Produced: Oct 2014
Author: Clinical Support
Ref: 195/01
Review: Oct 2016
Royal Orthopaedic Hospital NHS Foundation Trust Patient Information
Tendon Lengthening and
MLEP
Information for young people
Welcome to the Royal Orthopaedic Hospital (ROH).
For further information please visit www.roh.nhs.uk
This leaflet will give you information about tendon lengthening and multi lengthening
extremities procedures (MLEP)
Why am I having surgery?
You are having a combination of surgeries on the muscles and/or bones in your legs. This
is usually done in children with Cerebral Palsy (CP) with the aim to improve their leg
position. Generally there are 3 reasons why this may be done; to improve seating position,
improve standing position (and the ability to use a standing frame), or to improve their
walking. You will have discussed surgery and its aims specific to you with your surgeon,
and probably your community physiotherapist.
About your surgery
Every child’s surgery is different. The most common procedures that our surgeons do at
the ROH are described below. You may be having one or several of these. All of these will
happen once you are asleep.
Gastrocnemius lengthening. This involves releasing or lengthening the muscle in
your calf. The gastrocnemius is the bulky muscle that lets you point your toes, it
passes over 2 joints (your knee and ankle) and is often tight / shortened in children
with CP meaning that they stand on their tiptoes and cannot get their heels to the
floor. Following this surgery you will have a plaster cast below your knee which
cannot be removed. You will also have a long leg cylinder cast over the top, from
your hip to your ankle. This is removable to allow you to complete exercises.
These casts keep you knee and ankle in a good position so that your calf muscle
stays lengthened whilst it heals.
Hamstring lengthening. This is similar to a gastrocnemius lengthening and involves
releasing or lengthening the muscle at the back of your thigh. Your hamstrings are a
group of muscles that cross both your hip and knee joints and allow you to move
your leg backwards at the hip and also bend (flex) your knee. Children with tight
hamstrings cannot straighten their knee (called a fixed flexion deformity). This
results in standing and walking with bent knees. Following this surgery you will have
a long leg cylinder cast to keep your knee as straight as possible whilst the muscle
heals. This will be removable to allow you to complete your exercises.
Page 1
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Tendon Lengthening and MLEP
Foot stabilisation. This is a procedure on the bones around your heal and the back
half of your foot. The aim of this is to give your foot a better position to let you
stand and possibly walk. Your surgeon will use metalwork to hold the bones in a
good position and you will have a below knee cast after your surgery to
protect them whilst they heal. It is unlikely that you will be allowed to put any
weight on your foot for 6 weeks following this surgery.
Anterior epiphyseodesis. This surgery is on the bottom of your thigh bone (femur).
This part of your femur has a growth plate which lets you bones grow. During this
surgery a small plate is placed over the front of your growth plate to stop it from
growing. As you get older the growth plate at the back of your
knee continues to grow and your knee straightens. This is done, usually in
combination with a tendon lengthening, in children who cannot straighten their
knee.
What happens before my surgery?
This type of surgery is complex and will have an impact on your day to day functioning
for several weeks afterwards. This is why it is very important that you come for a
pre-operative assessment. This lets you meet the members of the team who will see
you after your surgery and lets us get an idea of what we may need to help you. You will
be seen by the nurses, physiotherapist and occupational therapist. They will look at how
you carry out your normal daily tasks now and how this may change after your
surgery. The occupational therapist will see if you will need any additional equipment at
home to help you and your parents after your surgery and also discuss wheelchairs with
you. It is generally easier for you to have a bed downstairs for the first 6 weeks after
your surgery.
Going home – What to expect after your surgery
What happens after your surgery is very much based on what combination of
procedures you have had done. The vast majority of children will have had a
combination of the above and will therefore normally have a below knee cast plus long
leg over-cylinder on. How much weight you can put on your leg will depend on your
surgery and the instructions given by your consultant. As a guideline, if you have had
bony surgery to your foot you will normally not be allowed to put any weight on your leg.
With most other combinations of surgery you will be allowed to put at least some weight
through your leg. If you have surgery on both legs you will be more restricted.
You will be seen by a physiotherapist on the ward who will talk you and your parents
through what you can and can’t do after your surgery. You will be shown some simple
exercises that you must carry out regularly.
The physiotherapists will also help your to get out of bed for the first time and into your
chair. Before you are allowed to go home you need to be safe getting in/out of bed, on/
off chairs and able to complete your exercises either by yourself or with help from your
parents. It is expected that you will need help from your parents for all of this due to you
plaster casts. If you need to be able to get up and down stairs you will be shown how to
do this safely.
Page 2
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Tendon Lengthening and MLEP
Exercise
It is VERY important that you start to do your exercises straight away.
You must complete your exercises at least 3 times a day at home. Due
to the nature of your surgery your muscles are at risk of becoming tight
so you will be shown some stretches and simple muscle strengthening
exercises to do with your parents.
Self care
We want you to be as independent as possible after your surgery however, due to the
nature of your surgery and your plaster casts you will need help with most day to day
tasks at home. Things like getting in / out of bed, on / off a chair and washing / dressing
are all a bit more difficult for the first few weeks. You and your parents will be shown
how to go about all of these tasks before you leave the ward. As the weeks go on these
things do get easier!
Pain relief
Often children have an epidural after this type of surgery, this is to help with pain control
in the early stages. Having an epidural can make your legs feel very numb and heavy,
this is normal. As the epidural wears off it is normal for you to have some pain and
discomfort. You will be given regular painkillers by the nurses on the ward to help with
this but please speak to them if you are still in pain. You will be given some painkillers to
take home with you, if you run out then see your GP. A lot of children also
experience muscle ‘spasms’ after this surgery, please let the nurses or physiotherapists
know if this happens.
