Rehabilitation Strategies for Equinus Foot Deformity and Claw Toes in Post-Stroke Patients: A Focus on Physical Therapy

 

Rehabilitation Strategies for Equinus Foot Deformity and Claw Toes in Post-Stroke Patients: A Focus on Physical Therapy

 

 

Stroke survivors often experience Equinus Foot Deformity (EFD), the most common lower limb issue after a stroke. It involves the ankle pointing downward with the foot turned inward, causing varus-supination, and sometimes clawed toes, further affecting the physiological anatomy of the foot. EFD and Equinovarus Foot Deviation (EVFD) are common in stroke patients due to muscle imbalances.

 

EFD affects walking, stability, and foot movement during the swing phase, leading to disability. Patients need orthotic support, assistance with transfers, and face a higher risk of falling, impacting their quality of life.

Various factors contribute to EFD, including spasticity, muscle imbalances, and soft tissue changes. Spasticity can be managed through surgery, medication, physical therapy, and orthotics. Physical therapy is a key non-invasive treatment for EFD in stroke survivors, with different approaches available to correct it.

 

 

 

Rehabilitation Strategies for Equinus Foot and Claw Toes

 

Treating this condition involves several approaches:

1. **Physical Therapy: ** 

Following a stroke, physical therapy plays a crucial role in retraining the foot muscles. It helps in correcting hammertoes by enhancing muscle flexibility and strength, enabling the toes to bend properly, and preventing the condition from worsening. Early intervention is vital for optimal results with this therapy.

 

2. **Surgical Procedures: ** 

In cases where hammertoes have become fixed in a bent position, surgical intervention may be necessary. This procedure involves manually adjusting the affected toes to correct the deformity for the long term. Subsequent stabilization of the injured toes is required to facilitate complete healing."

 

Non-surgical Treatment

Non-surgical approaches focus on alleviating the symptoms and associated conditions of equinus, rather than directly addressing the deformity. These strategies include:

Night Splint: 

Wearing a night splint helps maintain the ankle in a dorsiflexed position during sleep, counteracting the tightening of calf muscles that often occurs during rest.

Heel Lifts:

The use of heel lifts or shoe inserts can help compensate for the reduced ankle dorsiflexion, providing a more natural and comfortable walking position.

Arch Supports or Orthotic Devices: 

Orthotic devices, including arch supports, can enhance foot biomechanics, aiding in the correction of equinus deformities over time.

Ankle-Foot Orthoses (AFOs):

AFOs are recognized as effective conservative treatments for slowing the progression of equinus deformities. They provide support, stability, and controlled dorsiflexion during walking, improving gait and minimizing deformity advancement.

These non-surgical methods are primarily focused on enhancing patient comfort, mobility, and functional abilities while managing the symptoms associated with equinus deformity.

 

Physical Therapy

In the quest to address Equinus Foot Deformity (EFD) in post-stroke patients, there is a range of physical therapy modalities. These interventions are tailored to correct EFD and enhance patient recovery:

Physiotherapist-Guided Physical Exercise: 

A structured exercise regimen under the guidance of a physiotherapist focuses on strengthening and improving the range of motion in the affected foot and ankle, promoting a more natural gait pattern.

Stretching Techniques: 

Targeted stretching exercises aim to increase flexibility in the calf muscles and Achilles tendon, helping to alleviate the downward deformity of the ankle associated with EFD.

Shock Wave Therapy: 

This non-invasive approach involves the application of shock waves to stimulate tissue repair and improve blood flow, potentially assisting in the reduction of muscle stiffness and contractures contributing to EFD.

Electrical Stimulation: 

Electrical stimulation methods may be used to activate specific muscles, aiding in retraining and re-balancing the muscles involved in foot movement.

Dry Needling: 

Dry needling involves the insertion of thin needles into trigger points in muscles, releasing tension and promoting muscle relaxation, which can be beneficial in managing EFD-related muscle imbalances.

