Goals Understanding Equinus - Podiatry M SEPTEMBER2012| PODIATRYMANAGEMENT|159...

SEPTEMBER 2012 | PODIATRY MANAGEMENT | 157www.podiatrym.com

Equinus has been describedas “the most profoundcausal agent in foot path-omechanics and is fre-quently linked to common

foot pathology,” and also has beendescribed as “the greatest symptomproducer of the human foot;” yet it iscommonly overlooked and under-treated. The importance of equinus

cannot be overstated, and its manage-ment is crucial to treating of theunderlying pathology of all the fol-lowing foot and ankle conditions as

Continued on page 158

Continuing

Medical Education

Goalsand Objectives

After completing thisCME, the reader should:

1) Understand the defi-nition of equinus.

2) Understand the eval-uation of equinus.

3) Understand thetreatment of equinusbased on evidence basedmedicine.

4) Become more awareof the role of equinus infoot and ankle pathology.

5) Include equinustreatment as part of aglobal treatment plan,when indicated.

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.

You may enroll: 1) on a per issue basis (at $22.00 per topic) or 2) per year, for the special rate of $169 (you save $51).You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also takethis and other exams on the Internet at www.podiatrym.com/cme.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earnedcredits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake thetest at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 166. Other than those en-tities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be ac-ceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best ef-forts to ensure the widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goalof this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high qualitymanuscripts by noted authors and researchers. If you have any questions or comments about this program, you canwrite or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us [email protected].

Following this article, an answer sheet and full set of instructions are provided (pg. 166).—Editor

UnderstandingEquinus

BY PATRICK A. DEHEER,DPM

This profound causal agent is commonlyoverlooked and under-treated.

www.podiatrym.com

BIOMECHANICSANDORTHOTICS

EQUINUS

158 | SEPTEMBER 2012 | PODIATRY MANAGEMENT

documented in the literature:Heel spur syndrome/plantar fasci-

itis, Achilles tendinopathy, posteriortibial tendon dysfunction, diabeticfoot ulcers, Charcot neuropathy,metatarsalgia, Morton’s neuroma,lesser MPJ pathologies—PDS, capsuli-tis, hallux valgus, hammer digit syn-drome, ankle fracture/sprains, Sever’sdisease, pediatric flatfoot deformity,osteoarthritis forefoot/midfoot, 1stray hypermobility, pes plano valgus,hallux limitus, sesamoiditis, lateralcolumn syndrome, Freiberg’s infarc-tion, and forefoot callus. So, if equi-nus is so prevalent, how comethere is often a failure inrecognition, association topathology, and treatment ofthis condition?

There are several factors atplay that all lead to this under-appreciation and lack of treat-ment with equinus. It all startswith the definition of equines,as there is no standard defini-tion. The next crucial factor isthe lack of appreciation of therelationship between equinusand the above-listed patholo-gies. Finally, the lack of treat-ment is related directly to inef-fectual conservative manage-ment of the condition. Let’stake a journey through equi-nus to fully understand thecondition, and hopefully there-fore bring to it the respect it isdue.

AnatomyMost pathologies of the

foot and ankle start withanatomy. The anatomy of thetriceps surae consists of the gastroc-nemius, soleus, and plantaris mus-cles. The gastrocnemius muscle origi-nates on the posterior aspect of the

femoral condyles and posterior kneecapsule with the medial head beingthe larger of the two, and descendingfurther distally. The gastrocnemius

muscle crosses the knee, ankle, andsubtalar joints. This is a very impor-tant factor; the multi-joint crossing is

directly related to the most commonform of equinus, gastrocnemius equi-nus. The aponeurosis of the gastroc-

nemius muscle is anterior to the mus-cle. Its primary blood supply is fromthe popliteal and sural arteries, and itis innervated by the tibial nerve. The

gastrocnemius primary act to supplypower for propulsion, knee flexion,and plantarflexion of the ankle joint(Figure 1).

The soleus originates on the pos-terior aspect of the head of the fibu-lar, the middle one-third of the medial

border of the tibia, the soleal line, andthe interosseous membrane. Theaponeurosis of the soleus is posterior

to the muscle. The soleus onlycrosses the ankle and subtalarjoints. The soleus is innervat-ed by the tibial nerve and itsarterial supply is that of thetibial, peroneal, and sural ar-teries. The primary function ofthe sural artery is to stabilizethe leg onto the foot and plan-tarflex the ankle joint.

The plantaris tendon origi-nates medial and superior tothe lateral head of the gastroc-nemius muscle at the lateralhead of the femoral condyle,coursing lateral to the gastroc-soleal complex and medial toit. The plantaris tendon can beabsent 7 % of the time.

The Achilles tendon is thecontinuation of the aponeuro-sis of the gastrocnemius andsoleus merging together. form-ing the largest, thickest,strongest tendon in the body,approximately 15 centimeterslong. The tendon inserts intothe middle one-third of theposterior aspect of the calca-

neus with the plantaris tendon insert-ing medial to the Achilles tendon.There is a retrocalcaneal bursa be-tween the Achilles tendon and thecalcaneus. The fibers of the Achillestendon rotate laterally approximately90° so that the gastrocnemius fibersinsert primarily laterally and thesoleus fibers insert primarily medial-ly. The tendon is surrounded by atendon sheath which allows gliding ofthe tendon, and below this sheath isthe paratenon, which protects andnourishes the tendon. The vascular

There is a well-documented zoneof hypovascularity 4-5 cm proximal to the insertion

of the Achilles tendon.

The gastrocnemius muscle crosses the knee,ankle, and subtalar joints.


Continuing

MedicalEducation

Figure 1: Posterior view of the GSC complex and related anatomicalstructures.



