What is the management plan for a patient with lower limb dysmetria?

Management of Lower Limb Dysmetria

The management of lower limb dysmetria requires a multidisciplinary approach focusing on physical therapy, proper alignment techniques, and in some cases surgical intervention to optimize functional outcomes and quality of life.

Assessment and Diagnosis

• Accurate assessment of lower limb dysmetria should include measurement of intercondylar and/or intermalleolar distance to evaluate the severity of varus or varus leg deformities 1
• Regular clinical evaluation should include assessment of limb symptoms, functional status, lower extremity pulse examination, and foot assessment 1
• The 6-minute walk test (6MWT) in patients >5-6 years old can help quantify the functional consequences of dysmetria on bone and muscles 1
• Radiographic assessment is often necessary as clinical measurements alone cannot fully assess lower limb deformity and joint alignment 1

Physical Therapy Interventions

• Encourage optimal postural alignment at rest and during functional activities, considering a 24-hour management approach 1
• Promote even distribution of weight in sitting, transfers, standing and walking to normalize movement patterns and muscle activity 1
• Grade activities to increase the time that the affected limb is used with normal movement techniques within functional activities 1
• Implement tasks that promote normal movement, good alignment and even weight-bearing, such as transfers, sit-to-stand exercises, and standing activities 1
• Employ anxiety management and distraction techniques when undertaking tasks to improve motor control 1

Assistive Devices and Orthotics

• Ambulatory assistive devices (e.g., canes, walkers) should be used to help with gait and balance impairments, as well as mobility efficiency and safety when needed 1
• Ankle-foot orthoses (AFOs) should be used for ankle instability or dorsiflexor weakness to improve walking disability, step/stride length, and balance 1
• Wheelchairs should be prescribed for non-ambulatory individuals or those with limited walking ability to increase participation and improve quality of life 1
• The prescription of assistive devices should be specific to the patient's needs, environment, and preferences 1

Surgical Management

• Surgical treatment should be performed only after medical treatment has been maximized for at least 12 months 1
• Surgery should be performed by a surgeon with expertise in metabolic bone diseases 1
• Consider surgical intervention when there is persisting deformity (mechanical axis deviation Zone 2 or greater) despite optimized medical treatment and/or the presence of symptoms interfering with function 1
• The age of the patient is an important factor in the decision-making process: guided growth techniques depend on remaining growth potential and must be carried out at least 2-3 years before skeletal maturity 1
• Following surgery, regular clinical and functional assessments should be made, including radiography at 12 months post-surgery, or earlier if bone deformity worsens 1

Complications and Considerations

• Splinting may prevent restoration of normal movement and function and should be used cautiously 1
• Potential problems with splinting include: increasing attention to the area, increasing accessory muscle use, compensatory movement strategies, immobilization leading to muscle deconditioning, learned non-use, and increased pain 1
• Avoid postures that promote prolonged positioning of joints at the end of range (e.g., full hip, knee, or ankle flexion while sitting) 1
• Address associated problems of pain and hypersensitivity which may accompany lower limb dysmetria 1
• Recognize that lower limb dysmetria, even when asymptomatic, is associated with impaired lower extremity functioning and reduced quality of life 1

Follow-up Care

• Patients should receive regular follow-up with multidisciplinary teams organized by an expert in metabolic bone diseases 1
• Coordination of care among clinicians is essential to improve management and optimize patient outcomes 1
• Periodic assessment of functional status and overall health-related quality of life should be included as components of longitudinal follow-up 1
• For patients who have undergone lower extremity revascularization, follow-up should include periodic clinical evaluation of lower extremity symptoms and pulse and foot assessment 1