Understanding Equinus: a 2019 Update (Deheer, Camp, and Lining) Circle: 1

CONTINUING Medical Education / BIOMECHANICS

Goals and Understanding Objectives After completing this CME, the reader should: Equinus: A 2019 1) Understand the definition of equinus. 2) Understand the evaluation Update of equinus. 3) Understand the treatment of equinus based on evidence-based This profound causal agent medicine. is commonly overlooked 4) Become more aware of the and under-treated. role of equinus in foot and ankle pathology. 5) Include equinus treatment By Patrick A. DeHeer, DPM, as part of a global treatment Bryan Camp, DPM, and Matthew Lining, DPM plan, when indicated. 141

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quinus has been described as “the most profound causal agent in foot path- There are several factors at play omechanics and is fre- quently linked to common that all lead to this under-appreciation and lack Efoot pathology,” and also has been of treatment with equinus. described as “the greatest symp- tom producer of the human foot;” yet it is commonly overlooked and under-treated. The importance of ture: plantar heel pain/plantar fasci- syndrome, ankle sprains/fractures, equinus cannot be overstated, and itis, Achilles tendonitis/tendinosis, diabetic foot ulcers, charcot defor- its management is crucial to treat- posterior tibial tendon dysfunction/ mity, metatarsalgia, MPJ synovitis, ing the underlying pathology of all adult flatfoot deformity, muscle hallux abductovalgus, hammer toes/ the following foot and ankle condi- strains, stress fracture, shin splints, claw toes, Lisfranc/midfoot arthro- tions as documented in the litera- IT band syndrome, patellofemoral Continued on page 142

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Medical EducationEquinus (from page 141) is anterior to the muscle. Its prima- sis, hallux limitus/hallux rigidus, ry blood supply is forefoot calluses, Morton’s neuroma, from the popliteal chronic ankle stability, poor balance/ and sural arteries, increased fall rate in elderly, Sev- and it is innervated er’s disease, pediatric flat foot, lateral by the tibial nerve.

The triceps surae consists of the gastrocnemius, soleus, and plantaris.

foot pain, genu recurvatum, low back The primary act of pain, arch pain, ankle arthrosis, sub- the gastrocnemius talar arthrosis, sesamoiditis, anterior is to supply power compartment syndrome, and forefoot for propulsion, knee nerve entrapment.1 So, if equinus is flexion, and plantar- so prevalent, how come there is often flexion of the ankle a failure in recognition, association joint (Figure 1). 142 to pathology, and treatment of this The soleus orig- condition? inates on the pos- There are several factors at play terior aspect of the that all lead to this under-apprecia- head of the fibular, tion and lack of treatment with equi- the middle one- Figure 1: Posterior view of the GSC complex and related anatomical nus. It all starts with the definition third of the medial structures. of equinus, as there is no standard border of the tibia, definition. The next crucial factor is the soleal line, and the interosseous est, strongest tendon in the body, ap- the lack of appreciation of the rela- membrane. The aponeurosis of the proximately 15 centimeters long. The tionship between equinus and the soleus is posterior to the muscle. tendon inserts into the middle one- above-listed pathologies. Finally, the The soleus only crosses the ankle third of the posterior aspect of the lack of treatment is related directly and subtalar joints. The soleus is in- calcaneus with the plantaris tendon to ineffectual conservative manage- nervated by the tibial nerve and its inserting medial to the Achilles ten- ment of the condition. Let’s take arterial supply is that of the tibial, don. There is a retrocalcaneal bursa a journey through equinus to fully peroneal, and sural arteries. The pri- between the Achilles tendon and the understand the condition, and hope- mary function of the sural artery is calcaneus. The fibers of the Achilles fully therefore bring to it the respect it is due. The gastrocnemius Anatomy Most pathologies of the foot and crosses the knee, ankle, and subtalar joint. ankle start with anatomy. The anatomy of the triceps surae consists of the gastrocnemius, soleus, and plan- to stabilize the leg onto the foot and tendon rotate laterally approximately taris muscles. The gastrocnemius plantarflex the ankle joint. 