EQUINUS

supply of theAchilles tendon isfrom the myoten-donous junction,the paratenon, andthe calcaneal pe-riosteum. There is awell-documentedzone of hypovascu-larity 4-5 cm proxi-mal to the insertionof the tendon.

DefinitionAfter under-

standing the anato-my, the definitionbecomes the nextmost crucial factorand is surprisinglydifficult, especiallyamong differentspecialties. The def-inition of equinusranges from -10° to+ 22° in the litera-ture, with +10° asa consensus of thir-teen different stud-ies. Sgarlato36 in TheJournal of AmericanPodiatric MedicalAssociation in 1975first described the definition as +10°with the subtalar joint in neutral posi-tion and the midtarsal joint locked.

PseudoequinusThere are two primary types of

equinus—muscular and osseous, withsubgroups of each kind. In the mus-cular group there can be either spasticor non-spastic equinus. Either ofthese subgroups of spastic or non-spastic equinus can further be brokendown into gastrocnemius or gastro-soleus equinus. The osseous forms ofequinus include: anterior tibiotalarexostosis (best seen on a lateralcharger view on X-ray), distal tibial-fibular osseous bridging from priortrauma, pseudoequinus and com-bined equinus. Pseudoequinus occursin the cavus foot structure whereankle joint dorsiflexion occurs to dor-siflex the forefoot, which is plan-tarflexed to the rearfoot. The ankledorsiflexion used to do this then lim-its the amount available for normal

ambulation, therefore the term pseu-doequinus. The combined equinus isjust a combination of one type ofmuscular and osseous equinus.

Clinical EvaluationEvaluation of equinus clinically is

one of the primary stumbling blocks

between professions that inhibit effec-tive communication. The Silfverskoildtest is what is used to determine thetype of equinus. In this examination,the subtalar is placed in neutral posi-tion and the midtarsal joint is lockedby supination of the forefoot. The

ankle is dorsiflexed maximallywith the knee in full extension andthen checked with the knee in flexion(Figures 2 and 3). If the ankle jointdorsiflexes greater than 90° with boththe knee extended and flexed, there isno equinus. If the ankle joint dorsi-flexes greater than 90° with the kneeflexed by less than 90° with the kneeextended, the result is gastrocnemiusequinus. If the ankle dorsiflexion isless than 90° with both the kneeflexed and extended, then it can ei-ther be gastroc-soleus equinus or os-seous equinus. This is determined bythe quality of the end range-of-motionand with a charger dorsiflexion stresslateral ankle x-ray. A soft end range-of-motion is more likely a gastroc-soleus equinus, especially if no anteri-or ankle impingement is noted on thex-ray.

Biomechanics of EquinusUnderstanding the biomechanics

of equinus is crucial to getting an ap-preciation of the devastation it has onthe foot pathomechanics. The centerof pressure is about 6 cm anterior tothe ankle, roughly over the dorsal 2ndmetatarsal-cuneiform joint. Thiswould make us fall forward in normalstanding, but that reaction is is negat-ed by the pull of the plantarflexors.The triceps surae has been document-ed to be the primary plantarflexor ofthe ankle joint and therefore offsetsthe anteriorly displaced center ofpressure. It has further been demon-strated with equinus that the center ofpressure moves about 3 cm distally

and 3 mm laterally (Figures 4 and 5).The important concept lies in the

relation of the subtalar axis to thecenter of pressure and the subtalaraxis to the insertion of the Achillestendon. The Achilles tendon inserts


Continuing

Medical Education

If the ankle joint dorsiflexesgreater than 90° with the knee flexed by less than 90°

with the knee extended,the result is gastrocnemius equinus.

Figure 2: The Silfverskiold test is used to evaluate for equinus. Thisdemonstrates evaluation of the dorsiflexion of the ankle joint with theknee extended.

Figure 3: Evaluation of the ankle joint dorsiflexion with the knee bentremoves the pull of the gastrocnemius muscle and allows the practi-tioner to determine whether equinus is gastrocnemius equinus or gas-troc-soleal equinus.

www.podiatrym.com


EQUINUS


medially to the subtalar axis andits distance from the axis is about

the same as the laterally placed centerof pressure to the subtalar axis in afoot with a normal subtalar axis andno equinus. The medial position ofthe Achilles creates a supinatory mo-ment, while the lateral center of pres-sure due to ground reactive forces(GFR) creates a pronatory moment.These two cancel each other out, pro-viding a rectus foot structure.

When equinus is present, the dis-tal and lateral positioning of the cen-ter of pressure in relation to the sub-talar axis creates an increased prona-tory effect on the foot due to GRF,which is not offset by the supinatoryeffect of the Achilles tendon. Whenthe subtalar joint axis is more medial-ly deviated, such as in a pronatedfoot, this further distances the centerof pressure from the subtalar axis,causing even more pronatory defor-mity due to GRF. The opposite occursin the supinated foot, where the sub-talar joint axis is more laterally devi-ated to the point where even the cen-ter of pressure is on the subtalar axis,medial to the subtalar axix or just lat-eral to the subtalar axis. This putsboth the Achilles and center of pres-sure in supinatory moments (or atleast is a lesser pronatory momentthan the supinatory moment of the

Achilles tendon) due to GRF—there-fore making a cavus foot worse over aperiod of time due to increased rear-foot varus, peroneal pathology, andsubtalar instability.

