Clinical Sciences/Health Conditions
Ève Boissonnault, MD FRCPC (she/her/hers)
Assistant Professor
University of Alberta
Edmonton, Alberta, Canada
Justin C. Lewicke, BSc MBA
Motion Analyst
Glenrose Rehabilitation Hospital
Edmonton, Alberta, Canada
Stacey M. Wray, BKin BScN
Registered Nurse
University of Alberta
Edmonton, Alberta, Canada
Nicole Rinas, BScN BPE
Registered Nurse
University of Alberta
Edmonton, Alberta, Canada
Lalith Satkunam, MD FRCPC
Professor
University of Alberta
Edmonton, Alberta, Canada
A 53-year-old woman with chronic spastic left hemiparesis secondary to right MCA infarct was referred for gait assessment prior to left foot and ankle surgical intervention. Her objectives were to improve gait and reduce toe pain during ambulation.
Case Description:
Despite using an ankle-foot orthosis and receiving botulinum toxin injections, she reported painful toe flexion impacting her gait.
The foot and ankle resting position exhibited a partially reducible equinus and flexed toe deformity, with the hallux in a neutral position. However, with weight bearing, all toes were markedly flexed, and the tibia was in varus. The Lewicke Block Test showed correction of the hindfoot varus to neutral alignment when the toes were unloaded.
She underwent surgery, which included gastrocnemius recession, tendon lengthening of lesser toes, and hallux interphalangeal fusion, with very good outcomes where her pain reduced to 0/10 from 8/10.
Discussions:
The Lewicke Block Test aims to elucidate whether the hind foot varus is caused by a spastic tibialis posterior or being driven into this posture due to a spastic flexor hallucis longus.
The patient first stands on a flat surface, and the degree of calcaneal varus is documented. The toes are then offloaded by stepping on a block with the toes hanging in front. If the hindfoot varus corrects itself, then the main driver for the problem is the flexor hallucis longus.
This Lewicke block test should be distinguished from the Coleman block test, which drops the medial first ray over the medial side of the block, looking for hindfoot varus correction to determine if flexible versus rigid cavovarus foot deformity. (Coleman and Chestnut, 1977)
Conclusions:
This simple test enhances the clinician’s understanding of the patient’s biomechanics and can guide which muscles should be targeted for chemodenervation or surgical interventions.