90˚ so that the gastrocnemius fibers muscle originates on the posterior The plantaris tendon originates insert primarily laterally, and the so- aspect of the femoral condyles and medial and superior to the lateral leus fibers insert primarily medially. posterior knee capsule with the me- head of the gastrocnemius muscle The tendon is surrounded by a ten- dial head being the larger of the two at the lateral head of the femoral don sheath which allows gliding of and descending further distally. The condyle, coursing lateral to the gas- the tendon, and below this sheath is gastrocnemius muscle crosses the troc-soleal complex and medial to it. the paratenon, which protects and knee, ankle, and subtalar joints. This The plantaris tendon can be absent nourishes the tendon. The vascular is a very important factor; the multi- 7% of the time. supply of the Achilles tendon is from joint crossing is directly related to The Achilles tendon is the con- the myotendonous junction, the para- the most common form of equinus, tinuation of the aponeurosis of the tenon, and the calcaneal periosteum. gastrocnemius equinus. The aponeu- gastrocnemius and soleus merging There is a well-documented zone of rosis of the gastrocnemius muscle together, forming the largest, thick- Continued on page 143

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Equinus (from page 142) then checked with the knee in flex- A soft end range-of-mo- ion (Figures 2 and 3). If the ankle tion is more likely a gastroc-so- hypovascularity 4-5 cm proximal to joint dorsiflexes greater than 90˚ with leus equinus, especially if no an- the insertion of the tendon. both the knee extended and flexed, terior ankle impingement is noted on there is no equinus. If the ankle joint the x-ray. This brings into question Types of Equinus dorsiflexes greater than 90˚ with the how to reproducibly measure ankle There are two primary types of knee flexed by less than 90˚ with the joint dorsiflexion. There are over 23 methods described in the literature on how to evaluate ankle joint dorsi- The gastrocnemius flexes the knee, flexion.2 Ankle joint dorsiflexion can vary significantly, up to 10˚, based plantarflexes the ankle joint, and supplies power on supinated or pronated foot position.2 Supinating the foot and then for propulsion. dorsiflexing limits the midtarsal joint motion to 2.5˚, a clinically insignif- icant amount resulting in improved equinus—muscular and osseous, knee extended, the result is gastroc- consistency.2 with subgroups of each kind. In the nemius equinus. If the ankle dorsi- Dayton, et al. performed a similar muscular group, there can be either flexion is less than 90˚ with both the study and came to the same conclu- spastic or non-spastic equinus. Ei- knee flexed and extended, then it can sion. The authors compared radio- ther of these subgroups of spastic or either be gastroc-soleus equinus or graphic evaluation of ankle joint dor- non-spastic equinus can further be osseous equinus. This is determined siflexion with the foot pronated, su- broken down into gastrocnemius or by the quality of the end range-of- pinated, and in the neutral position.3 gastro-soleus equinus. The osseous motion and with a charger dorsiflex- They found a significant difference, 143 forms include anterior spurring of the ion stress lateral ankle x-ray. 14˚ between a pronated foot position ankle joint best seen on a and supinated foot posi- charger view (stress dorsi- tion, but only a 9˚ change flexion lateral x-ray), dis- between supinated and tal tibial-fibular osseous neutral, while radiograph- bridging, pseudo-equinus, ically the tibiotalar angle or combined equinus. did not change significant- Pseudoequinus occurs in ly. They concluded, “Mo- the cavus foot structure tion of the foot between where ankle joint dorsi- the neutral and supinated flexion occurs to dorsi- position introduced an ad- flex the forefoot, which ditional source of poten- is plantarflexed to the tial error from the mea- rearfoot. The ankle dor- surement technique when siflexion used to do this using the neutral position then limits the amount as the standard, which has Figure 2: The Silfverskiold test is used to evaluate for equinus. This available for normal am- demonstrates evaluation of the dorsiflexion of the ankle joint with the been recommended in the bulation; therefore, the knee extended. past. We recommend a su- term pseudo-equinus. The pinated foot position as a combined equinus is just more reliable foot position a combination of one type for measuring the clinical of muscular and osseous ankle joint range of mo- equinus. tion and propose it as a potential standard.”3 Clinical Evaluation The Silfverskiold test Definition is what is used to deter- After understanding mine the type of equi- the anatomy, the defi- nus. In this examination, nition becomes the next the subtalar is placed in most crucial factor and is neutral position and the surprisingly difficult, es- midtarsal joint is locked pecially among different by supination of the fore- specialties. The definition foot. The ankle is dorsi- Figure 3: Evaluation of the ankle joint dorsiflexion with the knee bent removes of equinus ranges from flexed maximally with the the pull of the gastrocnemius muscle and allows the practitioner to determine -10˚ to +22˚ in the litera- knee in full extension and whether equinus is gastrocnemius equinus or gastroc-soleal equinus. Continued on page 144 www.podiatrym.com SEPTEMBER 2019 | PODIATRY MANAGEMENT biomechanics Continuing