Johnson and Christensen17 exam-ined the effects of equinus on first raypathomechanics using cadaver

weight-bearing models in their land-mark series on first ray pathomechan-ics. Sensors were applied to each ofthe individual bones making up themedial column of the foot. Loading ofthe Achilles tendon was applied andthen three-dimensional data wererecorded for each segment of the me-dial column. The results showedplantarflexion of the talus and navicu-lar, and dorsiflexion of the medialcuneiform and 1st metatarsal occur-ring through the naviculacuneiformjoint. This occurs due to dampeningof the effect of the peroneal longustendon eversion of the medialcuneiform that leads to locking of themidtarsal joint. This lack of midtarsal

joint locking leads to the above de-scribed medial column instability.This study showed that the effect ofequinus is not a stretching of theplantar ligaments over a period oftime that leads to first ray instabilitybut, in fact, is a dampening of theperoneus longus function that leads

to first ray hypermobility.An important question that is

often overlooked in the biomechani-cal discussion of equinus is the effectof pronation on the GSC. Kevin Kirby,DPM says via personal communica-tion, “accommodative shortening ofthe GSC will occur with prolongedmedial deviation of the STJ axis andflattening of the medial arch of thefoot.”

Sgarlato36 described three types ofcompensation for equinus. The un-compensated equinus deformity man-ifests itself as a toe walker due to lackof ankle joint dorsiflexion and/or MTJpronation to get the heel down to theground. This accounts for about only1% of equinus cases. In the partiallycompensated equinus deformity, theheel is on the ground but the tibiadoes not achieve 10 degrees of flexionto the ground. This results in an earlyheel-off gait pattern. When the equi-nus deformity is fully compensated,the result is the severely pronated,hypermobile foot with heel contact toground and the tibia achieving morethan 10 degrees of flexion to theground. Heel-off in the fully compen-sated equinus deformity is normal.

The proximal pathologies associ-ated with equinus are numerous andeasily overlooked due to the profounddistal pathologies that often overshad-ow these proximal deformities. Lum-bar lordosis, hip flexion, knee flexion,genu recurvatum, and hamstring con-tractures have all been attributed toequinus. The more obvious distalpathologies that directly result from

An important question that is often overlookedin the biomechanical discussion of equinus is the

effect of pronation on the GSC.


Continuing

MedicalEducation

Figures 4 & 5: The center of pressure is located as shown on the left drawing approximately 6 cm dis-tal to the ankle joint. With equinus deformity the center of pressure moves distal and lateral furtheraway from the subtalar joint axis as shown on the right drawing.



EQUINUS

or have a relationship to equinus willbe discussed with some of the well-documented literature.

In Hill’s15 article, the incidence ofequinus with pathological conditionswas studied by examining 209 newpatient visits over a six week periodof time. Twenty-nine patients wereexcluded from the study becausethey did not meet study criteria. Of

the remaining 174 patients, six hadnormal ankle joint dorsiflexion, leav-ing 168 of the patients exhibitingequinus. Three of the patients hadgastrocnemius equinus and 165 hadGSC equinus. Their definition forequinus was less than 3-degrees dor-siflexion with knee extension. Theirfindings were that 96.5% of the pa-tients with foot and ankle pathologyexhibited equinus.

DiGiovanni8 in the Journal of Boneand Joint Surgery (2002) examinedankle joint dorsiflexion in symptomat-ic patients and a control group, andthe reliability of goniometer testing.The ankle joint dorsiflexion with theknee extended averaged 4.5 degreesin the symptomatic group and 13.1degrees in the control group. The per-centage of symptomatic patients withless than 5 degrees dorsiflexion was65% and the control group was 24%,while the amount with less than 10degrees dorsiflexion was 88% and44%, respectively. The correct diag-nosis via a goniometer, confirmedwith an equinometer for the less than

5 degree group, was 76% for thesymptomatic group and 94% for thecontrol group, while the 10 degreegroup diagnosis was correct 88% and79%, respectively.

This study has helped to clarifythe definition of equinus, which has awide range of definitions in the litera-ture, with the most common defini-tion being 10 degrees of dorsiflexionwith the knee extended and the sub-talar joint in neutral position and themidtarsal joint locked. This was origi-nally described by Sgarlato36 in

JAPMA 1975. According to DiGiovan-ni’s8 findings, with ankle joint dorsi-flexion of less than 5 degrees, the cor-rect diagnosis was made 76% of thetime in the symptomatic group, andthe incorrect diagnosis was avoidedin 94% of the time in the controlgroup. I believe the standard defini-tion for equinus should therefore be 5degrees of ankle joint dorsiflexionwith the knee extended based on the

findings of this study. Arrivingat a standard definition is crucialfor equinus and is the first step tostandardized treatment protocols.

Aronow’s1 study was one of thefirst to not only explore the changeson forefoot and rearfoot pressures as-sociated with equinus, but also to ex-amine the midfoot changes as well. Aload was applied to the GSC and thento just the gastrocnemius muscle, andthen the changes in pressures weremeasured. In the GSC group, the rear-foot pressures decreased (18%) andthe midfoot (38%) and forefoot(59%) increased. In the gastrocne-mius group, the rearfoot pressures de-

creased (16%) and the midfoot (32%)and forefoot (50%) increased. Thesenumbers were very consistent withother studies on the effect of equinusand forefoot pressure changes, suchas Jones18 in The American Journal ofAnatomy in 1941 and Ward43 in TheJournal of the American PodiatricMedical Association in 1998. Whenthe loads were removed, the pres-sures on the forefoot decreased 32%and the rearfoot pressures increased32%. These additional findings weresimilar to those of Mueller22 in TheJournal Bone and Joint Surgery 2003,who measured the effect of a tendo-Achilles lengthening on pressurechanges in the foot. In Mueller’sstudy, the forefoot pressures de-creased 31% and the rearfoot pres-sures increased by 34%.

Plantar Fasciitis and EquinusThe relationship with plantar

fasciitis and equinus is well docu-mented in the literature, with an esti-mated 2,000,000 cases of plantarfasciitis per year in the United States.Patel and DiGiovanni25 found that83% of plantar fasciitis cases were as-sociated with equinus. Cheung, et al.3

showed that equinus caused twice theamount of strain on the plantar fascia

In Mueller’s study, the forefoot pressuresdecreased 31% and the

rearfoot pressures increased by 34%.

