Case from an accomplished Physical Therapist bouncing some ideas……
Just eval’d a girl today: 27 y/o, hx of L acetabular labral tear (no repair), moderate pain throughout hip, but was recently dx’d with a brain tumor in her motor cortex leading to significant L foot drop. Her main complaint is L posterior knee pain ( her AFO causes a ton of hyper ext at her knee), and she gets moderate hyperextension at her knee without the AFO. Good proprioception but poor kinesthetics (she can’t hit a target on the floor with her foot, but with her eyes closed she had very good proprioception of her hip and knee). She gets a lot of ER while performing prone hip ext on the L. I have her working on eccentric knee control with prone HS curls, and bridges with ball between legs to emphasize IR with hip ext ( I know using the thoracic spine as point of contact isn’t the most functional position, and a ball between the legs usually is not recommended d/t enforcing valgus at the knees), but I didn’t know where to start with her. Her main concern right now is her knee pain and her gait patterning. She is aware of motor control and learning and is afraid her body is going to learn poor motor patterning as a result of the foot drop. I also have her doing timed half kneeling to challenge her core, and pelvic stability, and a kneeling HF stretch. My main concern is teaching her a gait pattern that reduces the hyper extension at her knee. If you have any experience with anything like this, I could use some help.
Here are some thoughts.
1. Temper expectations. That doesn’t mean give up or half ass it. That means to have a very healthy respect to brain lesions. These lesions are tangible. I have a hard time with affecting conditions with these types of sequelae unless you are named Kolar, etc. In this case a tumor is a battle that someone else will have to win for you unless you know how to do brain surgery. Methods and results you are used to getting may not be so quick and ready when you are going up against something like this.
2. Regarding prone curls and bridges with a ball, can I say, “Come on, man?”
Now, prone curls are not the worst of it, but I see this option as something for a Day 1 HEP for a spinal fusion. Utilize the length changes in the anterior hip to control the pelvic tilt.
If the hamstring is what I’m after in a very remedial away, let’s go hip hinge and progress into DL.
If you can’t get there, then how about a very, very mild GHR. Here’s how you set it up. If you have a 45 Degree Hyper, prop it up so it becomes like a 15 degree hyper and lower the pads so they are even with her knees. The feet are stabilized with the foot plate or pad down there, so the foot drop is minimized. She can work into neutral from the neck, lumbar, and pelvis, and drive the knees into the pad for the GHR movement. This is a brilliant approach for regressing the standard parallel to the floor GHR.
Let’s think a slow shuffle. We can define a forward shuffle as a pattern in which the swinging leg does not cross the stance leg into a new stride. The back leg only goes as far as the front leg before the front leg moves forward again. It’s a gallop. We need left leg forward, and the focus is the pulling of the rest of the body to narrow double leg stance with hip extension of the front leg. Use a cane or crutch on the right side if needed, or go the other direction and load up that side to create an RNT to stay on the left side. This is really a fantastic regression of SLDL for rehab folks.
3. A lot of neurological training techniques are hunt and peck as I see it. Some PNF “tricks” may work. Others may be useless. To facilitate DF, think D1 flexion. Try banded and hook handed resistance @ the hip and knee. Try in single-leg stance as well with core activated. Think unloaded – unloaded wth core activated – loaded – loaded with core activated. Every corrective approach will fit into that systematic thought process courtesy of Gray Cook. As an aside, his more recent publishings will be in the SFMA refined approaches for the rehab folks. I presented some of this stuff for the first time in public with Thomas Myers in October, and he went more in depth @ Titleist Medical Level 3 in Orlando a few weeks ago.
Back to neurological keyholes…….you can also try some forced position work with the D1 patterning. You can try something like a plantar fascia sock that pulls the foot into DF and hope and pray the D1 pattern clicks into it. It’s worth a try. I don’t remember if this is Bobath or Brunnstrom’s approach, but it would be combined with the irradiation principles of PNF as well.
4. Beyond the neurological limiting factors, think of setting up 2 separate sections of the training session. Work for a period of time on getting to the foot drop, but then ignore the foot drop. Train in positions that still target the weak link from a musculoskeletal level. Think of the drop foot as pain where you would not aggressively challenge it with exercise. Work the kneeling patterns where the knee, ankle, and foot are out of the equation. If her shoulders move well, you have a wealth of upper body choices that can drive core and hip stability such as chops and lifts with the bar, rope, bands, and medball, presses, halos, anything you can imagine, Just do it tall, and allow for success. Don’t let the foot and/or knee limitations get in the way. Block it into DF and toe hyperextension for passive length always.
5. Try this one yourself. Hip hinge or box squat with a negative shin angle. Sit way way back. You will feel the toes extend and the anterior tibs fire to create the weight shift. You know the hip hinge is valuable, and then if you go “too far,” you may very well be facilitating the antagonists to the foot drop. Progressing to SLDL would be amazing here. But also consider the bent-knee hip hinge, which is a pure Westside box squat. Start down on the box and set up with a negative shin angle. You’ll get a lot of forward lean, and that’s okay here as long as the lean is not from the anterior pelvic tilt. Try this as well.
6. I know it can be hard when working in a traditional PT setting, but don’t spend 60 minutes working on foot drop. Hammer it with what tools you have and the ones you see working, but overall train this person. Train them like an athlete that has nothing wrong with them. She should be hopping and doing 1-leg squats on the other leg if she can. The body is a funnel into a drain. One funnel is clogged up right now, but if we can put more good things into the other funnels, I truly believe the drain can start to clear up. This does mean ignoring the foot drop for a good portion of the session. Try it.
7. Try this product. https://www.andante.co.il/smart.asp?cat=17&in=0.
I am the Director of Clinical Education, and it is an excellent product that you can do anything loaded with. We just came out with aiPhone App with this. It can also be used for any limited weight bearing or gait training patient.
For this particular young lady, it can be used in conjunction with an FES for the anterior tib in conjuction with the biofeedback during gait. This will work for her.
Great. Thanks Charlie. I’m finally beginning to understand the entirety of your dense answers!