Medical EducationEquinus (from page 143) new patient visits over a six-week ter of pressure is about 6 cm anterior period of time. Twenty-nine patients to the ankle, roughly over the dorsal ture, with +10˚ as a consensus of were excluded from the study be- 2nd metatarsal-cuneiform joint. This thirteen different studies. Sgarlato4 cause they did not meet study crite- would make us fall forward in normal in The Journal of American Podiatric ria. Of the remaining 174 patients, six standing, but that reaction is negated Medical Association in 1975 first de- had normal ankle joint dorsiflexion, by the pull of the plantarflexors. The scribed the definition as +10˚ with leaving 168 of the patients exhibit- triceps surae has been documented the subtalar joint in neutral position ing equinus. Three of the patients to be the primary plantarflexor of the ankle joint and therefore offsets the anteriorly displaced center of pres- The zone of hypovascularity sure. It has further been demonstrated with equinus that the center of pres- of the Achilles tendon is located 4-5 cm proximal sure moves about 3 cm distally and 3 mm laterally (Figures 4 and 5). to the insertion of the tendon. The important concept lies in the relation of the subtalar axis to the center of pressure and the subtalar and the midtarsal joint locked. Gatt, had gastrocnemius equinus and 165 axis to the insertion of the Achilles et al.2 investigated the relationship had GSC equinus. Their definition for tendon. The Achilles tendon inserts between static diagnosis of ankle equinus was less than 3-degrees dor- medially to the subtalar axis and its equinus and dynamic ankle and foot siflexion with knee extension. Their distance from the axis is about the dorsiflexion during stance phase findings were that 96.5% of the pa- same as the laterally placed center of gait. This is the most applicable tients with foot and ankle pathology of pressure to the subtalar axis in a 144 study to date on the true definition exhibited equinus. foot with a normal subtalar axis and of equinus since it correlates mea- Jastifer and Martson6 also exam- no equinus. The medial position of surement as it relates to function. It ined the frequency of equinus, finding the Achilles creates a supinatory mo- is well established in late midstance that regardless of the type of measurement, while the lateral center of pres- prior to heel off, 10˚ to 15˚ of ankle ment technique (ankle range-of-mo- sure, due to ground reactive forces joint dorsiflexion is required to move tion device, goniometer, visual), there (GRF), creates a pronatory moment. the body from behind the foot over was a significant difference between These two cancel each other out, pro- the top of the planted foot. Gatt, et the group of patients with pathology viding a rectus foot structure. al.’s study consisted of two groups, of the foot and/or ankle and a control When equinus is present, the dis- group A measured <-5˚ ankle joint group. The authors concluded, “Pa- tal and lateral positioning of the cen- dorsiflexion with the foot maximally supinated and group B measured ≤ -5˚ to 0˚. In late midstance, ankle joint dorsiflexion measured 4.4˚ in Gastrocnemius equinus occurs group A and 13.9˚ in group B. when the ankle joint dorsiflexes less than 90 degrees Clearly, 4.4˚ is inadequate ankle joint dorsiflexion in late midstance with the knee extended or and will require proximal and/or greater than 90 degrees with the knee flexed. distal compensation. The authors concluded, “There is no relationship between a static diagnosis of ankle dorsiflexion at 0˚ with dorsiflexion tients with foot and ankle pain had ter of pressure in relation to the sub- during gait. On the other hand, those less ankle dorsiflexion than the con- talar axis creates an increased pro- subjects with less than -5˚ of dorsi- trol group. This is the largest study to natory effect on the foot due to GRF, flexion during static examination did date using a validated measurement which is not offset by the supinatory exhibit reduced ankle range of mo- device as well as a control group and effect of the Achilles tendon. When tion during gait.”2 Based on Gatt, et supports the findings of previous au- the subtalar joint axis is more medial.’s study, we believe the definition thors. This study supports the notion ally deviated, such as in a pronated for gastrocnemius equinus should be that an isolated gastrocnemius con- foot, this further distances the center -5˚ dorsiflexion of ankle/foot with tracture may be associated with foot of pressure from the subtalar axis, the foot maximally supinated and the and ankle pain.” causing even more pronatory defor- knee straight. mity due to GRF. The opposite oc- Biomechanics of Equinus curs in the supinated foot, where the Incidence of Equinus Understanding the biomechanics subtalar joint axis is more laterally In Hill’s5 article, the incidence of equinus is crucial to getting an ap- deviated to the point where even the of equinus with pathological condi- preciation of the devastation it has center of pressure is on the subtalar tions was studied by examining 209 on the foot pathomechanics. The cen- Continued on page 145

