title: Treatment strategies for genu recurvatum in adult patients with hemiparesis: a case series.
abstract: OBJECTIVE
  To report our clinical experience and propose a biomechanical factor-based treatment strategy for improvement of genu recurvatum (GR) to reduce the need for knee-ankle-foot orthosis (KAFO) or surgical treatment.
  
  
  METHODS
  Case series.
  
  
  METHODS
  Outpatient clinic of a Department of Physical Medicine and Rehabilitation in an academic medical center.
  
  
  METHODS
  Adult subjects (n = 22) with hemiparesis and GR who received botulinum injections alone or in combination with multiple types of orthotic interventions that included solid ankle-foot orthosis (AFO) ± heel lift, hinged AFO with an adjustable posterior stop ± heel lift, AFO with dual-channel ankle joint ± heel lift, or KAFO with offset knee joint. Biomechanical factors reviewed included muscle strength, modified Ashworth score for spasticity, presence of clonus, posterior capsule laxity, sensory deficits, and proprioception.
  
  
  METHODS
  Outcome factors were improvement or elimination of GR based on subjective assessment before and after the interventions by the same experienced clinician.
  
  
  RESULTS
  More than one biomechanical factor contributed to GR in all patients. Botulinum toxin A injection was used in patients who had significant plantar flexor spasticity and/or clonus. Four types of orthotic interventions were used based on the biomechanical factor: solid AFO in patients with severe ankle dorsiflexion and plantar flexion weakness or clonus; hinged ankle joint with adjustable posterior stop in patients with less severe ankle dorsiflexion weakness in the absence of clonus; AFO with a dual-channel ankle joint for quadriceps weakness or severe proprioceptive deficits; and KAFO with offset knee joints in patients with Achilles tendon contracture or severe proprioceptive deficits. Adjunctive options included the addition of heel lifts and toeplate modifications. Combinatorial interventions of botulinum injection, modified AFOs, and heel lifts improved or eliminated GR and avoided the need for cumbersome orthotics or surgical interventions.
  
  
  CONCLUSIONS
  GR in hemiparesis is multifactorial and can be successfully controlled by using a conservative biomechanical factor-based approach and combined medical and orthotic interventions. An algorithmic approach and a prospective study design is proposed to determine a combination of effective interventions to correct GR.
authors.affiliation: Department of Physical Medicine and Rehabilitation, Hofstra North Shore Long Island Jewish Health System, Manhasset, NY(∗). Electronic address: apmala01@gmail.com.
authors.forename: Malathy
authors.initials: M
authors.lastname: Appasamy
authors.affiliation: Department of Physical Medicine and Rehabilitation, Hofstra North Shore Long Island Jewish Health System, Manhasset, NY(†).
authors.forename: Michelle E
authors.initials: ME
authors.lastname: De Witt
authors.affiliation: Adventist Rehabilitation Hospital, Rockville, MD(‡).
authors.forename: Nisha
authors.initials: N
authors.lastname: Patel
authors.affiliation: Department of Physical Medicine and Rehabilitation, Hofstra North Shore Long Island Jewish Health System, Manhasset, NY(§).
authors.forename: Nancy
authors.initials: N
authors.lastname: Yeh
authors.affiliation: Feinstein Institute for Medical Research Manhasset, NY; Department of Physical Medicine and Rehabilitation, Hofstra North Shore Long Island Jewish School of Medicine, Manhasset, NY(¶).
authors.forename: Ona
authors.initials: O
authors.lastname: Bloom
authors.affiliation: Department of Physical Medicine and Rehabilitation, Hofstra North Shore Long Island Jewish Health System, Manhasset, NY(#).
authors.forename: Anthony
authors.initials: A
authors.lastname: Oreste
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use; D005081:Exercise Therapy; D005260:Female; D006801:Humans; D016916:Joint Deformities, Acquired / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D007593:Joint Instability / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D007719:Knee Joint; D008297:Male; D008875:Middle Aged; D009128:Muscle Spasticity / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D009465:Neuromuscular Agents / Q000627:therapeutic use; D009989:Orthotic Devices; D010291:Paresis / Q000150:complications* / Q000534:rehabilitation; D016059:Range of Motion, Articular; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A