Wound care
It is important that you keep your wounds clean and dry. The nurses on the ward will
discuss how to care for these with you and your parents before you go home.
Plaster care
If you have a below knee cast this cannot be removed for between 4 and 6 weeks after
your surgery. The over cylinder can be removed for washing/dressing, pressure area
relief and to complete your exercises. To gain the most benefit from your surgery it is
very important that you wear this over-cylinder for at least 8 hours during the day and
overnight.
With both casts if you feel that they are uncomfortable, or you experience a burning
sensation please contact the hospital immediately. If your parents notice any areas of
redness or the cast appears to be rubbing your skin please contact us immediately.
These are signs of pressure areas.
Children with CP often have altered or reduced sensation therefore you may not be
aware of this yourself. It is extremely important to check for pressure areas when you
take your over-cylinder off. Other signs to look out for are swelling of the toes,
discolouration and oozing.
Page 3
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Tendon Lengthening and MLEP
Sleeping
It is important that you do not sleep with a pillow or towel underneath your knee as this
will stop you being able to fully straighten your knee and your recovery will take longer.
You must sleep in your cylinder cast to prevent deformity from occurring.
School
You are usually allowed to go back to school as soon as you feel able to and your pain
is controlled. It is important that your parents discuss this with your teachers as some
schools will not let you go back whilst you are using a wheelchair or are unable to walk.
You can discuss this with your physiotherapist on the ward.
What happens after I go home?
Physiotherapy is very important after this surgery. To get the most benefit it is important
that you complete your exercises at least 3 times daily. If you have a community or
school physiotherapist they will continue to see you once you have gone home.
You will come back to the hospital once your below knee casts are allowed to be
removed. You will normally have some casts taken for splints (AFO’s). Once you have
been reviewed by your surgeon and they are happy for you to start standing and
walking you will be seen by one of the physiotherapists in clinic to start this.
Most children will come in for a week of intensive physiotherapy with us. This will be
discussed and arranged with you when it is appropriate. This week involves daily
hydrotherapy and gym sessions. After this you will be referred for on-going outpatient
physiotherapy either at your local hospital or with your usual community physiotherapist.
If you have any questions or need any advice about your exercises then please contact
the Physiotherapy Department between 8:00am—4:00pm Monday to Friday.
Royal Orthopaedic Hospital Physiotherapy Department: 0121 685 4120
Instructions for after your surgery:-
Page 4
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Tendon Lengthening and MLEP
Personal Exercise Program
MLEP
Royal Orthopaedic Hospital NHS Foundation Trust
Royal Orthopaedic Hospital
Bristol Road South, Northfield, B31 2AP, Birmingham, United Kingdom
Lying on your back.
Bend and straighten your leg.
Repeat 10 times.
Video
©PhysioTools Ltd
Lying on your back.
Squeeze buttocks firmly together. Relax.
Repeat 10 times.
Video
©PhysioTools Ltd
Lying on your back with legs straight.
Bend your ankles and push your knees down firmly
against the bed. Hold 5 secs. - relax.
Repeat 10 times.
Video
©PhysioTools Ltd
Page 5
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Tendon Lengthening and MLEP
Lying on your back. Bend your good leg and put
your foot on the bed. Place a rolled up towel under
the knee of your operated leg.
Tighten your thigh muscle and straighten your knee
(keep knee on the towel). Hold approx. 5 secs. and
slowly relax.
Video
Repeat 10 times.
©PhysioTools Ltd
Lying face down.
You can stay in this position for upto 20 minutes.
You should feel a stretch across the front of your
hip.
Video
©PhysioTools Ltd
Prone lying.
Encourage weight bearing equally through the
arms and the head to be held in the mid position.
©PhysioTools Ltd
Page 6
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Tendon Lengthening and MLEP
Position of hands for passive stretching of hamstrings.
Gradually straighten knee, keeping thigh still.
Hold 30 secs. Repeat 3 times.
©PhysioTools Ltd
Passive stretching of the hip adductor muscles.
Lying flat. Level hips as possible.
Gently and slowly draw legs apart, keeping knees
straight.
Hold 30 secs. Repeat 3 times.
©PhysioTools Ltd
Alternative hip adductor stretch.
Lying, place feet together.
Let hips roll out. Slowly add gentle outward pressure to the knees. Do not force this movement.
Hold 30 secs. Repeat 3 times.
©PhysioTools Ltd
Page 7
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Tendon Lengthening and MLEP
Stretching tendo - achilles.
Cup one hand around heel. Keep inside of forearm
in contact with the sole of the foot. Gently draw the
foot towards a right angle stabilising the leg with
the other hand. Use gentle pressure. Do not use
force.
Hold 30 secs. Repeat 3 times.
©PhysioTools Ltd
Passive stretching of quadriceps.
Lying on front.
Relax hips, ensure they are level and flat. Place
one hand on bottom and one hand around ankle.
Gently draw ankle towards bottom. A gentle stretch
should be felt in the front of thigh. Do not use any
force. Use gentle overpressure only.
©PhysioTools Ltd
Hold 30 secs. Repeat 3 times.
Passive stretching of quadriceps.
Lying on front.
Relax hips, ensure they are level and flat. Place
one hand on bottom and one hand around ankle.
Gently draw ankle towards bottom. A gentle stretch
should be felt in the front of thigh. Do not use any
force. Use gentle overpressure only.
©PhysioTools Ltd
Hold 30 secs. Repeat 3 times.
Page 8
Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000