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flattening of the medial arch of the foot.” More recently, Amis9, using slow motion photography, illustrat- ed a fourth rocker occurring in feet with equinus starting the last half of midstance when the swing phase foot starts to pass the stance foot and ends at stance as the heel lifts just prior to third rocker beginning. This fourth rocker occurred in the exact location Johnson and Christensen described, the naviculocuneiform joint. Amis noted this only lasted about 1/10 of a second but consider how many steps a day a person takes over a lifetime. Amis also noted that the knee goes into full extension at the exact same time, producing twice the abnormal force in half the time. Some authors41 question if equinus Figures 4 & 5: The center of pressure is located as shown on the left drawing approximately 6 cm is pathologic, because so many people distal to the ankle joint. With equinus deformity the center of pressure moves distal and lateral fur- have equinus without symptomatolo- ther away from the subtalar joint axis as shown on the right drawing. gy. This is a bit of not seeing the for- 145 est for the trees. As Amis stated, the Equinus (from page 144) and navicular, and dorsiflexion of the abnormal increase in both direct and medial cuneiform and 1st metatarsal indirect forces associated with what axis, medial to the subtalar axis, or occurring through the naviculacunei- he termed “The Split-Second Effect” just lateral to the subtalar axis. This form joint. This occurs due to damp- results in “occult, unrecognized, over- puts both the Achilles and center of ening of the effect of the peroneal use of imbalance”, leading eventually pressure in supinatory moments (or longus tendon eversion of the medial to damage to the foot and/or ankle. at least is a lesser pronatory moment cuneiform that leads to locking of the Likewise, Johnson and Christensen8 than the supinatory moment of the Achilles tendon) due to GRF; therefore, making a cavus foot worse over An important question that is often overlooked a period of time due to increased rearfoot varus, peroneal pathology, in the biomechanical discussion of equinus is the effect and subtalar instability. Thordarson, et al.7 proved that of pronation on the gastrocsoleus complex (GSC). increasing the load of the GSC is the primary arch deformer in both the sagittal and transverse planes, re- midtarsal joint. This lack of midtar- summarized this point well in their inforcing the pronatory effect. The sal joint locking leads to the above study stating, “In clinical practice, the windlass mechanism and posterior described medial column instability. early destructive influence of equi- tibial tendon were shown to be the This study showed that the effect nus is often not appreciated. Instead, primary arch augmenter for sagittal of equinus is not a stretching of the we are usually faced with the end re- and transverse planes, respectively. plantar ligaments over a period of sult of equinus effects…” The notion Johnson and Christensen8 exam- time that leads to first ray instability that because a person has equinus but ined the effects of equinus on first but, in fact, is a dampening of the does not have symptomatology, and ray pathomechanics using cadav- peroneus longus function that leads thus equinus is not pathological, is er weight-bearing models in their to first ray hypermobility. naïve at best. landmark series on first ray patho- An important question that is mechanics. Sensors were applied to often overlooked in the biomechan- Pathological Process of Equinus each of the individual bones making ical discussion of equinus is the ef- Sgarlato4 described three types up the medial column of the foot. fect of pronation on the gastrocsoleus of compensation for equinus. The Loading of the Achilles tendon was complex (GSC). Kevin Kirby, DPM uncompensated equinus deformity applied, and then three-dimensional says (via personal communication), manifests itself as a toe walker due data were recorded for each segment “accommodative shortening of the to lack of ankle joint dorsiflexion of the medial column. The results GSC will occur with prolonged me- and/or MTJ pronation to get the heel showed plantarflexion of the talus dial deviation of the STJ axis and Continued on page 146 www.podiatrym.com SEPTEMBER 2019 | PODIATRY MANAGEMENT biomechanics Continuing

