Essential Aspects Of Physiotherapy In The Successful Treatment Of A Patient With Cervical Disc Herniation: A Case Report

Background: Cervical disc herniation is one of the major conditions resulting in neck pain, which in turn affects the patient's activities of daily living. The Conservative approach is always being challenging among these patients due to the feeling of insecurity and the related severity of symptoms. McKenzie's approach has been used worldwide for slipped disc issues in providing relief by reducing the disc pressure and radiating symptoms. Deep Cervical Flexors strengthening plays a vital role in providing neck stability and thereby improving the posture. Case Summary: A case of neck pain with radiation into the left upper extremity going down to the left hand in a 47-year-old female was presented to physical therapy and has been referred by an orthopedic surgeon with a diagnosis of acute cervical disc prolapse at the C5-6 level. After the initial evaluation, muscle energy techniques were initially given to increase the ROM of the cervical spine as the neck was stiff. Mckenzie techniques were executed, including manual traction for 15 days along with basic ROM, neck isometrics, and DCF strengthening. Outcome measures: Numeric Pain Rating Scale (NPRS), Cervical ROM, Neck Disability Index (NDI), Tampa Scale for Kinesiophobia (TSK) were used. Conclusion: Mckenzie protocols combined with Muscle Energy Techniques (MET) and DCF strengthening exercises revealed that there was a significant improvement in the patient's functional ADL with a marked reduction in disc herniation and its associated symptoms.

A dominância de membros interfere no equilíbrio de força muscular do joelho de corredores recreacionais? / Does the limb dominance interfere with knee muscle strength balance in recreational runners?

Introdução: cerca de 5% da população brasileira pratica corrida de rua, e a falta de preparo físico das pessoas para esse esporte contribui para o aumento no índice de lesões, sendo o joelho uma das articulações mais acometidas. Sabendo que os parâmetros musculares interferem diretamente no desempenho e que a destreza de membros pode suscitar inferências relativas ao aumento de força no membro dominante, torna-se importante avaliar a força e a relação de equilíbrio muscular do joelho destes atletas tanto no membro dominante quanto no contralateral. Objetivo: verificar o equilíbrio muscular dos extensores e flexores de joelho dominante e não dominante em corredores recreacionais. Metodologia: foram incluídos 111 indivíduos com idade entre 18 e 65 anos, de ambos os sexos, praticantes de corrida há pelo menos 4 meses contínuos, sem histórico de lesão nos últimos 3 meses. Os participantes foram entrevistados e encaminhados para a coleta da força muscular isocinética dos grupos extensor e flexor do joelho com protocolo de 60°/s, 180°/s e 300°/s. As variáveis de interesse estudadas foram: membro dominante, tempo de prática de corrida, torque máximo, trabalho total e potência. Foram calculados os Índices de Deficiência Muscular (IDM) sendo admitido como referencial de equilíbrio até 10% na diferença entre os membros. A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa do Instituto de Ciências da Saúde da Universidade Federal da Bahia, sob parecer de nº 2.621.166. Resultados: o IDM indicou que 54,1% dos extensores de joelho estavam equilibrados e que 55,9% dos flexores de joelho encontravam-se numa relação de desequilíbrio muscular. Conclusão: a dominância de membros não é um fator ligado ao desequilíbrio de forças no membro inferior. Este achado de desequilíbrio de força entre joelhos pode estar ligado à predisposição de lesão e deve orientar as equipes multiprofissionais de saúde a definir um trabalho preventivo de treinamento muscular e esportivo.

Introduction: about 5% of the Brazilian population practices street running and the lack of physical fitness for this sport contributes to the increase in the injury rate, with the knee being one of the most affected joints. Knowing that muscle parameters directly interfere performance and that limb dexterity may lead to inferences regarding strength increase in the dominant limb, it is important to evaluate the strength and balance ratio of these athletes' knee in both dominant and contralateral limbs. Objective: to verify muscle balance of dominant and non-dominant knee extensors and flexors in recreational runners. Methodology: 111 individuals aged between 18 and 65 years old, male and female, who have been running for at least 4 continuous months, with no history of injury in the last 3 months, were included. Participants were interviewed and referred for the collection of isokinetic muscle strength of the knee extensor and flexor groups with a protocol of 60°/s, 180°/s and 300°/s. The variables of interest studied were: dominant limb, running practice time, maximum torque, total work and power. Muscle deficiency indices (MDI) were calculated and accepted as a balance reference up to 10% in the difference between the limbs. The research was approved by the Research Ethics Committee of the Institute of Health Sciences of the Federal University of Bahia, under technical advice no 2.621.166. Results: the MDI indicated that 54.1% of the knee extensors were balanced and 55.9% of the knee flexors were in a muscular imbalance ratio. Conclusion: limb dominance is not a factor related to lower limb imbalance of forces. This finding of strength imbalance between knees may be associated to injury predisposition and should guide multidisciplinary health teams to define preventive work on muscle and sports training

