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Lower limb spasticity

Lower limb spasticity is muscle overactivity in the hip, knee, ankle, foot or toes after stroke, spinal cord injury, brain injury, multiple sclerosis or similar conditions. It produces a foot that points down and turns in, a stiff or scissoring leg, and clawed toes — affecting walking, transfers, footwear and comfort. Targeted injections into the responsible muscles, with stretching, casting and orthotics, can improve gait, standing and care.

In the leg, spasticity most often pulls the foot downward and inward, stiffens the knee, and draws the thighs together. Walking becomes slow and effortful, the foot catches, shoes and braces will not fit, and standing or transferring becomes unsafe. For people who do not walk, tone in the legs still matters: it can cause pain, pressure areas, difficulty with hygiene and dressing, and spasms that disturb sleep.

The patterns. Equinovarus — the foot pointing down and turning in — is the commonest and most disabling, produced by overactive calf and inverting muscles; it prevents the heel from reaching the ground and tips weight onto the outer edge of the foot. A stiff knee that will not bend in swing makes the leg circle outward. A knee that collapses into flexion makes standing hard. Adductor spasticity pulls the thighs together, interfering with hygiene, catheter care and sitting. Clawed or extended toes rub in shoes and are painful to bear weight on. Each is treated by targeting the particular muscles responsible.

Treat, or leave alone? Not all lower limb tone should be reduced. A stiff, extended leg may be what allows someone to stand and transfer; take that tone away and the leg buckles. The assessment weighs what each muscle's overactivity is costing against what it may be providing, and the decision is made muscle by muscle, with you, your physiotherapist and your care team. This is where experience in spasticity management makes the difference.

Treatment. Spasticity injections into the overactive muscles reduce tone for a period of months, and are repeated as the effect wears off. For the equinovarus foot, injections are commonly followed by serial casting to lengthen the calf and by an ankle-foot orthosis to hold the correction during walking. Stretching and gait practice within the treatment window turn the change into a lasting one. Where a muscle has already shortened permanently, orthopaedic opinion is arranged.

Walking assessment. For people who walk, the pattern is observed in motion as well as on the couch, because spasticity that is modest at rest can dominate during gait. Treatment goals are framed around walking: heel contact, foot clearance, speed, safety, and the ability to wear normal footwear and a brace.

Who is seen. Adults with lower limb spasticity after stroke, spinal cord injury (paraplegia and tetraplegia), traumatic brain injury, multiple sclerosis, cerebral palsy and other neurological conditions, whether or not they walk. Telehealth assessment and review are available for rural and remote patients, with injection visits in Perth.