PROSTHETICS/ORTHOTICS/DEVICES

Treatment of Upper Motoneuron Plantarexion Contractures

by Using an Adjustable Ankle-Foot Orthosis
Samuel P. Grissom, MD, Sarah Blanton, PT
ABSTRACT. Grissom SP, Blanton S. Treatment of upper
motoneuron plantarexion contractures by using an adjustable
ankle-foot orthosis. Arch Phys Med Rehabil 2001;82:270-3.
Objective: To assess the effectiveness of an adjustable an-
kle-foot orthosis in the treatment of plantarexion contractures
after central nervous system injury or disease.
Design: Prospective, nonrandomized, interventional trial.
Setting: University medical centers acute inpatient rehabil-
itation hospital.
Participants: Nine ankles with plantarexion contractures
that could not be passively reduced to less than neutral position
occurring in 6 patients with stroke or other acquired brain
injury.
Intervention: To assure differentiation between spastic de-
formity and true contracture, patients received a 2% lidocaine
block of the posterior tibial nerve. The adjustable ankle-foot
orthosis was then applied on the affected ankle for 23 hours per
day for 14 days. Adjustments to increase dorsiexion passive
range of motion (PROM) ranged from 0 to 4.5 and were
attempted every 48 to 72 hours.
Main Outcome Measures: Dorsiexion PROM at the ankle
with the knee extended.
Results: Increased PROM (average, 20.1; range, 636)
was statistically signicant (p .0078). Complications related
to pressure with erythema or blister formation associated with
pain occurred in 44% of treated ankles at some time during the
2-week trial period.
Conclusion: Plantarexion contractures can be signicantly
reduced by using the adjustable ankle-foot orthosis with min-
imal complications.
Key Words: Ankle; Articular; Contracture; Foot; Orthotic
devices; Range of motion; Rehabilitation.
2001 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
A
NKLE PLANTARFLEXION contractures are a common
complication from central nervous system (CNS) injury or
disease that results in spasticity of the triceps surae complex.
1-4
The overall incidence of plantarexion contractures has been
reported as high as 76% in inpatients with head injuries
2
and
57% in patients with spinal cord injury.
5
Ankle plantarexion
contractures present a signicant secondary impairment, inter-
fering with the rehabilitation process, such that limitation of
dorsiexion at the ankle can compromise positioning, sitting,
and mobility.
6
Ability to transfer and ambulate can be mildly to
severely affected. Ankle dorsiexion of at least 5 is needed to
allow comfortable and energy-efcient walking. Plantarexion
contractures may limit the effectiveness of a solid ankle-foot
orthosis. Among patients who are ambulatory despite a con-
tracture, there is concern for damage to the knee caused by
hyperextension of the joint.
The most ideal approach is prevention of the contracture.
Once a contracture has occurred, prompt and effective treat-
ment is important. Studies comparing short- versus long-dura-
tion stretching have shown that manual, short-duration stretch-
ing lacks efcacy for plantarexion contractures.
7,8
Physiologic
evidence indicates that the attachments between collagen bers
have high resistance to suddenly applied tension, but begin to
relax or creep when exposed to prolonged tension.
9
Studies
by Tabary et al
10
and Tardieu et al
11
have shown that prolonged
stretching is necessary to affect positively sarcomere length in
muscle. Passive, sustained stretching uses force at the terminal
point of resisted movement to recover lost range of motion
(ROM) because of lost soft-tissue elasticity and length.
7
Various methods may be used to achieve this terminal
stretch, including orthoses.
12
Adjustable orthoses have several
advantages, which include simple removal for hygiene and
observation, as well as the capacity to make frequent adjust-
ments requiring relatively little time.
13
Several studies have
shown that dynamic orthoses are an effective form of treatment
for joint contractures.
13-16
Dynamic orthoses provide relatively
constant pressure by means of spring-loaded or hydraulic
mechanisms. Studies showing the effectiveness of dynamic
orthoses primarily address upper extremity or knee contrac-
tures. Most of the literature providing low-load, sustained
stretch for ankle contractures relates to serial casting, with the
exception of a customized adjustable orthosis described by
Collins et al
17
to be effective but costly.
Traditionally, treatment has consisted of physiotherapeutic
interventions: various forms of heat combined with stretch,
active ROM, and strengthening of antagonists.