Patel and DiGiovanni25 found that 83% ofplantar fasciitis cases were associated with equinus.


Continuing

Medical Education

Figure 6: In this side view of the EQ/IQ brace,you can see the hinge to be placed at theknee joint. When the brace crosses the kneejoint, it allows for stretching of the entireGSC. The hinge allows for the brace to en-gage just the soleus if taken down or the en-tire GSC if left intact.

www.podiatrym.com


EQUINUS


as body weight. This reaffirmedthe close relationship between

plantar fasciitis and equinus. Anytreatment plan for plantar fasciitismust include equinus management.

Treatment of equinus can be bro-ken down into either conservative

care or surgical care. As with mostpathologies, conservative care shouldbe attempted initially. The two mainforms of conservative care are manualstretching and bracing.

Radford, et al.28 in a meta-analysisshowed that calf muscle stretchingprovided a small but statistically sig-nificant increase in ankle joint dorsi-flexion. Their analysis showed that 15to 30 minutes per day provided thegreatest amount of ankle joint dorsi-flexion (3.03 degrees) for each of thethree groups. Grady and Saxena12 intheir study had patients stretch onceper day over a six-month period oftime for 30 seconds, 2 minutes, or 5minutes with the knee extended. Theincrease in ankle joint dorsiflexion foreach group was 2.15, 2.3, and 2.7 de-grees, respectively. These totals werenot statistically significant, but whenone takes into account the minimalamount of stretching done daily, theresults are actually encouraging.

Hill15 discussed the problems withmanual stretching stating, “Activestretching requires detail in teachingthe proper technique, and must bedone at least four times a day at five-minute to eight-minute sessions. Themost serious mistakes patients makeduring their previous attempts atstretching are inadequate stretch timeand abducted foot position during thestretch. It is critical that the foot beadducted 10 degrees during thestretching to lock the subtalar-mid-tarsal joints for maximum benefit atthe calf.”

Night splints have long been the

only mode of bracing for equinustreatment, but there are several flawswith them. First, they are designed tobe used at night while sleeping andthe most common sleeping positionwith these braces is on the side withknees bent. This means that the gas-

trocnemius muscle is not beingstretched. Remembering that the gas-trocnemius muscle crosses both theknee and ankle, it is most often thecontracted structure. This accountsfor the ineffective nature of nightsplints. Based on our personal experi-ence, compliance with night splints isalso very poor. These two factors ledto the mediocre results attributed tonight splints as described in theEvans9 study, which showed only 6 of20 patients achieving 10 degrees ofdorsiflexion with the use of nightsplints.

EQ/IQ BraceThe answer we have developed to

address ineffectual manual stretchingand the failures of night splints is theEQ/IQ brace. This brace does notneed to be slept in. We recommend

using it 30 minutes in the morningand 30 minutes in the evening (15stretching the GSC, and 15 minutesstretching the soleus). Let’s discussfeatures of the EQ/IQ brace fromproximal to distal. There is an above-the-knee extension with a hinge at theknee (Figure 6). The extension allowsthe knee to be locked into extensionto stretch the gastrocnemius muscle.

The hinge can be released to allow forease of application and isolatedstretching of the soleus. There is alsoa hinge at the ankle joint which al-lows the treating physician to set ex-actly the amount of dorsiflexion de-sired based on the patient’s biome-chanical exam (we see maybe 5 de-grees the first month, going up to 10degrees the second month, and ifneeded 15 degrees the third month).

The hinge goes from -30 degreesto +30 degrees, in 5 degree incre-ments (Figure 7). As podiatrists, wemeasure everything from x-ray anglesto forefoot varus position. Yet we slapon a night splint and tell our patientsto pull as tight as they can. Thismakes no sense to us; we shouldhave more control and precision overthe treatment of this condition. Wehave made this brace ambulatorywith a negative heel rocker sole,which allows ambulation with a fixeddorsiflexed position. The rocker solesare removable and come in differentsoles to match the amount of anklejoint dorsiflexion (i.e., 5, 10, and 15degrees). There is an adjustablewedge that goes under the hallux toengage the windlass mechanism,which supinates the rearfoot and alsoputs additional stretch on the plantarfascia. The supination of the rearfootis important as it puts the foot in themost desirable position for stretchingof the GSC. These wedges come invarious degrees (i.e., 35, 50, and 65degrees) and Velcro to the foot bed(Figure 8). We made varying degrees

of wedges to allow for those with hal-lux limitus or rigidus. The femoraland tibial uprights are adjustable forleg and thigh length and should be setby the physician. Finally, the stan-dard foot beds will fit asmall/medium size, but it can be re-placed to an extended version thatwill fit a large/extra-large size.

A study by Evans showed only6 of 20 patients achieving 10 degrees of dorsiflexion

with the use of night splints.

According to Hill,It is critical that the foot be adducted 10 degrees

during the stretching to lock the subtalar-midtarsaljoints for maximum benefit at the calf.