Morphometric analysis of palmaris longus muscle belly and its tendon: a cadaveric study in north india

Background: The Palmaris Longus Muscle is the first option in tendon graft procedures, for it fulfills the necessarycriteria of length, breadth and easy surgical accessibility. Therefore, the present study was performed with thepurpose to determine the morphometry of PL in North Indian population.Materials and methods: Material for the present study consisted of 40 limbs of different age group andsex(28Males&12Females). The limbs were made available in the Anatomy department for dissection purpose atSGRDIMSAR, Amritsar, Punjab. The length and width of the PL-Muscle Belly(PL-MB) and PL-Tendon(PL-T) weremeasured with the help of digital Vernier caliper. The unpaired t test was used to study the significance of thedifferences in male and females and right and left PLM.Results: The mean MBL and MBW of the PL was more (6.195+1.788cm & 2.095+0.723cm) on right side than(5.895+1.748cm & 1.920+0.740cm) on the left side. The mean TL on left side (15.690+1.336cm) was slightly morethan the right side (15.625+1.489cm) whereas TW on right side (0.435+0.099cm) was found to be slightly morethan the left side (0.426+0.108cm). It was also observed that the mean MBL, MBW, TL and TW was more in malecadavers as compared to female cadavers.Conclusion: PLM has importance in medical clinic, surgery, radiological analysis and has great significancewhen used as a donor tendon in reconstructive surgeries. Thus there are advantages to know the length and widthof the PL tendon for being the ideal choice for tendon graft procedures.

Effects of different voluntary forces of dynamic stretching on maximal dorsiflexion angle of the ankle joint and subjective fatigue / 体力科学

This study aimed to examine the effects of different voluntary forces of dynamic stretching (DS) on the maximal dorsiflexion angle of the ankle joint, passive torque, and subjective fatigue. Eleven healthy male participants were included in this study. Ankle angle and passive torque were measured before and after DS, which involved four sets of ankle plantarflexion-dorsiflexion performed for 30 s while sitting on an isokinetic machine with the knees fully extended. Although ankle plantarflexion was passively performed via an isokinetic machine, participants were instructed to perform the active ankle dorsiflexion under either of the following two conditions: with maximal voluntary contraction (MVC) (DSmax) or with submaximal voluntary contraction (DSsub). In DSsub, 80% MVC was set as the target voluntary force. Subjective fatigue during DS was measured using the visual analogue scale. In DSsub, participants actually demonstrated 87.0 ± 5.8% MVC. The maximal ankle dorsiflexion angle significantly increased after DS in both conditions. Subjective fatigue was significantly greater after two, three, and four sets of DSmax than after the corresponding repetitions of DSsub. Although passive torque at the maximal dorsiflexion angle tended to increase after stretching, no significant changes were observed in the passive torque from before to after DS. These results compared MVC with approximately 87% MVC, indicating that the voluntary force of DS did not influence the increment of the maximal dorsiflexion angle after DS. Our study findings also suggested that 80–90% MVC is recommended during DS to increase the maximal dorsiflexion angle without excessive subjective fatigue.

Tenosinovitis inespecífica en granos de arroz de los tendones flexores de la mano / Ténosynovite non spécifique d'aspect en grains de riz des tendons fléchisseurs de la main / Non-specific flexor tendons tenosynovitis in rice grains of the hand