12
All these
interventions, as well as serial casting and customized dynamic
orthoses, require the expertise and time commitment of skilled
therapy staff, adding to cost and interfering with more func-
tionally oriented rehabilitation treatments. The hypothesis of
our pilot study was that a commercially available adjustable
ankle-foot orthosis is a safe and effective way to treat ankle
plantarexion contractures resulting from upper motoneuron
lesions.
METHODS
Patients and Setting
Six patients with stroke or head injury admitted to a medical
universitys acute inpatient rehabilitation facility were the sub-
jects of this study (table 1). Selection criteria included: (1)
informed consent by the patient or legal guardian; (2) passive
ankle dorsiexion of 0 or less; (3) less than 5 change in
passive ROM (PROM) after 2% lidocaine block of the tibial
nerve; and (4) no evidence of skeletal injuries, heterotopic
From the Department of Rehabilitation Medicine, Emory University School of
Medicine, Atlanta, GA.
Accepted in revised form May 24, 2000.
Supported by Restorative Care of America, Inc.
No commercial party having a direct nancial interest in the results of the research
supporting this article has or will confer a benet upon the authors or upon any
organization with which the author(s) is/are associated.
Reprint requests to Samuel P. Grissom, MD, 1441 Clifton Rd NE, Atlanta, GA
30322, e-mail: sgrisso@emory.edu.
0003-9993/01/8202-5971$35.00/0
doi:10.1053/apmr.2001.19018
270
Arch Phys Med Rehabil Vol 82, February 2001
ossication, heel decubiti, venous thromboembolism, infection,
or signicant medical instability by clinical examination or
history.
Intervention
All patients received a diagnostic block of the posterior tibial
nerve with 2% lidocaine as described by Arendzen et al.
18
Thirty minutes after the block, ROM at the ankle was com-
pared with that obtained just before the block. All measure-
ments were taken by a single, nonblinded clinician while the
patient was supine with the knee extended. If there was a 5 or
less change in PROM after posterior tibial nerve blockade, then
the patient was tted for the adjustable orthosis.
The device
a
(g 1) is made of exible acrylic thermoplastic
stabilized by adjustable metal rods on the medial and lateral
sides. A rotating adjustable dial on the positioning bars can
increase or decrease the angle of the orthosis, with a complete
rotation being approximately 1.5. The device ts both the right
and left foot and is available in 3 sizes: pediatric, average, and
large. The device is tted based on the heel to toe measure-
ment. The orthosis was intended to be worn by the patient at
least 23 hours per day, being removed only for hygienic pur-
poses.
Complaints of pain or discomfort and evidence of equipment
failure were monitored on daily patient rounds by the physician
and by the physical therapist during treatment sessions, allow-
ing monitoring 7 days a week. Evidence of skin breakdown
was checked when the brace was removed for hygiene. At-
tempts to adjust the angle of the orthosis from 0 to as much as
4.5 were made by the nonblinded physical therapist every 48
to 72 hours as tolerated to increase ankle dorsiexion.
Outcome Measures
PROM. All measurements of ankle PROM were per-
formed when the orthosis was removed while the patient was
supine with the knee extended. Measurements were taken by
goniometric assessment of talocrural dorsiexion and plantar-
exion, by using the bular head and lateral border of the
plantar surface of the foot for landmarks.
19,20
The long arm of
the goniometer was placed over the line between the bular
head and the lateral malleolus. The other moving arm was
positioned over a line formed by the lateral plantar surface of
the foot below the fth metatarsal. The bony landmark of the
bular head was marked to increase reliability of goniometric
measurement. All measurements were taken by a single, non-
blinded physical therapist, with attempts at applying the same
maximal dorsiexion force for each measurement. Three val-
ues were taken and the average of those was recorded.
Intratester reliability. Intratester reliability was tested for
the therapist doing the measurements in a manner described by
Elvuru et al.