Continuing

MedicalEducation



EQUINUS

The time period we recommend isbased on recommendations for manu-al stretching from the meta-analysisby Radford28, but doubled. Most man-ual stretching is recommended to bedone about 30 minutes per day. Anhour a day is reasonable from a com-pliance standpoint, compared to 6 to8 hours at night while disturbing thepatient’s sleep. The ambulatory com-ponent of the brace is important also.We foresee patients getting dressed inthe morning while then putting on thebrace and then stretching while per-forming their morning rituals. A simi-lar scenario would play itself out forthe evening stretching. Additionally,the ambulatory nature of the braceprovides an active stretching compo-

nent as well as a static stretchingcomponent. A final consideration isthat this is not a brace that patientswill be able to buy at a drug store oron the Internet. We have had patientscomplain about the expense of a nightsplint when they can find the samething for about 20% of what ischarged for the brace. This is a tech-nical device that must be set, moni-tored, and adjusted by a physician.This brace will have a significant pos-itive impact on a practice manage-ment component of your practice.Most importantly, it will provide youa better way to treat the most signifi-cant producer of foot and anklepathologies—equinus deformity.

Surgical Approaches to EquinusThe surgical approach to equinus

is well documented in the literatureand focuses on mainly two differentprocedures, the tendo-Achilles length-ening (TAL) or gastrocnemius reces-sion. The TAL approach most com-monly utilized is the Hoke triple

hemisection. This procedure employsthree stab incisions starting one cen-timeter proximal to the insertion ofthe GSC, with two medial incisionsand one lateral incision between thetwo medial incisions. The tendon issectioned through the central portionand incised in the respective directionof the stab incisions. The tendon thenslides to a lengthened position. Thisprocedure is not without potentialcomplications, such as under-length-ening, or much worse, over-lengthen-ing.

The gastrocnemius recession isone of our favorite procedures and iswell documented in the literature. Weprefer the Bauman intramuscular ap-proach to lengthening of the gastroc-

nemius aponeurosis. This providescontrolled, sequential lengthening.The incision is placed at the medialaspect of the calf, midway betweenthe posterior calf and anterior borderof the tibia. The incision is typically3-4 cm long and is deepened to thelevel of the deep fascia. The fascia isincised, revealing the gastrocnemiusand soleus muscle bellies. Using a fin-ger to identify the natural separationbetween the aponeurosis of the twomuscles, an anal speculum is insertedto spread them apart. The foot is dor-siflexed with the knee extended, anda long-handled #15 blade is used tocut the proximal portion of the gas-trocnemius aponeurosis, including theintramuscular septum. This is a com-plete release from lateral to medial.The foot is dorsiflexed and the posi-tioned examined. If inadequate dorsi-flexion is noted, a second more distal(1 cm distal to the initial release) inci-sion is recommended over a soleusrecession (this is based on the studyby Herzenberg and Lamm14 in Foot

and Ankle International 2007.)The pre-operative group had 1 de-gree of ankle joint dorsiflexion withthe knee extended, and after gastroc-nemius recession, single and doubledorsiflexion increased significantly (9and 15 degrees, respectively). Addinga soleus recession only increased dor-siflexion by one degree—thus it ismore effective to perform a doublegastrocnemius recession.

The treatment of equinus alonehas shown to be effective for footsymptomatology without doing any-thing to the pathology within the foot.Maskill, et al.21 examined the effect ofan isolated gastrocnemius recessionon 29 patients (34 feet) that failed sixmonths of conservative therapy. Themeasure was the visual analog scale(VAS) and there were three categoriesof patients (plantar fasciitis, midfootpain, and arch pain). The VAS scorespre-operatively and post-operativelywere as follows for each group: plan-tar fasciitis 8.1 to 1.9, midfoot pain7.5 to 2.2, and arch pain 9.3 to 3.3.These drastic pain scale changes werethe result of only a gastrocnemius re-cession without doing anything to thefoot.

Equinus is an underlying factor inmost of the pathologies associatedwith the foot and ankle and must beaddressed either conservatively orsurgically as part of the overall treat-ment plan for any condition associat-ed with it. If the equinus deformity isleft untreated, the condition is neverfully treated and outcomes are not ashigh as they should be. Education ofpatients to the importance of equinustreatment in their overall treatmentplan must be discussed to ensurecompliance and the highest overalloutcomes. PM

References1 Aronow, MS; Diaz-Doran, V; Sulli-

van, RJ; Adams, DJ. The effect of tricepssurae contracture force on plantar footpressure distribution. Foot Ankle Int.27:43-52, 2006.

2 Charles, J; Scutter, SD; Buckley, J.Static ankle joint equinus. J Am PodiatrMed Assoc. 100:195-203, 2010.

3 Cheung, JT; Zhang, M; An, KN. Ef-fect of Achilles tendon loading on plantarfascia tension in the standing foot. Clin

The surgical approach to equinusis well documented in the literature and focuses

mainly on two different procedures,the tendo-Achilles lengthening (TAL) or

gastrocnemius recession.


Continuing

Medical Education

www.podiatrym.com


EQUINUS


Biomech. 21:194-203, 2006.4 Chimera, NJ; Castro, M; Manal, K.

Function and strength following gastroc-nemius recession for isolated gastrocne-mius contracture. Foot Ankle Int. 31:377-384, 2010.

5 Dananberg, HJ; Shearstone, J; Guil-iano, M. Manipulation method for thetreatment of ankle equinus. J Am PodiatrMed Assoc. 90:385-389, 2000.

6 Davis, PF; Severud, E; Baxter, DE.Painful heel syndrome: results of nonoper-ative treatment. Foot Ankle Int. 15:531-535, 1994.

7 Dietz, FR; Albright, JC; Dolan, L.Medium term follow up of Achilles tendonlengthening in the treatment of ankle equi-nus in cerebral palsy. Iowa Orthop J.26:27-32, 2006.

8 DiGiovanni, CW; Kuo, R; Tejwani,N; Price, R; Hansen Jr, ST; Cziernecki, J;Sangeorzan, BJ. Isolated gastrocnemiustightness. J Bone Joint Surg Am. 84:962-970, 2002.

9 Evans, A. Podiatric medical applica-tions of posterior night stretch splinting. JAm Podiatr Med Assoc. 91:356-360, 2001.