La tenosinovitis con cuerpos libres en forma de granos de arroz es una afección muy infrecuente que se presenta, generalmente, asociada a artritis reumatoide o tuberculosis. Los casos no asociados a estas enfermedades son extremadamente raros. Se presenta un paciente masculino de 62 años de edad, intervenido quirúrgicamente por un síndrome del túnel carpiano derecho hace 7 años. En aquel momento se le realizó una apertura del retináculo transverso del carpo y una sinovectomía de los tendones flexores. La biopsia sinovial reportó una "sinovitis crónica". Evolucionó satisfactoriamente durante los primeros 4 años, luego comenzó a presentar nuevamente los síntomas compresivos del nervio mediano y un aumento progresivo del volumen en la cara anterior de la muñeca. El ultrasonido mostró una marcada hipertrofia sinovial de los tendones flexores a nivel de la muñeca. Los estudios neurofisiológicos reportaron daño axonal y mielínico en las fibras del nervio mediano derecho. Se le realizó una nueva intervención donde se visualizó la hipertrofia sinovial y abundantes cuerpos libres en forma de granos de arroz agrupados en sacos sinoviales. Se le descomprimió el túnel carpiano, se resecaron los cuerpos libres y se le hizo una sinovectomía amplia. El resultado de la biopsia fue una sinovitis inespecífica con cuerpos libres en granos de arroz. Después de dos años de operado el paciente está asintomático.

Tenosynovitis with loose rice grain-like structures is a very rare condition that usually presents associated with rheumatoid arthritis or tuberculosis. Cases not associated with these diseases are extremely rare. A 62-year-old male patient underwent surgery for a right carpal tunnel syndrome seven years ago. At that time, an opening of the transverse retinaculum of the carpus and synovectomy of the flexor tendons were performed. Synovial biopsy reported "chronic synovitis". It evolved satisfactorily during the first four years; then the patient began to present again the compressive symptoms of the median nerve and progressive increase in volume in the anterior aspect of the wrist. The ultrasound showed marked synovial hypertrophy of the flexor tendons at the level of the wrist. Neurophysiological studies reported axonal and myelin damage in the fibers of the right median nerve. A new intervention was performed. Synovial hypertrophy was visualized and abundant free loose rice grain-like structures grouped in synovial sacs. The carpal tunnel was decompressed, the free bodies were resected and wide synovectomy was performed. The result of the biopsy was non-specific synovitis with free rice grain-like structures. After two years of surgery, the patient is asymptomatic.

La ténosynovite à corps étrangers libres d'aspect en grains de riz est une affection très peu fréquente, étant généralement associée à l'arthrite rhumatoïde ou à la tuberculose. Les cas non associés à ces maladies sont extrêmement rares. Le cas d'un patient âgé de 62 ans, atteint de syndrome du canal carpien droit, et traité chirurgicalement il y a sept ans, est présenté. En ce moment-là, il a subi une incision du ligament transverse du carpe (rétinaculum) et une synovectomie des tendons fléchisseurs. La biopsie synoviale a dévoilé une «synovite chronique¼. L'évolution a été satisfaisante au cours des quatre premières années; puis après la compression du nerf médian et l'inflammation progressive de la face antérieure du poignet ont réapparues. L'échographie a montré une marquée hypertrophie synoviale des tendons fléchisseurs au niveau du poignet. Les examens neurophysiologiques ont révélé un dommage axonal et myélinique des fibres du nerf médian droit. Dans la nouvelle intervention effectuée, une hypertrophie synoviale et plusieurs corps étrangers d'aspect en grains de riz groupés en bourses synoviales ont été remarqués. Une décompression du canal carpien, une résection des corps étrangers et une large synovectomie ont été réalisées. La biopsie a repéré une synovite non spécifique à corps étrangers libres en forme de grains de riz. Le patient reste encore asymptomatique depuis deux ans.

The mechanical characteristics of single-leg squat exercise with emphasis on pelvic elevation / 体力科学

Movement control and muscle function for pelvic movement in the frontal plane (pelvic elevation) are important for various single-leg sports activities. We aimed to clarify mechanical characteristics of pelvic squat (P-Sq: single-leg squat exercise with emphasis on pelvic elevation, developed by our research group) compared with the double-leg squat (D-Sq) and single-leg squat (S-Sq). Twelve male track and field athletes performed D-Sq, S-Sq, and P-Sq exercises at various loads (90%, 75%, and 60% of 1-repetition maximum [1RM]), using maximum effort. Kinematic and kinetic data were calculated using data recorded with a motion capture system and force platforms. We observed the highest values with P-Sq, followed by S-Sq and D-Sq under all load conditions as follows: peak vertical ground reaction force and rate of force development (RFD), range of pelvic elevation, peak pelvic elevation velocity, peak powers associated with hip abduction torque and trunk lateral flexion torque. In P-Sq, RFD at 90% 1RM was smaller than under the other load conditions, whereas peak vertical ground reaction force at 90% 1RM was larger than under the other load conditions. There were no differences among load conditions with regard to hip abduction and trunk lateral flexion torques and powers. Therefore, characteristics of P-Sq compared to those of D-Sq and S-Sq are 1) larger and faster pelvic elevation, using related muscles (hip abductors and trunk lateral flexors) under all load conditions, 2) larger peak ground reaction force with pelvic elevation under large load conditions, and larger RFD in pelvic elevation under low load conditions.