21
A patient with a CNS lesion and plantarexion
contracture was identied and positioned prone with the knee
extended. With the blinded side of the goniometer toward the
therapist, a maximal dorsiexion force was applied while the
long arm of the goniometer was placed over the line between
the bular head and the lateral malleolus. The other moving
arm was positioned over a line formed by the lateral plantar
surface of the foot below the fth metatarsal. The goniometer
was then read and the number of degrees was recorded from the
nonblinded side. This was repeated 3 times, with attempts at
applying the same maximal dorsiexion force for each mea-
surement. The patients foot and ankle was then passively
circumducted and the patient was repositioned supine with the
knee extended. The therapist then repeated the measurements
as previously described, which were again read and recorded.
The intraclass correlation coefcient (ICC) was calculated by
using the means of the rst set of 3 measurements and the
second set of 3 measurements.
Statistical analysis. To determine the statistical signicant
increase of the outcome dorsiexion PROM, the value was set
at p .05. A paired t test evaluating outcome data was used to
determine a p value. A conservative nonparametric test (Wil-
Table 1: Characteristics of 6 Patients Treated With Adjustable
Ankle-Foot Orthosis
Patient Age (yr) Gender Diagnosis
1 21 Man Traumatic brain injury
2 51 Woman Intracerebral hemorrhage
(ruptured aneurysm)
3 24 Woman Pontine hemorrhage
4 44 Woman Right frontal AVM resection
5 61 Woman Right thalamic intracerebral
hemorrhage
6 62 Man Left middle cerebral artery infarct
Abbreviation: AVM, arteriovenous malformation.
Fig 1. Static adjustable ankle-foot orthosis made of exible plastic
stabilized by adjustable metal rods.
271 PLANTARFLEXION CONTRACTURES, Grissom
Arch Phys Med Rehabil Vol 82, February 2001
coxon or sign test) was also used to evaluate the change in
ROM and established a p value. Both of these p values are
2-tailed.
RESULTS
Of the 6 patients enrolled in the study and tted with
orthotics, 5 completed the study, wearing the brace for a
minimum treatment span of 14 days. The patient who did not
complete the study withdrew on the second day at the request
of the family. This patient had suffered a traumatic brain injury
and was categorized as being at a Rancho Los Amigos Scale
level IV.
22
The patients family was concerned that the use of
the orthosis might increase his level of agitation, though a
change was not observed by the family, physician, or rehabil-
itation staff. Three of the remaining 5 patients had been tted
with bilateral adjustable orthoses.
The mean pre- and postorthotic dorsiexion measures of the
8 ankles that completed the study were 13.6 and 6.5,
respectively. The mean gain in dorsiexion PROM was 20.1
(p .0078), with a range of 6 to 36 (table 2). While
determining intratester reliability, the ICC was calculated to be
greater than .90 by using the means of the rst set of 3
measurements and the second set of 3 measurements.
Skin and pain complications occurred in 3 patients or 4
ankles (44% of treated ankles). One patient developed a blister
on the dorsum of each ankle where a Velcro strap positioned
the foot down into the orthosis. Though the sheepskin-like
material of the brace folded over the dorsum of the ankle to
protect from the strap, additional padding was placed under the
strap. The blisters healed without discontinuing use of the
orthoses in this patient. This same patient developed pain in
both lower extremities on the 13th day requiring discontinua-
tion for 1 day until the splint manufacturers representative
a
could are the trim lines to allow better t and alleviate
bruising of the lower calves. Two patients (2 ankles) developed
redness over bony prominences including the medial malleo-
lus, navicular, and fth metatarsal head. The patient with
redness over the fth metatarsal head was found by the splint
manufacturers representative to have been tted with a brace
that was too small because the wrong sizing chart had initially
been used. Once the proper sized brace was used, the redness
resolved. The other patients redness resolved without inter-
vention other than careful monitoring.
Equipment failure occurred in 1 patient. The lateral adjust-
able metal rod was found detached from the foot plate of the
brace. This occurrence appeared to be the result of faulty
threading of a screw. The brace was replaced and the patient
completed the study without further complications.
DISCUSSION
This pilot study supports the effective use of the adjustable
ankle-foot orthosis to increase PROM in plantarexion con-
tractures resulting from upper motoneuron injuries. Although
the complications related to the device were limited to minor
skin and pain problems, implications could be made that the
careful monitoring was the reason more serious complications
did not develop. Although there has been a case report describ-
ing the effectiveness of a customized adjustable orthosis for
contractures at the ankle,
17
ours is the rst study to our knowl-
edge to evaluate the effectiveness of a prefabricated commer-
cially available static adjustable ankle-foot orthosis.