10 Flanigan, RM; Nawoczenski, DA;Chen, L; Wu, H; DiGiovanni, BF. The in-fluence of foot position on stretching ofthe plantar fascia. Foot Ankle Int. 28:815-822, 2007.

11 Grady, JF; Kelly, C. Endoscopic gas-trocnemius recession for treating equinusin pediatric patients. Clin Orthop RelatRes. 468:1033-1038, 2010.

12 Grady, JF; Saxena, A. Effects ofstretching the gastrocnemius muscle. JFoot Surg. 30:465-469, 1991.

13 Grant, WP; Sullivan, R; Sonenshine,DE; Adam, M; Slusser, JH; Carson, KA;Vinik, AI. Electron microscopic investiga-tion of the effects of diabetes mellitus onthe Achilles tendon. J Foot Ankle Surg.36:272-278, 1997.

14 Herzenberg, JE; Lamm, BM; Corwin,C; Sekel, J. Isolated recession of the gas-trocnemius muscle: the Baumann proce-dure. Foot Ankle Int. 28:1154-1159, 2007.

15 Hill, RS. Prevalence and linkage tocommon foot pathology. J Am PodiatrAssoc. 85:295-300, 1995.

16 Holstein, A. Hallux Valgus—an ac-quired deformity of the foot in cerebralpalsy. Foot Ankle. 1:33-38, 1980.

17 Johnson, CH; Christensen, JC.Biomechanics of the first ray part V: theeffect of equinus deformity. J Foot AnkleSurg. 44:114-120, 2005.

18 Jones, RL. The human foot. An ex-perimental study of its mechanics, and therole of its muscles and ligaments in thesupport of the arch. Am J Anat. 68:1-38,1941.

19 Lamm, BM; Paley, D; Herzenberg,

JE. Gastrocnemius soleus recession. A sim-pler, more limited approach. J Am PodiatrMed Assoc. 95:18-25, 2005.

20 Lavery, LA; Armstrong, DG; Boul-ton, AJ. Ankle equinus deformity and itsrelationship to high plantar pressure in alarge population with diabetes mellitus. JAm Podiatr Med Assoc. 92:479-482, 2002.

21 Maskill, JD; Bohay, DR; Anderson,JG. Gastrocnemius recession to treat isolat-ed foot pain. Foot Ankle Int. 31:19-23, 2010.

22 Mueller, MJ; Sinacore, DR; Hastings,MK; Strube, MJ; Johnson, JE. Effect ofAchilles tendon lengthening on neuropath-ic plantar ulcers. A randomized clinicaltrial. J Bone Joint Surg. 85-A:1436-1445,2003.

23 Myers, KA; Long, JT; Klein, JP;Wertsch, JJ; Janisse, D; Harris, GF. Biome-chanical implications of the negative heelrocker sole shoe: Gait kinematics and ki-netics. Gait Posture. 24:323-330, 2006.

24 Nemec, SA; Habbu, RA; Anderson,JG; Bohay, DR. Outcomes following mid-foot arthrodesis for primary arthritis. FootAnkle Int. 32:355-361, 2011.

25 Patel, A; DiGiovanni, B. Associationbetween plantar fasciitis and isolated con-tracture of the gastrocnemius. Foot AnkleInt. 32:5-8, 2011.

26 Pinney, SJ; Sangeorzan, BJ; HansenJr, ST. Surgical anatomy of the gastrocne-mius recession (Strayer procedure). FootAnkle Int. 25:247-250, 2004.

27 Porter, D; Barrill, E; Oneacre, K;May, BD. The effects of duration and fre-quency of Achilles tendon stretching ondorsiflexion and outcome in painful heelsyndrome: A randomized, blinded, controlstudy. Foot Ankle Int. 23:619-624, 2002.

28 Radford, JA; Burns, J; Buchbinder,R; Landorf, KB; Cook, C. Does stretchingincrease ankle dorsiflexion range of mo-tion? A systematic review. Br J SportsMed. 40:870-875, 2006.

29 Reimers, J; Pedersen, B; Brodersen,A. Foot deformity and the length of the tri-ceps surae in Danish children between 3and 17 years old. J Pediatr Orthop [B].4:71-73, 1995.

30 Rompe, JD; Cacchio, A; Weil Jr, L;Furia, JP; Haist, J; Reiners, V; Schmitz, C;Maffulli, N. Plantar fascia-specific stretch-ing versus radial shock-wave therapy asinitial treatment of plantar fasciopathy. JBone Joint Surg Am. 92:2514-2522, 2010.

31 Roukis, TS; Schweinberger, MH.Complications associated with uni-portalendoscopic gastrocnemius recession in adiabetic patient population: An observa-tional case series. J Foot Ankle Surg.49:68-70, 2010.

32 Rush, SM; Ford, LA; Hamilton, GA.Morbidity associated with high gastrocne-mius recession: Retrospective review of

126 cases. J Foot Ankle Surg. 45:156-160,2006.

33 Saxena, A; Kim, W. Ankle dorsiflex-ion in adolescent athletes. J Am PodiatrMed Assoc. 93:312-314, 2003.

34 Saxena, A; Ramdath, S; O’Halloran,P; Gerdesmeyer, L; Gollwitzer, H. Extra-corporeal pulsed-activated therapy forAchilles tendinopathy: A prospective study.J Foot Ankle Surg. 50:315-319, 2011.

35 Scharfbillig, RW; Jones, S; Scutter,SD. Sever’s disease: What does the litera-ture really tell us? J Am Podiatr MedAssoc. 98:212-223, 2008.

36 Sgarlato, TE; Morgan, J; Shane, HS;Frenkenberg, A. Tendo Achilles lengthen-ing and its effect on foot disorders. J AmPodiatry Assoc. 65:849-871, 1975.