Medical EducationEquinus (from page 145) ican Podiatric Medical Association nent many of the biomechanical the- in 1998. When the loads were re- orists portray, why is the emerging down to the ground. This accounts moved, the pressures on the forefoot research on this topic so definitive? for about only 1% of equinus cases. decreased 32% and the rearfoot pres- In the partially compensated equinus sures increased 32%. These addi- Treatment deformity, the heel is on the ground, tional findings were similar to those Treatment of equinus can be bro- but the tibia does not achieve 10 de- of Mueller13 in The Journal of Bone ken down into either conservative grees of flexion to the ground. This and Joint Surgery 2003, who mea- care or surgical care. As with most pathologies, conservative care should be attempted initially. The two main Genu recurvatum, forms of conservative care are manual stretching and bracing. hamstring contractures, and lumbar lordosis are Radford, et al.26 in a meta-analysis showed that calf muscle stretch- all associated with equinus. ing provided a small but statistically significant increase in ankle joint dorsiflexion. Their analysis showed results in an early heel-off gait pat- sured the effect of a tendo-Achilles that 15 to 30 minutes per day pro- tern. When the equinus deformity is lengthening on pressure changes in vided the greatest amount of ankle fully compensated, the result is the the foot. In Mueller’s study, the fore- joint dorsiflexion (3.03 degrees) severely pronated, hypermobile foot foot pressures decreased 31% and for each of the three groups. Grady with heel contact to the ground and the rearfoot pressures increased by and Saxena27 in their study had pa- the tibia achieving more than 10 de- 34%. tients stretch once per day over 146 grees of flexion to the ground. Heel- a six-month period of time for 30 off in the fully compensated equinus Plantar Fasciitis and Equinus seconds, two minutes, or five min- deformity is normal. The relationship between plan- utes with the knee extended. The The proximal pathologies asso- tar fasciitis and equinus is well doc- increase in ankle joint dorsiflexion ciated with equinus are numerous umented in the literature, with an for each group was 2.15, 2.3, and and easily overlooked due to the pro- estimated 2,000,000 cases of plantar 2.7 degrees, respectively. These to- found distal pathologies that often fasciitis per year in the United States. tals were not statistically significant, overshadow these proximal defor- Patel and DiGiovanni14 found that but when one takes into account the mities. Lumbar lordosis, hip flexion, 83% of plantar fasciitis cases were minimal amount of stretching done knee flexion, genu recurvatum, and associated with equinus. Cheung, daily, the results are actually encour- hamstring contractures have all been et al.15 showed that equinus caused aging. Macklin, et al.28 had thirteen attributed to equinus. The more ob- vious distal pathologies that directly result from or have a relationship to A meta-analysis by Radford, et al. equinus will be discussed with some of the well-documented literature. showed that calf muscle stretching provided an increase Aronow’s10 study was one of the first to not only explore the changes in ankle joint dorsiflexion. on forefoot and rearfoot pressures associated with equinus, but also to examine the midfoot changes. A load twice the amount of strain on the runners use a ramp for four minutes was applied to the GSC and then to plantar fascia as body weight. This each morning and night for stretch- just the gastrocnemius muscle, and re-affirmed the close relationship ing. The amount of ankle joint dorsi- then the changes in pressures were between plantar fasciitis and equi- flexion was measured with a goniom- measured. In the GSC group, the nus. Any treatment plan for plantar eter three times and the average was rearfoot pressures decreased (18%) fasciitis must include equinus man- taken. They found that as the ankle and the midfoot (38%) and forefoot agement. Likewise, Nakale, et al.16 joint flexibility increased, the partic- (59%) increased. In the gastrocne- demonstrated almost identical re- ipants verbally reported improved mius group, the rearfoot pressures sults to Patel and DiGiovanni14 with running times. They discussed that decreased (16%) and the midfoot an 80% rate of equinus deformity “these results also strongly indi- (32%) and forefoot (50%) increased. demonstrated in their plantar fasci- cate that this specific non-invasive These numbers were very consistent itis subgroup. The relationship is so stretching regime could be consid- with other studies on the effect of clear now that nine different peer-re- ered before resorting to more inva- equinus and forefoot pressure chang- viewed journal articles advocate a sive options.” es, such as Jones11 in The American gastrocnemius recession for chronic Hill5 discussed the problems Journal of Anatomy in 1941 and refractory plantar fasciitis.17-25 If equi- with manual stretching stating, Ward12 in The Journal of the Amer- nus is not the pathological compo- Continued on page 147

