A gait training suggestion for lengthening gastrocnemius-soleus muscles: suggestion from the field

A Gait Training Suggestion for Lengthening Gastrocnemius-Soleus Muscles: Suggestion from the Field Burns on the posterior lower extremity from the popliteal space to Achilles tendon areas often result inan atypical standing posture and gait pattern. During the acute care hospital stay, the patient frequently assumes a stance position of excessive knee flexion and ankle plantar flexion because of pain splinting or soft tissue shortening, or both (Fig. 1). This burn distribution frequently results in a temporary shortening of the gastrocnemius-soleus muscles. The abnormal stance translates into a familiar gait pattern of absent heel-strike in addition to decreased stride length, weight bearing, [1] and duration of stance phase on the involved lower extremity. Furthermore, the pattern may be observed before and after skin grafting is performed. Early intervention is important because a patient is more likely to have optimal results after skin grafting if full active range of motion was attained during the pregrafting phase of burn rehabilitation. [1] Correction of postural and gait deviations as soon as possible, therefore, is to the patient's advantage.

Following a skin-grafting operation, there is typically a protective period of immobilization of several days' duration to the involved lower extremity during which weight bearing is prohibited or strictly limited. [1] When ambulation and aggressive rehabilitation are resumed, then the physical therapist must deal not only with the patient's pain tolerance to stretching the skin grafts but also with the general effects of immobilization on the musculoskeletal system such as transient joint stiffness, disuse atrophy of muscles, and muscle weakness. [2] These orthopedic symptoms are not unlike those of patients with a subacute ankle sprain or after cast or Unna boot removal. The functional nature of normal gait for the burn patient adds a power dimension in achieving pyschological as well as physical independence. [1]

Current treatment approaches for lengthening gastrocnemius-soleus muscles may generally be classified as static or dynamic in nature. Static stretching of these muscles can be achieved by splinting, [3] use of a tilt table, towel stretch, or standing on a wedge. A more dynamic stretching of these muscles can often be derived from stair climbing, [1] ramp ambulation, [4] or the use of a shoe wedge. Shoe wedges are not commonly used during acute burn rehabilitation because pedal edema or concurrence of sensitive foot-toe burns negate the use of constrictive footwear.

An alternative technique for stretching gastrocnemius-soleus muscles essentially incorporates a portable human "wedge block" (ie, shoe) that facilitates dynamic heelcord lengthening by taking advantage of gravity and weight shift. Three criteria are recommended for selecting this method. First, the patient should be trusting and lightweight relative to the physical therapist. Second, the patient should have been non-weight bearing on the involved extremity for a period of seven days or less. Third, the therapist should wear comfortable footwear that will disperse the compression forces from the partial body weight of the patient.

To begin this gait training technique, both patient and therapist should stand facing each other in a hallway or large room. The patient and therapist then grasp each other's arms just above the elbows, and the patient places the forefoot of the involved leg on top of the therapist's shoe while the other foot remains on the floor (Fig. 2). The therapist then slowly walks backward while leading or pulling the patient forward, much as a dancer would lead his partner (Figs. 3, 4). In this manner, the therapist can control the stride lengthof the involved extremity. To increase weight bearing on the affected leg, the therapist can block the patient's knee into extension and use the upper extremity hold to laterally shift the patient's center to gravity to the affected side (Fig. 5). Depending on the degree of lateral or medial foot placement relative to the therapist's shoe, the therapist can also exert a certainamount of stretching on the ankle everter or inverter muscles, respectively (Fig. 6).

Once the patient adjusts to slow, short strides as controlled by the therapist, longer strides are advised until the patient begins to demonstrate a consistent heel-strike pattern. When this heel-strike pattern is achieved, the therapist's foot is no longer needed to support the involved leg. Pediatric patients respond better to this technique when it is presented to them as a game (eg, "Simon Says," "Red Light-Green Light"). Experience with this technique in the Burn Center at the Baton Rouge General Medical Center (Baton Rouge, La) has resulted in measurable gains in stride length, relative weight bearing, standing knee extension and ankle dorsiflexion ROM, and hell-toe gait pattern.

The recommended length, frequency, and carry-over effects of this treatment vary from patient to patient, depending on the patient's pain tolerance, motivation, and willingness to take frequent, short walks between physical therapy sessions. In general, however, performing this technique for approximately 10 minutes twice daily as part of an overall exercise and gait training program has been a successful approach. Positive results of this gait training method are usually attained in one to three treatments, depending on the factors described earlier. Prior stretching of the lower extremities while the patient is positioned supine or sitting and the use of frequent rest periods are strongly advised.

Whether "tight" (contracted) gastrocnemius-soleus muscles will result in a temporary versus a permanent gait and postural deformity depends largely on the patient's compliance with an overall rehabilitation program established in consultation with the physical therapist and the "hands-on" skills of that therapist. The gait training technique described above for lengthening gastrocnemius-soleus muscles may facilitate the rapid restoration of normal gait and standing posture for some patients when incorporated as part of a comprehensive rehabilitation program.

Acknowledgements

I thank Amye Jennings, Media Specialist, Baton Rouge General Medical Center, Baton Rouge, La, for her photographic expertise. I also thank my colleagues in the Physical Medicine Department, especially Derylin Dobyns, LOTR, for their assistance in preparing this manuscript.

References

[1] Northdruft D, Smith PS, LeMAster JE: Exercise and treatment modalities. In Fisher SV, Helm PA (eds): Comprehensive Rehabilitation of Burns. Baltimore, MD, Williams & Wilkins, 1984, pp 96-147

[2] Salter RB: Textbook of Disorders and Injuries of the Muscoloskeletal System, ed 2. Baltimore, MD, Williams & Wilkins, 1983, pp 80-81, 406-407

[3] Covey MH: Occupational therapy. In Boswick JA (ed): The Art and Science of Burn Care. Rockille, MD, Aspen Publishers Inc, 1987, pp 297-298

[4] Duncan CE: Use of a ramp surface for lower extremity exercise with burn-injured patients. J. Burn Care Rehabil, to be published

C. Duncan, MS, PT, is Clinical Specialist in Burn Rehabilitation, Physical Medicine Department, Baton Rouge General Medical Center, PO Box 2511, Baton Rouge, La 70821 (USA).