Neurological Foot Presentations

Original Editor - Wendy Walker

Lead Editors  


Contents

Introduction

Any changes in neurological control of the lower limb are likely to result in altered positioning and weight-bearing in the foot.

Specific Foot Conditions

There are specific conditions which have a direct effect on the ankle and foot mechanism, which each have a separate Physiopedia page:

The Foot in Hemiplegia & Diplegia

This section will cover the presentations seen in hemiplegia (from both Stroke and Cerebral Palsy) as well as diplegia.

Following brain injury (whether caused by stroke, cerebral palsy, or acquired brain injury) a person with hemiplegia experiences a marked change in postural tone and a loss of motor control.

The foot is the last link in the lower limb kinematic chain, and is affected by the changes in alignment in the trunk and higher joints of the lower limb as well as by the alteration in muscle tone and reduction in motor control.

In addition, the foot may develop oedema, muscle shortening and hyper or hypomobility.

Clinical Presentation

Drop Foot is a frequent consequence of neurogical disturbance  due to inability to selectively control the ankle dorsiflexors during the swing phase of the gait cycle.

Frequently there is equinus seen in the stance phase because of spasticity and/or
contracture of the gastroc-soleus muscles.

Combinations of the following will usually be seen[1]:

  • Loss of ankle joint dorsiflexion
  • Compensatory stance patterns of mid tarsal and subtalar joint pronation
  • Or in contrast the above, supination of midtarsal and subtalar joints may be seen
  • Forefoot plantarflexion and abduction
  • Reduced ability or inability to produce toe clearance in the swing phase due to reduced strength of ankle and foot dorsiflexor muscles
  • Hammer toes

Hypermobility

Joint hypermobility frequently ocurs as a result of poor postural alignment, reduced motor control and tge biomechenical influence of the altered position of the lower limb on the foot weight is placed on the foot[1].

Muscle Shortening

In hemiplegia in particular, shortening of the large multi-joint muscles in the leg is a major problem.

For instance, loss of ankle range in standing and walking frequently occurs as a direct result of shortening of the gastrocnemius muscle[1].

Oedema

Oedema in the foot can occur in Stroke and other neurological conditions which affect the lower limb, such as Multiple Sclerosis.

Reduction of vascular tone in the affected limb causes leakage of fluid into the soft tissue. This tendency is exacerbated by the reduction in activity in the leg.

It is useful to remember that oedema in the foot begins in the plantar surface and invades all the soft tissues in the foot before it becomes visible on the dorsum of the foot.

Muscle tone

Although there is frequently spasticity of the lower limb in neurological conditions, including cerebral palsy, stroke and MS, recent research suggests that in hemiplegia at least the role of spasticity is relatively small[2].

Another study looked at foot deformity in Stroke, and found that the more severe the spasticity, the more supinated the foot[3].

Management / Interventions

Specialised neurological physiotherapy is required to optimise the position and function of the foot in Stroke, Cerebral Palsy, MS and other neurological conditions.

Additional interventions include:

  • A variety of different orthotics - to improve posture of foot/ankle, or prevent foot drop
  • Functional Electrical Stimulation - to correct foot drop
  • Gait training
  • Botox - in cases where spasticity is contributing to foot deformity

Recent Related Research (from Pubmed)

References

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  1. 1.0 1.1 1.2 Wall JC, Ashburn A. Assessment of gait disability in hemiplegics. Hemiplegic gait. Scand J Rehabil Med. 1979; 11(3):95-103.
  2. Ada L1, Vattanasilp W, O'Dwyer NJ, Crosbie J. Does spasticity contribute to walking dysfunction after stroke? J Neurol Neurosurg Psychiatry. 1998 May;64(5):628-35
  3. Jang, Gwon Uk; Kweon, Mi Gyoug; Park, Seol; Kim, Ji Young; Park, Ji Won. A study of structural foot deformity in stroke patients. Journal of Physical Therapy Science