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Equinus (from page 146) the tibia and aiding in locking of the lar approach to lengthening knee into full extension. of the gastrocnemius aponeu- “Active stretching requires detail in rosis. This provides controlled, teaching the proper technique and Surgical Approaches to Equinus sequential lengthening. The incision must be done at least four times The surgical approach to equinus is placed at the medial aspect of the a day at five- to eight-minute ses- is well documented in the literature calf, midway between the posterior sions. The most serious mistakes and focuses on mainly two differ- calf and anterior border of the tibia. patients make during their previ- ent procedures, the tendo-Achilles The incision is typically 3-4 cm long ous attempts at stretching are inad- lengthening (TAL) or gastrocnemius and is deepened to the level of the equate stretch time and abducted recession. The TAL approach most deep fascia. The fascia is incised, re- foot position during the stretch. It commonly utilized is the Hoke triple vealing the gastrocnemius and sole- is critical that the foot be adducted hemisection. This procedure employs us muscle bellies. Using a finger to 10 degrees during the stretching to three stab incisions starting one cen- identify the natural separation be- lock the subtalar-midtarsal joints for timeter proximal to the insertion of tween the aponeurosis of the two maximum benefit at the calf.” the GSC, with two medial incisions muscles, an anal speculum is insert- Night splints have long been the and one lateral incision between the ed to spread them apart. The plantaris tendon is identified when present either on the soleus or gastrocnemius Hill states that it is side and then cut, as the tendon acts as a tether. Substantial increase in important to adduct the foot 10 degrees when dorsiflexion is noted upon release of the plantaris tendon. The foot is stretching the calf muscles. dorsiflexed with the knee extended, and a long-handled #15 blade is used 147 to cut the proximal portion of the only mode of bracing for equinus two medial incisions. The tendon is gastrocnemius aponeurosis, including treatment, but there are several flaws sectioned through the central por- the intramuscular septum. with them. First, they are designed tion and incised in the respective This is a complete release from to be used at night while sleeping direction of the stab incisions. The lateral to medial with care taken to and the most common sleeping posi- tendon then slides to a lengthened minimally invade the underlying tion with these braces is on the side position. This procedure is not with- muscle. If inadequate dorsiflexion is with knees bent. This means that the out potential complications, such as noted, a second more distal (1 cm gastrocnemius muscle is not being under-lengthening, or much worse, distal to the initial release) incision stretched. Remembering that the gas- over-lengthening and a calcaneal is recommended over a soleus re- trocnemius muscle crosses both the gait. Calcaneal gait deformity is an cession (this is based on the study knee and ankle, it is most often the extremely difficult condition to treat by Herzenberg and Lamm35 in Foot contracted structure. This accounts and can be devastating in a compro- and Ankle International 2007.) The for the ineffective nature of night mised foot. pre-operative group had 1 degree of splints. Based on our personal expe- The research on recalcitrant di- ankle joint dorsiflexion with the knee rience, compliance with night splints abetic forefoot ulcers treated with extended, and after gastrocnemius is also very poor. These two factors TALs provides great insight to the recession, single and double dorsi- led to the mediocre results attributed many cautions that should be taken flexion increased significantly (9 and to night splints as described in the with using a TAL to treat equinus. 15 degrees, respectively). Adding a Evans29 study, which showed only 6 Although the forefoot ulcers healed soleus recession only increased dor- of 20 patients achieving 10 degrees in the vast majority of these pa- siflexion by one degree—thus it is of dorsiflexion with the use of night tients, the heal ulcer transfer rate more effective to perform a double splints. ranged from 2%-13% leading to gastrocnemius recession. Rong, et The Equinus Brace® offers numer- often devastating results.30-33 Rush, al.36 compared three gastrocnemius ous advantages over traditional night et al.34 looked at the morbidity as- recession procedures for isolated splints both in terms of functionality sociated with a high gastrocnemius gastrocnemius equinus. The study and compliance. The Equinus Brace® recession in 