Hi Slasherkill

It sounds like you are on to it but here are some things you could double check on. I think that it is worth being as precise as you can about identifying the predominant impairment(s) before deciding on your management. So I suggest you be more specific and clarify in your head what is really going on ( I know you may have done this already but if not have a go).

From your assessment the patient has:


1. weakness of the dorsiflexors - One thing I would be interested to know is more about the type of contraction in tib ant the patient can produce From an assessment To prevent foot drop he needs to be able to dorsiflex within the mid to inner range prior to initial contact and also produce an eccentric contraction and initial contact - Any deficit you note would be worth tackling. I agree that FES can be very helpful here - if you have access to a unit with a heel switch then stimulate the dorsiflexors when the heel switch is off (swing phase) and stimulation is off when the heel switch is on. Have the unit slowly ramp down so that at contact response you get an eccentric contraction

2. tightness of the plantarflexors/ restricted dorsiflexion and you think spasticity is present. Carefully checked out whether this is mainly a:

a) non contractile issue with the plantar flexors, (see also if you can differentiate if it is soleus or gastrocnemius which is predominantly tight a combined program of casting wearing an AFO when not in a cast and stretches may be warranted

b) an articular problem (ankle joint stiffness to dorsiflexion) superimposed on tight plantarflexors then do the above but also include mobilisations

c) if there is a contractile/spasticity issue - have a good look at velocity dependent stretch – for a measure try the Tardieu scale for spasticity - it is a more valid test than the Ashworth scale. If spasticity is a major issue then a combination of a botox injection in to the gastroc/soleus combined with an aggressive casting, stretching and stimulation program may be helpful that is if botox is available

Hope this is of help. If you would like an English copy of the Tardieu scale I would be happy to forward it to you. the original is in French

All the best with your studies