Transcutaneous Electrical Nerve Stimulation (TENS):  

TENS devices deliver low-level electrical currents to nerve pathways, helping to manage pain and potentially aiding in muscle function restoration.

Vibration Therapy:  

The application of controlled vibrations can improve muscle activation and proprioception, contributing to better foot control and stability.

Ultrasound Therapy:  

Ultrasound waves are used to generate heat and promote blood circulation, which may assist in reducing muscle stiffness and increasing the effectiveness of other interventions.

Cryotherapy:  

Cold therapy can help reduce inflammation and pain in the affected area, potentially providing relief and facilitating other forms of treatment.

 

These diverse modalities offer a range of options for healthcare professionals to tailor treatment plans to the specific needs of post-stroke patients with EFD, with the goal of enhancing mobility and quality of life.

 

 

Stroke-related foo/toe impairments, Claw Toe, and Hammer Toe:

 

Claw Toe:  

where their toes curl under their feet, making walking painful. This happens because the muscles in the foot contract excessively due to a neurological issue. Toe muscles are usually weak, so the overactive foot muscles overpower them, tightening the tendons and causing the smaller toes to buckle or curl unnaturally. Claw Toe most commonly affects the foot on the side affected by the stroke and can lead to painful blisters, calluses, or corns on the ball of the foot.

 

Hammer Toe:  

Unlike Claw Toe, Hammer Toe affects only the middle joint of the toe, creating a steep curve that prevents it from straightening. The flexibility of the affected toe while in this position determines if it's flexible or rigid. In advanced cases, tendon surgery may be needed to release the toe's rigid grip. Flexible Hammer Toe indicates an earlier stage with a better recovery outlook.

These conditions can also affect individuals with joint diseases like rheumatoid arthritis, cerebral palsy, nerve damage from poor circulation, such as diabetes, and those who have been bedridden for extended periods.

 

Treatment options for this condition include:

 

Rehabilitation:

Recovering from a stroke is an ongoing process that demands determination and patience. Effective rehabilitation often involves a combination of exercises and other treatments for the best results.

Exercises for Curled Toes:

While surgery may be necessary for severe cases, many instances of claw toe and hammer toe can be improved with noninvasive treatments. Rehab exercises help regain control of foot muscles affected by these conditions.

Note: You may not be able to physically perform all the exercises but try initiating them and visualize completing each one.

Extensor Stretch:

 Pull your toes downward, emphasizing the arch. Hold for 20-30 seconds. Adding gentle pressure on the arch with your thumb helps. Repeat until you achieve better flexibility. Pull up on the tip of the toe after pulling it down to straighten it.

 

Marble Pickup:  

Use your toes to pick up marbles from the floor and place them in a container. This exercise loosens the foot and toe muscles.

Towel Curl:  

Place a towel on the floor, sit down, and use your toes to scrunch and pull the towel toward you. Then, stretch the towel back out with your toes.

Toe Taps:

Sit with feet flat on the floor. Point the big toe down and the other four toes upward, then tap them on the floor. Reverse the motion, pointing the big toe up and the others down.

These exercises benefit stroke patients with claw or hammer toes. If pain persists or worsens, or if sores develop, consult a doctor. Surgery is typically reserved for severe cases where toe mobility is greatly hindered.

 

Treatment Options through Surgery:

When conservative treatments like orthotics, physical therapy, and stretching exercises fail, medical professionals may recommend surgical interventions such as nerve sutures, tendon transfers, grafting, or decompression.

An example of surgical intervention is Tenotomy, which is used for severe spasticity. It involves cutting the impacted tendon to extend it, reducing discomfort, and improving mobility.

Surgery becomes an option when other treatments like physical therapy and stretching exercises are ineffective in addressing claw toes. Some surgeries are minimally invasive, requiring a small incision and a miniature camera for the procedure. Tendon transfer is another surgical option, involving the relocation of the posterior tibial tendon.

 

My Personal Journey with Eqinus Foot, Foot Drop and Claw Toes.