126 cases. The com- demonstrated a Baumann gastrocne- allows for one hour per day treat- plications included four with nerve mius recession with two recessions ment, an above-the-knee extension to problems, three with wound dehis- providing equal range-of-motion lock the knee in full extension while cence, two with superficial infec- compared to a Strayer gastrocnemius the foot is dorsiflexed, adjustable tions, seven with scar problems, and recession, while providing superior hinges for controlled treatment to two with other complications. stability. Other studies found signifi- match clinical measurements, and The gastrocnemius recession is cantly less weakness associated with a toe wedge to engage the Windlass one of our favorite procedures and the Baumann procedure compared to mechanism, allowing for stretching is well documented in the literature. the Strayer procedure.37-40 in supination and external rotation of We prefer the Bauman intramuscu- Continued on page 148 www.podiatrym.com SEPTEMBER 2019 | PODIATRY MANAGEMENT biomechanics Continuing “Gastrocnemius contracture in patients with gastrocnemius recession in 73 patients.” Foot Medical EducationEquinus (from page 147) and without foot pathology.” Foot & ankle and Ankle Surgery 20.4 (2014): 272-275. The treatment of equinus alone international 37.11 (2016): 1165-1170. 20 Monteagudo, Manuel, et al. “Chronic 7 has shown to be effective for foot Thordarson, David B., et al. “Dynamic plantar fasciitis: plantar fasciotomy versus symptomatology without doing any- support of the human longitudinal arch. A gastrocnemius recession.” International or- biomechanical evaluation.” Clinical ortho- thopaedics 37.9 (2013): 1845-1850. thing to the pathology within the foot. paedics and related research 316 (1995): 165- 21 Ficke, Brooks, et al. “Gastrocnemius 17 Maskill, et al. examined the effect of 172. recession for recalcitrant plantar fasciitis in an isolated gastrocnemius recession 8 Johnson, CH; Christensen, JC. Bio- overweight and obese patients.” Foot and on 29 patients (34 feet) that failed mechanics of the first ray part V: the effect Ankle Surgery 24.6 (2018): 471-473. six months of conservative therapy. of equinus deformity. J Foot Ankle Surg. 22 Hoefnagels, E., et al. “Chronic therapy The measure used was the visual 44:114-120, 2005. resistant plantar fasciitis, the effect of length- analog scale (VAS) and there were 9 Amis, James. “The split second effect: ening the gastrocnemius muscle.” Foot and three categories of patients (plantar the mechanism of how equinus can damage Ankle Surgery 2.22 (2016): 58. 23 fasciitis, midfoot pain, and arch pain). the human foot and ankle.” Frontiers in sur- Ortega-Avila, Ana Belen, et al. “Con- The VAS scores pre-operatively and gery 3 (2016): 38. tribution levels of intrinsic risk factors to the 10 Aronow, MS; Diaz-Doran, V; Sullivan, management of patients with plantar heel post-operatively were as follows for RJ; Adams, DJ. The effect of triceps surae pain: A pilot study.” Journal of the American each group: plantar fasciitis 8.1 to 1.9, contracture force on plantar foot pressure Podiatric Medical Association 106.2 (2016): midfoot pain 7.5 to 2.2, and arch pain distribution. Foot Ankle Int. 27:43-52, 2006. 88-92. 9.3 to 3.3. These drastic pain scale 11 Jones, RL. The human foot. An exper- 24 Molund, Marius, et al. “Proximal me- changes were the result of only a gas- imental study of its mechanics, and the role dial gastrocnemius recession and stretching trocnemius recession without doing of its muscles and ligaments in the support of versus stretching as treatment of chronic anything to the foot. Equinus is an underlying fac- 148 tor in most of the biomechanically Equinus must be addressed either conservatively based pathologies associated with the foot and ankle. Equinus must or surgically as part of the overall treatment plan for any be addressed either conservatively or surgically as part of the overall condition with an associated equinus deformity. treatment plan for any condition with an associated equinus deformity. Comprehensive treatment of lower the arch. Am J Anat. 68:1-38, 1941. plantar heel pain.” Foot & ankle international extremity pathologies mandates treat- 12 Ward, ED; Phillips, RD; Patterson, PE; 39.12 (2018): 1423-1431. ing all components of the deformity. Werkhoven, GJ. The effects of extrinsic mus- 25 Cheney, Nicholas, et al. “Isolated The research is clear, undeniable, cle forces on the forefoot-to-rearfoot load- Gastrocnemius Recession for Plantar Fasci- and robust. Either we practice evi- ing relationship in vitro. J Am Podiatr Med itis.” Foot & Ankle Orthopaedics 3.3 (2018): Assoc. 88:471-482, 1998. 