Serial casting is a technique that has been used effectively to
reduce plantarexion contractures of upper motoneuron origin
for over 25 years.
3
In 1983 a study examining the effectiveness
of serial casting lower extremities in patients with head injuries
was published. The mean casting duration was 28 days,
whereas the mean change in ROM in patients with cortical and
brainstem lesions was 19 and 24, respectively. The investi-
gators advocated cast changes every 7 to 10 days. Conine et
al
23
have recommended more frequent cast changes of every 5
to 7 days. At our institution, the charge for a single, berglass,
short-leg cast with foot plate is $1075, with $250 allocated for
75 minutes of skilled therapy time and $825 covering the
materials and supplies needed to apply the cast. Given that the
cost to the patient for the adjustable ankle-foot orthosis at our
institution is approximately $300, the potential for cost savings
could be considerable, allowing savings in scal and human
resources to be invested in more functionally oriented rehabil-
itation treatments.
Several limitations in our study should be reviewed. A
signicant aw was that the clinician doing the diagnostic
nerve block and assessments on daily rounds, as well as the
physical therapist monitoring change in ROM and skin checks,
were not blinded. The use of a force transducer plate may have
helped ensure that the clinician and therapist applied the same
maximal dorsiexion force during successive measurements
throughout the study period.
Another aw was the lack of a control group. The observed
before and after changes in dorsiexion PROM may be attrib-
uted to spontaneous recovery that can occur after CNS injury,
despite attempts to differentiate spastic deformity (dynamic
equinus foot) from true contractures by using the diagnostic
nerve block.
18
The confounding effects of other therapy inter-
ventions were difcult to control, such as weight-bearing ac-
tivities. Evidence shows that weight bearing, as occurs with the
use of a tilt table-wedge board regime, can increase dorsiex-
ion PROM from 3 to 17 at a rate of .11 to 1.0 per day.
20
In
addition, occasionally patients were found to have had the
orthosis removed for a time period longer than necessary for
hygiene, even though clear physician orders and staff education
were completed.
Another possible limiting factor is that the outcome mea-
surement of ankle dorsiexion PROM using a goniometer can
be unreliable. However, a study by Elvuru et al
21
showed
intratester reliability of .95 for such measurements in patients
with neurologic disorders. In addition, an intratester reliability
check was conducted for the therapist performing the measure-
ments in this study.
Although this pilot study indicated that use of the adjustable
ankle-foot orthosis coincided with a signicant improvement in
PROM of plantarexion contractures, future research should
include blinded, controlled studies comparing its use with other
treatment methods (serial casting, dynamic orthoses). Further
evaluation of the safety and effectiveness of the static adjust-
Table 2: Changes in Dorsiexion PROM in 8 Ankles
Ankle Initial PROM Final PROM Change in PROM
1 18 4 22
2 20 16 36
3 16 2 18
4 10 3 13
5 25 10 35
6 4 2 6
7 2 12 10
8 18 3 21
Mean (SD) 13.6 (9.0) 6.5 (5.4) 20.1 (10.9)
Abbreviation: SD, standard deviation.
272 PLANTARFLEXION CONTRACTURES, Grissom
Arch Phys Med Rehabil Vol 82, February 2001
able orthosis used in this study, if applied and adjusted by
nonskilled therapy staff or family, is warranted to show even
more cost savings.
CONCLUSION
The expedient management of contractures is necessary in
the rehabilitation of individuals with CNS injury or disease to
facilitate maximum functional outcome. The use of the static
adjustable ankle-foot orthosis is effective in reducing plantar-
exion contractures with minimal complications, provided
there is careful monitoring. The adjustable ankle-foot orthosis
is an adjunct to treatment and can be incorporated into a
therapeutic program, allowing time for more functionally ori-
ented rehabilitation treatments.
Acknowledgments: The authors thank Steven L. Wolf, PhD, for
his critical review of manuscript drafts.
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Supplier
a. Phase II Multipodus Splint; Restorative Care of America, 11236
47th St N, Clearwater, FL 34622.
273 PLANTARFLEXION CONTRACTURES, Grissom
Arch Phys Med Rehabil Vol 82, February 2001