1
A PT notes a patient ambulates with audible foot slap. Which muscle would MOST likely be responsible?
Anterior tibialis
Going on toes of R leg to clear the toes of the L leg (what kind of compensation is this)
Vaulting
A PT is working with a patient with a diagnosis of foot slap. Which nerve should the therapist expect to be affected?
Deep fibular/peroneal nerve
Phase: mid stance
Description: heel comes off ground in mid stance
Possible causes: spasticity, contracture of PF
Analysis/examine: ROM, tone for PF spasticity
Early heel rise
Phase: loading response
Description: forefoot "slaps" ground following heel first initial contact
Possible causes: weak DF (eccentric)
Analysis/examine: strength of ankle DF, muscle activation timing of pretibial muscles
Foot slap
Phase: stance or swing
Description: subtalar joint excessively inverted or everted
Possible causes: excessive inversion (primitive extensor pattern), excessive eversion (primitive flexor pattern)
Analysis/examine: strength and timing of LE movements and tone, ROM/contractures
Excess inversion or eversion
Phase: Initial contact
Description: toes or forefoot first point of contact with ground
Possible causes: LLD, PF contracture, spasticity, DF weakness, painful heel
Analysis/examine: ROM (hip/knee), leg length, ankle PF contractures, muscle tone and timing of activity in PF, pretibial strength, heel pain
Toes or forefoot contact
Phase: swing
Description: some portion of reference foot contacts ground during swing
Possible causes: pretibial muscle weakness, PF spasticity or contractures, inadequate knee or hip flexion
Analysis/examine: ROM of ankle, knee and hip; strength of muscles critical for limb clearance
Drag
A PT is working with a patient with a diagnosis of foot slap. Which nerve root SHOULD the therapist expect to be affected?
L4
Phase: terminal stance and/or pre-swing
Description: heel fails to elevate from ground appropriately during terminal stance
Possible causes: weak PF, weak invertors that fail to lock midfoot in terminal stance, inadequate toe extension ROM, painful forefoot or toes
Analysis/examine: strength of PF and tibialis anterior, toe extension ROM and strength, forefoot pain
No heel off
A PT is working with a patient with a gait deviation of foot slap. Which muscles should the therapist assess first?
Eccentric ankle DF
Phase: stance
Description: toes flex and "grab" floor
Possible cause: spasticity of toe flexors, excessive activation of toe flexors to compensate for weakness of the gastroc and soleus, plantar grasp reflex that is only partially integrated, positive supporting reflex
Analysis/examine: tone of toe flexors, strength of PF, presence of primitive reflexes
Toe clawing
A PT is working with a patient with a diagnosis of foot slap due to a LMN injury at the level of the nerve root. What sensation deficit would you expect to see?
Decreased sensation in the medial lower anterior tibia region
Phase: initial contact
Description: entire foot simultaneously touches ground (no heel strike)
Possible causes: PF contracture, weak DF, knee flexion contracture prevents optimum al tibial alignment prior to initial contact
Analysis/examine: ROM at ankle and knee, strength of anterior tibialis
Foot flat contact
Phase: mid stance and/or terminal stance
Description: ankle fails to achieve 5 degrees DF at mid stance and/or 10 degrees DF at terminal stance; "decreased tibial translation"
Possible causes: PF contracture, overactivity or spasticity of the PF, intentional to avoid ankle and knee collapse if PF and vastii are weak
Analysis/examine: ROM, PF contracture, PF tone, strength of cald muscles and vastii, intentional due to dual areas of weakness
Excess PF
If we have excessive ankle DF .. will we have excessive knee flexion or extension?
Knee flexion
Phase: mid stance and/or terminal stance
Description: ankle collapses into more than 5 degrees DF at mid stance and/or more than 10 degrees DF at terminal stance
Possible causes: inability of PF to control tibial advance, knee flexion contractures, hip flexion contractures
Analysis/examine: ROM ankle, PF strength, hip and knee flexion contractures
Excess DF
T/F: hamstring spasticity is more common than quad spasticity?
FALSE.. quad spasticity is more common than hamstring spasticity
Description: extension of knee beyond anatomical neutral
Possible causes: structural abnormality; flaccid/weak quads or hams; quadriceps spasticity; accommodation to a fixed PF deformity; impaired proprioception
Analysis/examine: strength, tone, spasticity of PF and quads, ROM, knee proprioception
Knee hyperextension
Phase: all
Description: knee greater flexion than expected for phase
Possible cause: knee flexor spasticity or contracture that exceeds position required for given phase, painful or effused knee, proprioceptive loss at knee, shorter LE on contralateral side, weak calf or hip flexion contracture if during single limb support
Analysis/examine: tone, spasticity, ROM, pain, effusion, proprioceptive loss at knee, LLD
Excess knee flexion
Phase: stance
Description: alternating flexion and extension at knee joint
Possible cause: proprioceptive impairments, alternating spasticity of knee flexors and extensors
Analysis/examine: proprioception, tone/spasticity
Wobble
Phase: loading response
Description: knee achieves less than expected 20 degrees flexion
Possible causes: intentional to decrease demands on weak quads; PF or quadriceps tone, spasticity, or contracture; proprioceptive impairment at knee
Analysis/examine: strength, tone, spasticity, PF and knee extension ROM, knee proprioception
Limited knee flexion
Phase: swing
Description: lateral circular movement of limb consisting initially of abduction, ER, followed by adduction and internal rotation in latter portion of swing
Possible causes: weak hip flexors, inability to shorten leg for limb clearance
Analysis/examine: strength of hip flexors, knee flexors, and ankle DF; ROM in hip and knee flexion and ankle DF; abnormal tone/extensor pattern
Circumduction
Phase: pre-swing and initial swing
Description: knee achieves less than expected flexion for given phase
Possible cause: PF tone, spasticity, or contracture; quadriceps tone, spasticity; proprioception impairment at knee; knee pain or effusion; calf weakness or hip flexion contracture that limits ability to achieve trailing limb terminal stance; knee flexor weakness
Analysis/examine: tone and spasticity of PF, ROM, knee proprioception, pain, effusion, PF strength and for hip contracture, knee flexor strength
Limited knee flexion
Phase: initial contact, loading response, initial swing, mid swing, terminal swing
Description: hip positioned in less flexion than expected for given phase
Possible cause: intentional to limit demand on weak hip extensors during loading response, weak hip flexors, hamstring spasticity or contracture
Analysis/examine: strength of hip flexors and extensors, ROM of hip, tone/spasticity of hip extensors and hamstring
Limited hip flexion