Isokinetic Strength of Knee Flexors and Extensors and Relationship with Functions in Patients with Knee Osteoarthritis / 中国康复理论与实践

Objective To investigate the isokinetic strength of knee extensors and flexors in patients with knee osteoarthritis (KOA), and to establish the correlation between the isokinetic strength and function in patients with KOA. Methods 23 patients with bilateral KOA and 14 matched normal controls finished the isokinetic test of knee extensors and flexors, the Five Times Sit-to-Stand Test (FTSST), Gait analy-sis, and Balance test. The KOA patients were evaluated with Visual Analog Scale (VAS) for pain and Western Ontario and McMaster Univer-sity Osteoarthritis Index (WOMAC). Results It was less of the peak torque, average peak torque, average power, max rep total work, total work of knee extensors and flexors in the mainly involved limbs than the contralateral limbs (P0.05). Conclusion It is weak of the isokinetic strength of knee extensors and flexors in patients with KOA in the mainly involved limb, as well as the isokinetic strength of knee extensors compared with the normal controls. The changes in the ex-tensors and flexors are not equivalent. The peak torque of knee extensors significantly correlated with the pain and functions of the knee.

Efeitos do alongamento ativo excêntrico dos músculos flexores do joelho na amplitude de movimento e torque / Effects of an active eccentric stretching program for the knee flexor muscles on range of motion and torque

OBJETIVO: Avaliar a amplitude de movimento (ADM) e o torque flexor e extensor do joelho após a realização de um programa de alongamento ativo excêntrico dos músculos flexores do joelho. MATERIAIS E MÉTODOS: Trinta e quatro voluntários (23 mulheres e 11 homens), 34,42±9,3 anos, realizaram um programa de alongamento ativo excêntrico dos músculos flexores do joelho na postura em pé, que consistiu de sete repetições de um minuto com 30 segundos de descanso entre as repetições. O programa de alongamento foi realizado duas vezes por semana, durante quatro semanas. A ADM de extensão e o torque flexor e extensor do joelho foram avaliados no dinamômetro isocinético pré e pós-programa de alongamento. O torque foi avaliado nos modos isométrico e isocinético concêntrico e excêntrico a 30º/s e 60º/s. RESULTADOS: Houve aumento na ADM de 53,7±13º para 30,1±16º (p=0,0001), no torque isométrico flexor de 89±32Nm para 93±33Nm (p=0,01) e extensor de 178±67Nm para 187±73Nm (p=0,006). O torque flexor concêntrico e excêntrico a 30º/s aumentou de 90±31Nm para 96±31Nm (p=0,001) e de 100±34Nm para 105±35Nm (p=0,01), respectivamente. O torque extensor concêntrico a 60º/s aumentou de 144±51Nm para 151±58Nm (p=0,02) e o excêntrico a 30º/s de 175±71Nm para 189±73Nm (p=0,01). CONCLUSÕES: O programa de alongamento proposto foi efetivo para aumentar a flexibilidade dos músculos alongados e torque dos grupos musculares agonistas (alongados) e seus antagonistas.

