ativação do músculo sóleo encontrava-se significativamente diminuída do lado afetado. No entanto, a depressão pós-ativação do músculo TA era maior no lado afetado que no lado não afetado. Tanto o sóleo quanto o TA serão ativados, mas o tempo para isso pode ser diferente. O desequilíbrio entre o tônus dos músculos sóleo e TA nos estágios iniciais pode estar relacionado à deformidade equina.

Stress fracture of the navicular bone in a patient with cerebral palsy: a case report.

A 14-year-old girl with cerebral palsy (spastic diplegia) underwent examination due to a chief complaint of right foot pain, and was diagnosed with a stress fracture of the central one third of the navicular bone. The fracture was considered to have developed due to repeated loading on the navicular bone as a result of an equinus gait.Therefore, she underwent osteosynthesis and Achilles tendon lengthening to correct the equinus deformity. Following our review of the current literature, we did not identify any reports of stress fracture of the navicular bone in cerebral palsy. We believe that in cases where cerebral palsy patients with paralytic equinus complain of foot pain, the possibility of stress fracture of the navicular bone should be considered.

The transverse Vulpius gastrocsoleus recession for equinus gait in children with cerebral palsy.

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles.

High resolution muscle measurements provide insights into equinus contractures in patients with cerebral palsy.

Muscle contractures that occur after upper motor neuron lesion are often surgically released or lengthened. However, surgical manipulation of muscle length changes a muscle's sarcomere length (Ls ), which can affect force production. To predict effects of surgery, both macro- (fascicle length (Lf )) and micro- (Ls ) level structural measurements are needed. Therefore, the purpose of this study was to quantify both Ls and Lf in patients with cerebral palsy (CP) as well as typically developing (TD) children. Soleus ultrasound images were obtained from children with CP and TD children. Lf was determined and, with the joint in the same position, CP biopsies were obtained and formalin fixed, and Ls was measured by laser diffraction. Since soleus Ls values were not measurable in TD children, TD Ls values were obtained using three independent methods. While average Lf did not differ between groups (CP=3.6±1.2 cm, TD=3.5±0.9 cm; p>0.6), Ls was dramatically longer in children with CP (4.07±0.45 µm vs. TD=2.17±0.24 µm; p<0.0001). While Lf values were similar between children with CP and TD children, this was due to highly stretched sarcomeres within the soleus muscle. Surgical manipulation of muscle-tendon unit length will thus alter muscle sarcomere length and change force generating capacity of the muscle.

Kinematic foot types in youth with equinovarus secondary to hemiplegia.

BACKGROUND: Elevated kinematic variability of the foot and ankle segments exists during gait among individuals with equinovarus secondary to hemiplegic cerebral palsy (CP). Clinicians have previously addressed such variability by developing classification schemes to identify subgroups of individuals based on their kinematics. OBJECTIVE: To identify kinematic subgroups among youth with equinovarus secondary to CP using 3-dimensional multi-segment foot and ankle kinematics during locomotion as inputs for principal component analysis (PCA), and K-means cluster analysis. METHODS: In a single assessment session, multi-segment foot and ankle kinematics using the Milwaukee Foot Model (MFM) were collected in 24 children/adolescents with equinovarus and 20 typically developing children/adolescents. RESULTS: PCA was used as a data reduction technique on 40 variables. K-means cluster analysis was performed on the first six principal components (PCs) which accounted for 92% of the variance of the dataset. The PCs described the location and plane of involvement in the foot and ankle. Five distinct kinematic subgroups were identified using K-means clustering. Participants with equinovarus presented with variable involvement ranging from primary hindfoot or forefoot deviations to deformtiy that included both segments in multiple planes. CONCLUSION: This study provides further evidence of the variability in foot characteristics associated with equinovarus secondary to hemiplegic CP. These findings would not have been detected using a single segment foot model. The identification of multiple kinematic subgroups with unique foot and ankle characteristics has the potential to improve treatment since similar patients within a subgroup are likely to benefit from the same intervention(s).

Functional hallux rigidus and the Achilles-calcaneus-plantar system.

Functional hallux rigidus is a clinical condition in which the mobility of the first metatarsophalangeal joint is normal under non-weight-bearing conditions, but its dorsiflexion is blocked when first metatarsal is made to support weight. In mechanical terms, functional hallux rigidus implies a pattern of interfacial contact through rolling, whereas in a normal joint contact by gliding is established. Patients with functional hallux rigidus should only be operated on if the pain or disability makes it necessary. Gastrocnemius release is a beneficial procedure in most patients.