37 Sheridan, L; Lopez, A; Perez, A;John, MM; Willis, FB; Shanmugam, R.Plantar fasciopathy treated with dynamicsplinting. A randomized controlled trial. JAm Podiatr Med Assoc. 100:161-165, 2010.

38 Stovitz, SD; Coetzee, C. Hyperprona-tion and foot pain. Phys Sportsmed. 32:19-26, 2004.

39 Strayer, LM. Recession of the gas-trocnemius: An operation to relieve spasticcontracture of the calf muscles. J BoneJoint Surg Am. 32:671-676, 1950.

40 Tabrizi, P; McIntyre, WMJ; Quesnel,MB; Howard, AW. Limited dorsiflexion pre-disposes to injuries of the ankle in children.J Bone Joint Surg Br. 82:1103-1106, 2000.

41 Thordarson, DB; Schmotzer, H;Chon, J; Peters, J. Dynamic support of thehuman longitudinal arch. Clin Orthop RelRes. 316:165-172, 1995.

42 Vallejo, RB; Iglesias, ME; Sanz, DR;Frutos, JC; Fuentes, PS; Chicharro, JL.Plantar pressures in children with andwithout Sever’s disease. J Am Podiatr MedAssoc. 101:17-24, 2011.

43 Ward, ED; Phillips, RD; Patterson,PE; Werkhoven, GJ. The effects of extrin-sic muscle forces on the forefoot-to-rear-foot loading relationship in vitro. J Am Po-diatr Med Assoc. 88:471-482, 1998.

Dr. DeHeer is in pri-vate practice in CentralIndiana. He is the teampodiatrist for the IndianaPacers and the IndianaFever and is on the edi-torial Board of PodiatryToday. He is the inven-tor of the EQ/IQ brace,President and Founder

of Wound Care Haiti, and a medical missionary.Dr. DeHeer is President of the Indiana PodiatricMedical Association and continuing educationchairperson. He is recipient of the 2011 APMAHumanitarian of the Year Award.

Continuing

MedicalEducation

CME EXAMINATION

1) The triceps surae consists ofthe following muscles:

A) GastrocnemiusB) SoleusC) PlantarisD) All of the above

2) The gastrocnemius crosseswhich of the following joints?

A) KneeB) AnkleC) SubtalarD) All of the above

3) Which of the following is NOTan action of the gastrocnemius?

A) Dorsiflex the ankle jointB) Supply power for propulsionC) Flex the kneeD) Plantarflex the ankle joint

4) Which of the following jointsdoes the soleus cross?

A) AnkleB) KneeC) SubtalarD) A & C

5) The zone of hypovascularity ofthe Achilles tendon is located:

A) 4-5 cm proximal to the in-sertion of the tendonB) 7 cm proximal to the inser-tion of the tendonC) 1 cm proximal to the inser-tion of the tendonD) At the insertion of the tendon

6) Muscular equinus includes:A) Spastic equinusB) Non-spastic equinusC) Distal tibial-fibular osseousbridgingD) A & B

7) Osseous equinus includes:A) Anterior spurring of theankle jointB) Distal tibial-fibular osseousbridgingC) PseudoequinusD) All of the above

8) There is a gastrocnemius equi-nus when:

A) The ankle joint dorsiflexesgreater than 90 degrees withthe knee extendedB) The ankle joint dorsiflexesless than 90 degrees with theknee extendedC) The ankle joint dorsiflexesgreater than 90 degrees withthe knee flexedD) B & C

9) The _________ test is used todetermine the type of equinus.

A) SilfverskoildB) Coleman blockC) HubscherD) Jack’s

10) The proximal pathology NOTassociated with equinus is:

A) Hamstring contracturesB) Quadriceps contracturesC) Genu recurvatumD) Lumbar lordosis

11) Which of the following is NOTseen in a partially compensatedequinus?

A) Early heel-off gait patternB) The heel is on the groundC) Toe walkingD) Tibia does not achieve 10degrees of flexion to theground

12) The most common definitionof equinus is 10 degrees of dorsi-flexion with:

A) The knee extendedB) The subtalar joint in neu-tralC) The midtarsal joint lockedD) All of the above

13) According to the study byAronow, when a load was appliedto the gastrocnemius muscle,which of the following did NOThappen?

A) Rearfoot pressures de-creasedB) Midfoot pressures de-creasedC) Midfoot pressures increasedD) Forefoot pressures in-creased

14) According to the study byMueller, which occurred asan effect of a tendo-Achilleslengthening?

A) Forefoot pressuresincreasedB) Forefoot pressuresdecreasedC) Rearfoot pressuresdecreasedD) Rearfoot pressuresremained the same

15)What percentage of plantarfasciitis cases was associated withequinus in the study by Patel andDiGiovanni?

A) 95%B) 100%C) 83%D) 50%


SEE ANSWER SHEET ON PAGE 167.


Continuing

Medical Education

Continued on page <None>

PM’sCPME Program

Welcome to the innovative Continuing EducationProgram brought to you by Podiatry ManagementMagazine. Our journal has been approved as asponsor of Continuing Medical Education by theCouncil on Podiatric Medical Education.

Now it’s even easier and more convenient toenroll in PM’s CE program!

You can now enroll at any time during the yearand submit eligible exams at any time during yourenrollment period.

PM enrollees are entitled to submit ten examspublished during their consecutive, twelve–monthenrollment period. Your enrollment period beginswith the month payment is received. For example,if your payment is received on September 1, 2006,your enrollment is valid through August 31, 2007.