OBJECTIVE: To evaluate the changes in knee range of motion (ROM) and torque of knee flexor and extensor muscles after an active eccentric stretching program for the knee flexor muscles. METHODS: Thirty-four volunteers (23 women and 11 men), aged 34.42±9.3 years, performed an active eccentric stretching program for the knee flexor muscles in the standing posture, consisting of seven repetitions of one minute each, with 30 seconds of resting between them. The stretching program was performed twice a week, for four weeks. Knee extension ROM and the torque of the knee flexor and extensor muscles were evaluated using an isokinetic dynamometer before and after the stretching program. The torque was evaluated in the isometric, isokinetic concentric and eccentric modes at 30º/s and 60º/s. RESULTS: There was an increase in ROM from 53.7±13º to 30.1±16º (p=0.0001), in isometric torque of the flexors from 89±32Nm to 93±33Nm (p=0.01) and of the extensors from 178±67Nm to 187±73Nm (p=0.006). The concentric and eccentric torque of the flexors at 30º/s increased from 90±31Nm to 96±31Nm (p=0.001) and from 100±34Nm to 105±35Nm (p=0.01), respectively. The concentric torque of the extensors at 60º/s increased from 144±51Nm to 151±58Nm (p=0.02), and the eccentric torque at 30º/s increased from 175±71Nm to 189±73Nm (p=0.01). CONCLUSIONS: The stretching program proposed was effective for increasing the flexibility of the stretched muscles and the torque of the agonist (stretched) muscle groups and their antagonists.

Incidence of palmaris longus muscle absence in nigerian population / Incidencia de la ausencia del músculo palmar largo en la población de Nigeria

A lot has been reported about variation of palmaris longus muscle in journals and conventional textbooks. The incidence of palmaris longus muscle absence among people of the six geo-political zones of Nigeria was evaluated using 600 subjects. 31.25 percent (187 subjects) lack palmaris longus muscleon either of the forearms. 12.5 percent (75 subjects) shows unilateral absence and 18.75 percent (112 subjects) shows bilateral absence. 25 percent (150) of subjects lacks palmaris longus muscleon their right forearms while 25 percent also lacks it on their left forearms. 6 percent (37) shows double tendons of palmaris longus muscleon both forearms. Highest incidence of absence was recorded among people of South-West zone.

Mucho se ha informado acerca de la variación del músculo palmar largo en revistas y libros de texto convencionales. La incidencia de ausencia del músculo palmar largo entre las personas de las seis zonas geo-políticas de Nigeria se evaluó usando 600 sujetos. 31,25 por ciento (187 sujetos) no tenían músculo palmar largo en cualquiera de los antebrazos, 12,5 por ciento (75 sujetos) mostró ausencia unilateral y 18,75 por ciento (112 sujetos) mostró ausencia bilateral. 25 por ciento (150) de los sujetos carece de músculo palmar largo en su antebrazo derecho, mientras que el 25 por ciento carece de él también en su antebrazo izquierdo. 6 por ciento (37) muestra dobles tendones de músculo palmar largo en ambos antebrazos. Mayor incidencia de ausencia se registró entre las personas de la zona Sur-Oeste.

Estudo eletromiográfico dos músculos motores primários da articulação do joelho na mesa romana: estudo de caso / Eletromyography study of the primary motors muscles of the knee articulation executed in roman table: study of case

Através dos estudos eletromiográficos é que se tem conhecido a efetiva participação dos músculos esqueléticos. Participaram do estudo 05 sujeitos do sexo masculino, na faixa etária entre 17 e 22 anos, praticantes de musculação. Foram utilizados eletrodos de superfície. Os músculos reto femoral, vasto lateral e vasto medial foram analisados no movimento de extensão do joelho realizado sentado na mesa romana; os músculos bíceps femoral, semimembranoso e semitendinoso foram analisados no movimento de flexão do joelho em decúbito ventral na mesa romana. Os resultados expressos em RMS foram: 543,86 (±127,39) para o músculo semimembranoso, 400,08 (±124,10) para o semitendinoso, 222,92 (±69,28) o valor do bíceps femoral, 288,12 (±152,4) para o músculo reto femoral, 215,63 (±117,30) para o músculo vasto lateral e 190,58 (±75,01) o valor do vasto medial. As cargas máximas utilizadas foram maiores no movimento de extensão do joelho. Os resultados demonstraram maior participação dos músculos flexores do joelho quando coparado com os extensores.

Through the electromyography studies it is that is had known the effective participation of the skeletal muscle. They participated in the study five subject of the masculine sex, in the age group among 17 and 22 years. Surface electrodes were used. The vastus lateralis, vastus medialis, rectus femoris muscles was analyzed in the extension movement of the knee, sat down in the roman table; the biceps femoris, semimembranosus and semitendinosus muscles was analyzed in the flexion movement of the knee, in decubitus ventralis, in the roman table. The results, expressed in RMS, were: 543,86 (±127,39) for the semimembranosus muscle, 400,08 (±124,10) for semitendinosus, 222,92 (±69,28) the value of the biceps femoris muscles, 288,12 (±152,4) for the rectus femoris, 215,63 (±117,30) for the vastus lateralis muscle and 190,58 (±75,01) the value of vastus medialis. The used maximum loads were larger in the extension movement of the knee. The results demonstrated larger participation of the flexors muscles of he knee when compared with the extensors muscles.

