Journal of Rehabilitation Medicine 51-5 | Page 64

J Rehabil Med 2019; 51: 380–384 SHORT COMMUNICATION ANATOMICAL LANDMARKS FOR TIBIAL NERVE MOTOR BRANCHES IN THE MANAGEMENT OF SPASTIC EQUINOVARUS FOOT AFTER STROKE: AN ULTRASONOGRAPHIC STUDY Alessandro PICELLI, PhD 1,2 , Elena CHEMELLO, MD 1 , Elisabetta VERZINI, MD 1 , Federico FERRARI, MD 1 , Annalisa BRUGNERA, MD 1 , Marialuisa GANDOLFI, PhD 1,2 , Leopold SALTUARI, MD 3,4 , Angela MODENESE, MD 2 and Nicola SMANIA, MD 1,2 From the 1 Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 2 Neurorehabilitation Unit, Hospital Trust of Verona, Verona, Italy, 3 Department of Neurology, Hochzirl Hospital, Zirl, Austria and 4 Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy Objective: To identify the anatomical landmarks of tibial motor nerve branches to the gastrocnemii, so- leus and tibialis posterior muscles for selective mo- tor nerve blocks in the management of spastic equi- novarus foot. Design: Observational study. Patients: Twenty-five chronic stroke patients with spastic equinovarus foot. Methods: Motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were tracked in the affected leg, using ultrasonography, and located in the space (vertical, horizontal and deep) according to the position of the fibular head (proximal/distal) and a virtual line from the middle of the popliteal fos- sa to the Achilles tendon insertion (medial/lateral). Results: Mean coordinates for the gastrocnemius medialis motor branch were: 1.5 cm (standard devi- ation (SD) 2.7) vertical (proximal), 1.7 cm (SD 1.3) horizontal (medial), 1.1 cm (SD 0.4) deep; for the gastrocnemius lateralis motor branch: 0.9 cm (SD 2.2) vertical (proximal), 1.8 cm (SD 1.7) horizontal (lateral), 1.0 cm (SD 0.3) deep; for the soleus motor branch: 1.4 cm (SD 1.1) vertical (distal), 1.6 cm (SD 0.7) horizontal (lateral), 2.8 cm (SD 0.7) deep; and for the tibialis posterior motor branch: 4.3 cm (SD 1.5) vertical (distal), 1.9 cm (SD 0.9) horizontal (la- teral), 4.2 cm (SD 0.8) deep. Conclusion: These findings may help in the identi- fication of tibial motor nerve branches to the gast- rocnemii, soleus and tibialis posterior muscles for selective motor nerve blocks in the management of spastic equinovarus foot. Key words: equinus deformity; muscle spasticity; rehabilita- tion; ultrasonography. Accepted Feb 12, 2019; Epub ahead of print Mar 6, 2019 J Rehabil Med 2019; 51: 380–384 Correspondence address: Alessandro Picelli, Neuromotor and Cogniti- ve Rehabilitation Research Center, Department of Neurosciences, Bio- medicine and Movement Sciences, University of Verona, Verona. P.le L.A. Scuro, 10. 37134 Verona, Italy. E-mail: [email protected] S pastic muscle overactivity is a positive feature of upper motor neurone syndrome, which may lead to multiple patterns of motor dysfunction affecting the upper (adducted shoulder with internal rotation; flexed LAY ABSTRACT This study aimed to identify the motor nerve branches to the main calf muscles, in order to assist in the ma- nagement of spastic foot. Twenty-five chronic stroke patients with spastic foot were evaluated with ultraso- nography. The nerve branches to the gastrocnemii, so- leus and tibialis posterior muscles were located in space (vertical, horizontal and deep), based on the position of the fibular head (proximal/distal) and a posterior line in the middle of the leg (medial/lateral). The coordinates for the gastrocnemius medialis motor branch were: 1.5 cm proximal, 1.7 cm medial, 1.1 cm deep; for the gast- rocnemius lateralis motor branch: 0.9 cm proximal, 1.8 cm lateral, 1.0 cm deep; for the soleus motor branch: 1.4 cm distal, 1.6 cm lateral, 2.8 cm (SD 0.7) deep; and for the tibialis posterior motor branch: 4.3 cm distal, 1.9 cm lateral, 4.2 cm deep. These findings may help in the management of spastic foot. elbow; pronated forearm; flexed wrist; flexed fingers; thumb-in-palm; clenched fist) and/or lower (adduc- ted thigh; flexed knee; extended knee; plantar flexed foot/ankle; equinovarus foot; striatal toe; flexed toes) limbs (1–3). Patients with spastic muscle overactivity usually need clinical interventions, such as drugs, physical therapy or other rehabilitation procedures in combination (4, 5). Spastic equinovarus foot is the pattern most com- monly treated in patients with stroke (3). It has 4 main causes: calf muscles (soleus, gastrocnemii, tibialis posterior, flexor digitorum and flexor hallucis longus muscles) spastic overactivity; calf muscles contracture/ shortening leading to fixed deformity; drop-foot during the swing phase of gait due to muscle weakness (e.g. tibialis anterior, extensor digitorum and hallucis); imbalance between the tibialis anterior and peroneus (brevis and longus) muscles leading to hindfoot varus in the swing phase of gait (6). Nerve blocks involve the injection of medications near to peripheral nerves in order to obtain a (short- or long-term) reduction in, or abolition of, conduction. Selective neural blockade technique is commonly ba- sed on the use of a disposable needle for conduction anaesthesia (delivering electrical stimulation), positio- This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm doi: 10.2340/16501977-XXXX Journal Compilation © 2019 Foundation of Rehabilitation Information. ISSN 1650-1977