Here is My Question:
Under what circumstances is Trendelenburg sign / gait seen in the MS setting? Does it ever occur with footdrop? In a patient catching toe when walking, is the catching possibly related to the hip drop? What would cause Trendelenburg sign if related to MS? What are the differential diagnoses? 

Answer:
The Trendelenburg sign is a term used to describe a type of gait deviation. It can be seen in anyone, and is associated with weakness of the hip abductor muscles. It can occur with foot drop, but both can occur independently of each other as well. A Trendelenburg sign is not the cause of a foot drop. Foot drop either occurs due to weakness in the tibialis anterior muscle, spasticity of the plantarflexors (calf muscles) or sometimes can be more pronounced with weakness of the hip flexors (not abductors). Differential diagnosis would be muscle strength testing (MMT) of the lower extremities, to determine which muscle groups are weak.
 
Sarah Frank, PT, DPT, MSCS
Outpatient Rehab
Mt. Sinai Rehabilitation Hospital
490 Blue Hills Ave.
Hartford, CT 06112

Here is My Question:
How does foot drop start? My left foot at the ankle feels weak and uncomfortable to walk on. I can walk straight no issues.

Answer:
A foot drop is an inability to dorsiflex the foot (move upward at the ankle joint). The first symptom noticed is catching the toe or foot on the ground while bringing the leg forward during your normal stride. If more severe, a person with a foot drop walks with a high step gait during the forward swing phase to allow the foot to clear the ground. Others may notice that the foot makes a loud slapping noise when it hits the ground.

If a foot drop is caused by a central nervous system problem, there may be a spastic or dystonic turning in of the foot while walking. This may create a sense of instability or discomfort at the ankle joint since the foot can roll over during normal walking.

You can read more about foot drop on our symptom page for it...READ MORE

​Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Here is My Question:
My right leg is weaker than the left, almost like it is dead. I constantly trip because I can't control it, and I also drag my right foot.

Even though I use a frame I find it hard to keep my balance and walk due to the weaker leg. Is there anything I can do to help me with muscle recovery in my right leg?

Answer:
For people with MS who suffer from a weak leg with significant proximal (the muscle that work at the hip joint) and distal (the muscles that work around the ankle joint) weakness, it is extremely important to take a 4 step approach to management that requires the assistance of your MS specialist, a physical therapist with neurological training and an orthotic expert.

1. You must eliminate the foot drop to improve safety, gait mechanics and stresses on other joints, particularly the knee and hip. The traditional way to do this is to obtain an ankle foot orthotic device (AFO).  I prefer the dynamic AFOs with a foot plate that provides a spring action to help with the, “toe off” phase of your gait. A popular model for those with more significant weakness is the Blue Rocker.  As an alternative to an AFO, you may want to investigate a functional electrical stimulation device (FES) that electrically stimulates the weak muscles (called the foot dorsiflexors) to contract at just the right stage of your gait. There are two available models, the Bioness and the WalkAide. Both have their advocates based on various features and means of activation. The last time I looked the Walkaide was considerably cheaper, but both range from $4,000 to $6,000 and there may be difficulty obtaining insurance approval. These devices are well tolerated, work well and do not restrict movement like the AFOs. They also tend to decrease spasticity in the limb and strengthen muscles, both beneficial features.

2. You need to ensure adequate leg lift by your proximal muscles. This is achieved through progressive resistance training (strengthening) and can be enhanced through the use of a Hip Flexor Assist Orthosis (HFAO). The HFAO basically looks like a weight lifters belt with two bungee cords attached that descend down both sides of the leg and end by attaching to your shoe. When you walk the bungee cords are stretched when the leg is extended and assist with hip flexion when you bring the leg forward.  

3. You may also benefit from the addition of Ampyra. This is a Potassium channel blocker approved by the FDA to improve walking speed. It accomplishes this by improving the efficiency of electrical currents in your nervous system and, therefore, may improve the activation of the muscles in your weaker leg.

4. Physical therapy with a therapist trained in neurological disorders is essential to put everything together in a customized fashion to improve your walking safety and efficiency. You may also benefit from a stabilization device such as a cane or walker depending on your degree of postural instability and weakness.

You can also read our symptom pages for strength and balance issues http://www.healthcarejourney.com/balance-and-walking-issues.html

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Here is My Question:
I was recently diagnosed with MS. I underwent IV steroid treatments. After steroid treatment, my drop foot was gone. Now, a week after being off of steroids, my drop foot is returning. Is it normal for symptoms to return like this after being resolved on steroids?

Answer:
IV steroids can produce amazingly rapid benefits, especially in newly diagnosed patients. However, it is not unusual for someone to experience a little “rebound” in their symptoms shortly after stopping IV steroids. You should contact your MS specialist to inform him or her of this experience. All of us take a slightly different approach to managing this issue; some like myself wait and see if there is any continued worsening before retreating unless the worsening is dramatic; others are inclined to retreat with steroids more quickly and possibly use a prednisone taper for several weeks.  In either case it can take weeks to obtain full recovery from a relapse but 90% of patients do eventually experience almost complete return of function from initial attacks. Good luck.

Rip Kinkel, MD