If you’re not enrolled, you may also submit anyexam(s) published in PM magazine within the pasttwelve months. CME articles and examinationquestions from past issues of Podiatry Manage-ment can be found on the Internet athttp://www.podiatrym.com/cme. Each lesson isapproved for 1.5 hours continuing education con-tact hours. Please read the testing, grading and pay-ment instructions to decide which method of par-ticipation is best for you.

Please call (631) 563-1604 if you have any ques-tions. A personal operator will be happy to assist you.

Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may be earnedduring any 12-month period. You may select any 10in a 24-month period.

The Podiatry Management Magazine CMEprogram is approved by the Council on PodiatricEducation in all states where credits in instructionalmedia are accepted. This article is approved for1.5 Continuing Education Contact Hours (or 0.15CEU’s) for each examination successfully completed.

Home Study CME credits nowaccepted in Pennsylvania

Continuing

MedicalEducation

CME EXAMINATION

www.podiatrym.com166 | SEPTEMBER 2012 | PODIATRY MANAGEMENT

16) Hill states that it is important to do whichof the following when stretching the calfmuscles:

A) Adduct the foot 10 degreesB) Abduct the foot 10 degreesC) Keep the foot at 0 degreesD) Stretch for 30 seconds

17) According to Evans’ study, how manypatients (out of 20) achieved 10 degrees ofdorsiflexion with the use of night splints?

A) 10B) 15C) 16D) 6

18) What is the recommended stretching timeperiod using the EQ/IQ brace?

A) 30 minutes per dayB) 30 minutes twice per dayC) 60 minutes twice per dayD) 6-8 hours while sleeping

19) Based on the study by Herzenbergand Lamm, which of the following is mosteffective?

A) A double gastrocnemius recessionB) A soleus recessionC) A single gastroc recessionD) A single gastroc with the addition of asingle soleus recession

20) A meta-analysis by Radford, et al. showedthat calf muscle stretching provided:

A) A decrease in ankle joint dorsiflexionB) No change in the amount of ankle dorsi-flexion achievedC) An increase in ankle joint dorsiflexionD) An increase in knee flexion

See answer sheet on page 167.

Please print clearly...Certificate will be issued from information below.

Name _______________________________________________________________________ Soc. Sec. #______________________________Please Print: FIRST MI LAST

Address_____________________________________________________________________________________________________________

City__________________________________________________ State_______________________ Zip________________________________

Charge to: _____Visa _____ MasterCard _____ American Express

Card #________________________________________________Exp. Date____________________

Note: Credit card is the only method of payment. Checks are no longer accepted.

Signature__________________________________ Soc. Sec.#______________________ Daytime Phone_____________________________

State License(s)___________________________ Is this a new address? Yes________ No________

Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be chargedto your credit card.)

______ I am not enrolled. Enclosed is my credit card information. Please charge my credit card $22.00 for each examsubmitted. (plus $2.50 for each exam if submitting by fax or phone).

______ I am not enrolled and I wish to enroll for 10 courses at $169.00 (thus saving me $51 over the cost of 10 individualexam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

Note: If you are mailing your answer sheet, you must complete allinfo. on the front and back of this page and mail with your credit cardinformation to: Podiatry Management, P.O. Box 490, East Islip,NY 11730.

TESTING, GRADING AND PAYMENT INSTRUCTIONS(1) Each participant achieving a passing grade of 70% or higher

on any examination will receive an official computer form stating thenumber of CE credits earned. This form should be safeguarded andmay be used as documentation of credits earned.

(2) Participants receiving a failing grade on any exam will be noti-fied and permitted to take one re-examination at no extra cost.

(3) All answers should be recorded on the answer form below.For each question, decide which choice is the best answer, and circlethe letter representing your choice.

(4) Complete all other information on the front and back of this page.(5) Choose one out of the 3 options for testgrading: mail-in, fax, or

phone. To select the type of service that best suits your needs,please read the following section, “Test Grading Options”.

TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information and

mail with your credit card information to:

Podiatry ManagementP.O. Box 490, East Islip, NY 11730

PLEASEDONOTSENDWITH SIGNATURE REQUIRED, ASTHESEWILLNOTBEACCEPTED.

There is no charge for the mail-in service if you have already en-

ENROLLMENT FORM & ANSWER SHEET

� Continuing

Medical Education

rolled in the annual exam CPME program, and we receive this examduring your current enrollment period. If you are not enrolled, pleasesend $22.00 per exam, or $169 to cover all 10 exams (thus saving $51over the cost of 10 individual exam fees).

Facsimile GradingTo receive your CPME certificate, complete all information and fax

24 hours a day to 1-631-563-1907. Your CPME certificate will be datedand mailed within 48 hours. This service is available for $2.50 per examif you are currently enrolled in the annual 10-exam CPME program (andthis exam falls within your enrollment period), and can be charged toyour Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME program, thefee is $22 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free service.

Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday throughFriday. Your CPME certificate will be dated the same day you call andmailed within 48 hours. There is a $2.50 charge for this service if you arecurrently enrolled in the annual 10-examCPME program (and this examfalls within your enrollment period), and this fee can be charged to yourVisa, Mastercard, American Express, or Discover. If you are not current-ly enrolled, the fee is $22 per exam.When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information, pleasecontact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

Over, please SEPTEMBER 2012 | PODIATRY MANAGEMENT | 167www.podiatrym.com

�

ENROLLMENT FORM & ANSWER SHEET (continued)Continuing

MedicalEducation

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educationalobjectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #7/12Understanding Equinus

(DeHeer)

www.podiatrym.com168 | SEPTEMBER 2012 | PODIATRY MANAGEMENT

Goals Understanding Equinus - Podiatry M SEPTEMBER2012| PODIATRYMANAGEMENT|159...

Documents

Transcript of Goals Understanding Equinus - Podiatry M SEPTEMBER2012| PODIATRYMANAGEMENT|159...