THERAPEUTIC THERA-BAND EXERCISE ON OSTEOARTHRITIS OF THE KNEE-EFFECTS OF SIMULTANEOUS EXERCISE OF KNEE EXTENSORS AND FLEXORS- / 体力科学

Purpose : We examined the effect of therapeutic exercise on osteoarthritis (OA) of the knee. Objects and Method : We evaluated seven women with bilateral OA of the knees of over Grade I on the Kellgren and Lawrence scale. The patients were instructed in therapeutic exercise for both knees. The exercise was to tie a Thera-Band <SUP>®</SUP> around the leg just above both ankles in the 8 figure, and then, in a sitting position, extend one leg while simultaneously retracting the other, repeating alternatively every 5 seconds. One set consisted of repeating this motion 10 times, and 2 sets were performed per day. Before exercise, 1 month, and 3 months after exercise, we evaluated the effect of this therapy by the JOA score, isokinetic muscle strength of knee extensors and flexors, and surface EMG signals recorded from rectos femoris (RF), vastus medialis (VM), vastus lateralis (VL), and biceps lemons (BF) . The integrated signal, the root mean square (RMS), and the mean power frequency (MPF) parameters were extracted.<BR>Result : The parameters of the JOA score, muscle strength of knee flexors, integrated EMG from RF, VM, VL, and RMS from VM, VL were significantly increased at 3 months after exercise. MPF from VM at 3 months after exercise decreased significantly.<BR>Conclusion : We thought a proper balance of knee extensors and flexors are related to the improvement of symptoms of OA of the knee. The decrease of MPF might suggest the possibility of muscle fiber type change. It is also possible that pain reduction results from the improvement of balance between knee extensors and flexors as well as from the increase of knee joint stability. Therapeutic exercise with the Thera-Band R is extremely easy and is effective in promoting con-tinuous exercise.

Role of Toe - Flexors in Ankle Plantar Flexion during Normal and Rapid Walking - 3 Dimensional Kinetic Study / 대한정형외과학회잡지

It is known that the toe-flexors exert some power generation in ankle plantar flexion. However, there has been no paper published in which the power generation was quantified. The purpose of this paper, therefore, is to quantify the amount of contribution of the toe-flexors to the ankle plantar-flexion in normal and rapid walking using the kinetic data of three dimensional gait analysis system. In order to restrict the action of the toe-flexors, we designed special braces which can be applied to the forefeet of the examinee during walking. We performed the gait analysis in ten normal adult volunteers with and without braces, and evaluated the moment and power of toe-flexors during terminal stance and pre-swing phase of gait cycle. Gait analysis was done with the VICON 3-dimensional motion analysis system (VICON, Oxford Metrics, Oxford, England) and 2 force plates (AMTI, Advanced Mechanical Technoiogy, Newton, MA, U.S.A,). The kinetic results are as follows: l. Average speeds of normal and rapid walking were 1.12m/sec and 1.41m/sec respectiveIy. 2. In normal walking, peak ankle plantar-tlexion moment decreased 5.5% with braces, and sum of ankle plantar-flexion moment decreased 12.3% with braces. Both of the results were not significant statistically (p>0.05). Peak ankle power generation decreased 11.0% with braces, and sum of ankle power generation decreased 10.4% with braces. These decreases were also insignificant statistically (p>0.05). 3. In rapid walking, peak ankle plantarflexion moment decreased 26.7% with braces. The decrease was horderline significant statistically (p=0.062). The sum of ankle plantar-tlexion moment decreased 26.6% with braces, but the decrease was not significant statistically (p>0.05). Peak ankle power generation decreased 40.2% with braces, and sum of ankle power generation decreased 37.9% with braces. These decreases showed borderline significance statistically (p=0.062). In conclusion, toe-flexors may contribute about 10% of the total ankle plantar-flexion power generation, and the contribution will be increased with increase of walking velocity. We must be very careful to sacrifice the toe-flexors in cases with weak triceps power.