Case of the Week 15/3/99: What people said...

Comment on the 5 yrs old Hemi
Reply from Dicky Wong ( HongKong )

The child may present with dynamic ankle equinus at the hemiplegic limb, the initial contact was made with
forefoot. When the knee started to extent from loading response to the mid-stance, the heel lost the contact
with the ground. The triceps surae muscles may hyperactive throughout the gait cycle. The equinus was
not too obvious at initial contact to loading response as the knee was flexed for the shock absorption, as
the gastrocnmius passed thro' two joints. Once the knee started to extend, the triceps surae muscles was
stretched further or in addition to the spasm of the muscle itself !

Basically we can think of the triceps surae muscles has weak eccentric contraction from loading response
thro' the mid-stance, which was  occurred in normal walking. I will suggest two means to modified such

  1. 1 Strengthening ex. for the triceps surae muscles with the subject stand on the hemiplegic foot on the inclined board. Progress with increase the speed of lowering down the heel , eccentic dorsiflexion. Remarks: prevent compensation from hip flexion or locking the knee during the exercise.
  1. 2. Try using the domestic shirt buttons attached on the ball of the toes, the intensity of such stimulus can be altered  by a cushion pad between the buttons and the foot. I have tried on quite a number of dynamic equinus with good proximal control, it may work for some patients if the stimulus was appriopiate.

I just have a chance to see the page about the child with hemiplagia and
realised that the child has
*double bump pattern on the right and single bump pattern on the left pelvis
* pelvis is down thro' the gait cycle on the left side and up on the
opposite side

*decreasing hip flexion on the left in Ic and Lr
*increasing hip adduction during at Ic,Lr,Mst,Msw and Tsw on the left
Mst,Tst,Psw, Msw and Tsw on the right
* internally hip rotation during stance on the left side and vice versa on
the right ( but internally rotation insisting thro' the all gait cycle on
the right)
* Knee valgus thro' the gait cycle on both sides
*increased external rotation of the pelvis on the left and vice versa on the
*increased knee flexion on both side ( L>R ) in terminal swing, initial
contact and loading respons
* increased knee valgus thro' the gait cycle on the left
* increased ankle planter flexion during Lr,Mst,Tst,Psw on the
* There is an increased power absorbsion in connection with increased
extension moment at the left knee at Lr and Mst
* tendency of genurecurvatum on the left
*increased ankle dorsiflexion moment from Ic to the end of Mst then
inadequate ankle moment connection with decreased A2 power the rest of the
stance on the left side
* decreased step length on the left

I wish I have a chance to see child's physical examination and EMG results
because it would be great to see the hamstrings tibialis posterior, adductor
and hip flexor muscle activities and tightness.
I suggest that hamstrings and hip adductor muscle stretching ex should add
the stretching program. Because the single bump pattern at the left side and
increased knee flexion connection with increased knee flexion moment and
power absorbsion in Lr and Mst make me worry that related muscles might be
already tight or will be tight in soon So I need the draw a stretching
program includes riding a toy horse ( My little pony stuff ) to stretch
adductor muscles, pick up the flower while the child in stand and knees
stabled in extension ( The left leg need to be front to provide further
stretch at the left ).... I used ankle dorsiflexion exercises beginning with
sitting position and gradually I put some pillows on the seat to provide
knee extension finally stand the child in full knee extension to strengthen
the anterior tibialis muscle and to get nice relaxation of gastro-soleus
muscle using reciprocal inhibition. Exercises on the inclined board is good
idea but I do not really familiar with domestic shirt buttons could you send
to me some information about it please?

After the 6 months or 1 year period the gait analysis should be repeated. I
think she may get benefit from botox what do you think about it ?

I give night splint to my patients to keep the ankle in 90 degree who have
less then 5 degree active dorsiflexion and less then +10 passive ankle
dorsiflexion. I think she may get some benefit from using night splint to
gain some range and relaxation.

N.Ekin Akalan MSc. PT
Ýstanbul University
Pediatry Department
Fax:011 90 (212) 631 3997

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