Something about genu recurvatum, foot drop and splints

I have been seeing an elderly gentleman with complex past medical history leaving him with hemiparesis on left side of the body. However his left lower limb is mostly affected, he has foot drop, whereas upper limb has preserved function. The patient is able to independently  mobilise indoor with wheeled zimmer frame and with 2 walking sticks outdoor. He is unstable with walking sticks and he experienced frequent falls in last 12 months.

First time when I met this gentleman I thought of his safety and quality of gait. He presents with genu recurvatum in stance phase and lack of heel strike and reduce foot clearance on swing phase. In the past he was advised to use AFO for his left foot, however he admitted to me that he does not like it because it is not comfortable, difficult to apply, causing him pain and he is not able to feel the ground. Although we agreed to exchange his 2 walking stick to 3-wheeled delta frame for outdoor mobility, the problem with his left lower limb was not solved.

After the appointment with this lovely gentleman I had dilemma; if I should accept his willing not to use AFO and if should I introduce him other alternatives to improve quality of his gait. Because he is 80 years old it is difficult to change his attitude but from the other hand he is very keen on exercising.

Seeing this gentleman let me find time to dig and look for other option which might be useful for him as well for my future patients.

There is a very good article ‘ Treatment of genu recurvatum in hemiparetic adult patients:A systematic literature review’ from 2009.

 http://www.sciencedirect.com/science/article/pii/S1877065710000023?via%3Dihub

They explain different reasons of genu recurvatum (knee extensor weakness or spasticity, weakness of the buttock muscles, weakness or over-extension of the hamstring muscles, limited dorsal ankle flexion as a result of spasticity and/or retraction of the muscles in the posterior compartment of the leg, avoidance of painful pressure on the ball of the foot and, lastly, proprioceptive disorders) and clinical indications for the most appropriate treatment including orthotic devices. Here you can find summary:

Reason of possible genu recurvatum	Treatment options
knee extensor weakness- it is important for a patient to maintain recurvatum to take steps safely, with a load line, which stays in front of the knee, as in femoral amputees or polio victims.	A hinged leg orthosis may be useful for stopping the recurvatum from worsening but the device must be adjusted so that the patient can maintain slight recurvatum in the stance phase. If the risk of knee unlocking is high, a rigid, full leg brace that maintains the knee in extension may be useful for both correcting recurvatum and countering the risk of unlocking.
knee extensor spasticity (the impact of which is often aggravated by hamstring weakness), genu recurvatum is present during both the swing phase (“stiff-knee gait”) and stance phase of gait. This gait pattern is difficult to correct.	Botulinum toxin injections in the quadriceps were shown to improve knee flexion in the swing phase and to reduce the energy cost of gait. However, this improvement was not clinically obvious and did not exceed 5° of knee flexion
significant hamstring weakness and/or overextension (as has been described in children with cerebral palsy), concentric reinforcement of the hamstring muscles.	ankle-foot orthosis (AFO) with limited plantar flexion can help the subject to control their knee during the stance phase
buttock muscle weakness (leading to excessive hip flexion and compensatory knee hyperextension).	a combination of analytical reinforcement of the buttock muscles and functional electrical stimulation can help the patient to change his/her gait pattern.
spasticity of the posterior leg muscles or the knee extensors, it may be useful to consider focal treatment of the spasticity. When the spasticity is complicated by irreducible retraction of the posterior leg muscles, two therapeutic options can be envisaged.	(e.g. botulinum toxin injections or selective neurotomy), as suggested by Caillet et al surgical extension of the muscle and tendon systems at the back of the leg (i.e. the Achilles tendon and the toe flexors). orthopaedic shoes, with compensation of equinus foot. When treatment of spasticity and retraction is not possible or not sufficient, an appropriate device (a hinged ankle-foot orthosis with limited plantar flexion, in this case) can help the patient to progressively adopt a different gait pattern
quadriceps weakness	An AFO will prevent the ankle from positioning itself in dorsal flexion; this runs the risk of generating knee flexion on heel strike, which may well “unlock” the flexed knee and induce a fall
painful pressure on the ball of the foot	spastic toe curl, which may benefit from treatment with botulinum toxin or tendon extension. There may also be overpressure pain at the heads of the metatarsals or pain related to hallux valgus. In both circumstances, use of orthopaedic insoles and/or appropriate footwear can relieve the pain
major sensory disorders	AFO with limited plantar flexion can help the patient to adequately position his/her knee during the swing phase. An anti-recurvatum orthosis (such as the Swedish Knee Cage) may also be of value in proprioceptive retraining. If the proprioceptive impairment is significant, the same reasoning as in cases of quadriceps weakness can be adopted and use of a full leg brace with free or locked flexion may be considered.

Although, there are different types of foot splints it is important to consider its effectiveness and comfort. 

https://www.footankle.com/self-care/dropfoot-braces/ 

Here are evidence why foot splints work.

http://www.archives-pmr.org/article/S0003-9993(09)00122-1/fulltext