- 作者：F. Pellas ; Dr ; frederic.pellas@chu-nimes.fr" class="auth_mail" title="E-mail the corresponding author ; C. Gagnard ; Dr
- 刊名：Annals of Physical and Rehabilitation Medicine
- 出版年：2015
- 出版时间：September 2015
- 年：2015
- 卷：58
- 期：supp_S1
- 页码：e86
- 全文大小：142 K
Case history
Thirty years aged men, with multiple sclerosis spastic tetraparesis, cerebellar hypotonia and ataxia. Functional exam: completely independent in everyday life activities, with difficulties to put on shoes, needing one croutch outside. Physical exam: paresthesia, thermoalgesic and proprioceptive hypoesthesia in both lower legs (LL), proximal weakness prevailing on the left, dystonia of extensor hallucis longus (Hallucis erectus) and clonus of soleus and gastrocnemius of both legs.
Gait analysis
FL is responsible for a left-hand side pattern prevailing on the left-hand side, associating “footdrop” and sole's eversion during swinging phase, valgus-valgus instability of the heel during stance and heel medial-lateral oscillations when standing tiptoe; [pre-injection video].
Treatement's history
First, all three calf muscles of both legs have been injected (total of 300 UI Botox) but patient developed a botulism-like syndrome with; he had no profit of second injection with 25 units in both gastrocnemius and TP of each leg, rather it caused drastic weakening of propulsion. Treatment aims: improve control of inversion-eversion couple during terminal stance, without weakening propulsion strength or heel's medio-lateral stability during tiptoe stance.
Treatment
Injection of only left leg trigger muscles (FL and it's antagonists: TP, Extensor Hallucis Longus) with 50 UI each (total = 150)
Post injection exam
bilateral decrease of medial-lateral heel & leg-body oscillationsduring tiptoe stance, better leg shortenig during swing & no personal sensation of propulsion.
Conclusion
muscles actions must always be considered taking into account both proximal and distal fixed points. In case of proximal fixed point, LPL plantar flexes foot and reverse sole; when fixed point is distal, FL steadies leg (and body) upon the foot in frontal plane and draws leg's lateral side outwards.