 

Regrettably, because of the stroke I experienced, I've been dealing with Equinus Foot, Foot Drop, and Claw Toes. These conditions have presented numerous challenges in my everyday life. Walking and even standing have become more difficult, and they have significantly hindered my ability to engage in activities like running or jogging, which were once enjoyable pursuits. These physical limitations have been a significant part of my post-stroke journey, and I'm actively seeking ways to manage and improve these conditions.

Here are the approaches I've taken during inpatient rehabilitation and at home, following both medical advice and my personal experience.

I used an AFO during my stay at the rehabilitation center. However, upon returning home, I decided to discontinue using it to prevent my ankle and foot from becoming overly reliant on it. I've embraced the principle of "use it or lose it."

To maintain and improve my foot flexibility, I've incorporated a routine of regular stretching exercises using a slant board. I've integrated this into my workday, using it whenever I'm seated at my desk.

In addition to stretching, I've employed electrical stimulation as part of my regimen. I've even devised a homemade tool to aid in toe stretching.

 

 

 

 

 

While walking, I find relief by wearing toes separator, a metatarsal pad, secured in place with an elastic band. Additionally, I've added a heel lift to my footwear.

 

All these practices are geared toward alleviating discomfort during walking. I make it a point to engage in frequent walking and stair climbing throughout the day to further support my rehabilitation efforts.

 

 

stretching exercises:

 

Gastrocnemius Stretch:

1. Place the slant board on a flat surface.

2. Stand facing the board with your heels hanging off the edge.

3. Keep your legs straight and your feet parallel.

4. Gently lower your heels below the level of the board until you feel a stretch in your calf muscles.

5. Hold the stretch for 20-30 seconds, then slowly raise your heels back to the starting position.

6. Repeat this stretch 3-4 times.

Soleus Stretch:

1. Sit on the floor with your legs extended.

2. Position the slant board under your feet, with your toes pointing upward and your heels resting on the lower edge of the board.

3. Lean forward, aiming to touch your toes while keeping your knees straight.

4. Hold the stretch for 20-30 seconds, feeling the stretch in your lower calf muscles.

5. Relax and repeat the stretch several times.

 

Toe Raises:

1. Stand on the slant board with your heels on the lower edge and your toes on the higher edge.

2. Hold onto a stable surface for balance support if needed.

3. Slowly raise your toes as high as you can while keeping your heels on the board.

4. Hold the raised position for a few seconds, then lower your toes back down.

5. Repeat this exercise for 10-15 repetitions.

 

Heel Raises:

1. Stand on the slant board with your toes on the lower edge and your heels on the higher edge.

2. Use support for balance if necessary.

3. Slowly raise your heels as high as you can while keeping your toes on the board.

4. Hold the raised position briefly, then lower your heels back down.

5. Perform 10-15 repetitions of this exercise.

 

Equinus Foot Stretch (Side Placement):

1. Position the slant board on its side to create an incline.

2. Sit next to the slant board.

3. Place your affected foot on the board with the inner part (medial side) resting on the lower edge and the outer part (lateral side) elevated.

4. Gently apply pressure to the inner edge of your foot to push it downward, stretching the calf and Achilles tendon.

5. Hold the stretch for 20-30 seconds, feeling the tension along the back of your lower leg.

6. Release the stretch and repeat it several times, gradually increasing the duration.

 

 

Calf and Heel Stretch on Stairs:

1. Find a staircase or a step with a sturdy railing for support.

2. While walking up the stairs, place the ball of your affected foot on the edge of a step, keeping your heel hanging off.

3. Hold onto the railing for balance.

4. Gently lower your heel below the step's edge to stretch your calf and Achilles tendon.

5. Hold the stretch for 20-30 seconds, then release.

6. Repeat this stretch a few times as you ascend the stairs.

 

These stretching exercises, including the calf and heel stretch on stairs, can help improve ankle flexibility, reduce calf tightness, and address Equinus Foot and Foot Drop issues often associated with stroke. Always consult with a healthcare provider or physical therapist before starting any new exercise routine, especially if you have specific medical conditions or limitations.