2473011418S00186. dence-based medicine, or we do not. 13 Mueller, MJ; Sinacore, DR; Hastings, 26 Radford, JA; Burns, J; Buchbinder, R; If we do, then treating equinus when MK; Strube, MJ; Johnson, JE. Effect of Achil- Landorf, KB; Cook, C. Does stretching in- present should be a given. PM les tendon lengthening on neuropathic plan- crease ankle dorsiflexion range of motion? A tar ulcers. A randomized clinical trial. J Bone systematic review. Br J Sports Med. 40:870- References Joint Surg. 85-A:1436-1445, 2003. 875, 2006. 1 DeHeer, Patrick A. “Equinus and 14 Patel, A; DiGiovanni, B. Association 27 Grady, JF; Saxena, A. Effects of lengthening techniques.” Clinics in podiatric between plantar fasciitis and isolated con- stretching the gastrocnemius muscle. J Foot medicine and surgery 34.2 (2017): 207-227. tracture of the gastrocnemius. Foot Ankle Int. Surg. 30:465-469, 1991. 2 Gatt, Alfred, et al. “A pilot investigation 32:5-8, 2011. 28 Macklin, K., Aoife Healy, and Na- into the relationship between static diagnosis 15 Cheung, JT; Zhang, M; An, KN. Effect chiappan Chockalingam. “The effect of calf of ankle equinus and dynamic ankle and of Achilles tendon loading on plantar fascia muscle stretching exercises on ankle joint foot dorsiflexion during stance phase of gait: tension in the standing foot. Clin Biomech. dorsiflexion and dynamic foot pressures, Time to revisit theory?.” The Foot 30 (2017): 21:194-203, 2006. force and related temporal parameters.” The 47-52. 16 Nakale, Ngenomeulu T., et al. “Asso- Foot 22.1 (2012): 10-17. 3 Dayton, Paul, et al. “Experimental ciation between plantar fasciitis and isolated 29 Evans, A. Podiatric medical applica- comparison of the clinical measurement of gastrocnemius tightness.” Foot & ankle inter- tions of posterior night stretch splinting. J ankle joint dorsiflexion and radiographic Ti- national 39.3 (2018): 271-277. Am Podiatr Med Assoc. 91:356-360, 2001. biotalar position.” The Journal of Foot and 17 Maskill, John D., Donald R. Bohay, 30 Holstein, P, et al. “Achilles tendon Ankle Surgery 56.5 (2017): 1036-1040. and John G. Anderson. “Gastrocnemius re- lengthening, the panacea for plantar forefoot 4 Sgarlato, TE; Morgan, J; Shane, HS; cession to treat isolated foot pain.” Foot & ulceration.” Diabetes/metabolism research Frenkenberg, A. Tendo Achilles lengthening ankle international 31.1 (2010): 19-23. and reviews 20.S1 (2004): S37-S40. and its effect on foot disorders. J Am Podia- 18 Abbassian, Ali, Julie Kohls-Gatzoulis, 31 Nishimoto, Gordon S., Christopher E. try Assoc. 65:849-871, 1975. and Matthew C. Solan. “Proximal medial Attinger, and Paul S. Cooper. “Lengthening 5 Hill, RS. Prevalence and linkage to gastrocnemius release in the treatment of the Achilles tendon for the treatment of di- common foot pathology. J Am Podiatr Assoc. recalcitrant plantar fasciitis.” Foot & ankle abetic plantar forefoot ulceration.” Surgical 85:295-300, 1995. international 33.1 (2012): 14-19. Clinics 83.3 (2003): 707-726. 6 Jastifer, James R., and Jessica Marston. 19 Molund, Marius, et al. “Results after Continued on page 149

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Equinus (from page 148) 41 Jarvis, Hannah L., et al. “Challenging the foundations of the clinical model of foot function: further evidence that 32 Mueller, Michael J., et al. “Effect of Achilles Tendon Length- the root model assessments fail to appropriately classify foot ening on Neuropathic Plantar Ulcers*: A Randomized Clinical Trial.” function.” Journal of foot and ankle research 10.1 (2017): 7. JBJS 85.8 (2003): 1436-1445. 33 Chilvers, Margaret, et al. “Heel overload associated with heel Disclosure: Patrick A. DeHeer, DPM discloses he is cord insufficiency.” Foot & ankle international 28.6 (2007): 687-689. the inventor of The Equinus Brace® and Principal of IQ 34 Rush, SM; Ford, LA; Hamilton, GA. Morbidity associated with Medical. high gastrocnemius recession: Retrospective review of 126 cases. J Foot Ankle Surg. 45:156-160, 2006. 35 Herzenberg, JE; Lamm, BM; Corwin, C; Sekel, J. Isolated re- Dr. DeHeer is in private practice in Central Indi- cession of the gastrocnemius muscle: the Baumann procedure. Foot ana. He is the team podiatrist for the Indiana Pac- Ankle Int. 28:1154-1159, 2007. ers and the Indiana Fever. He is the inventor of the 36 Rong, Kai, et al. “Comparison of the efficacy of three isolated EQ/IQ brace, President and Founder of Wound gastrocnemius recession procedures in a cadaveric model of gastroc- Care Haiti, and a medical missionary. Dr. DeHeer nemius tightness.” International orthopaedics 40.2 (2016): 417-423. is a Trustee of the APMA and is recipient of the 37 Nawoczenski, Deborah A., et al. “Ankle power and endurance 2011 APMA Humanitarian of the Year Award. outcomes following isolated gastrocnemius recession for Achilles ten- Dr. Camp completed dinopathy.” Foot & ankle international 37.7 (2016): 766-775. his undergraduate de- 38 Saraph, V., et al. “The Baumann procedure for fixed contrac- gree at Indiana Universi- ture of the gastrosoleus in cerebral palsy: evaluation of function of the ty. Dr. Camp is a gradu- ankle after multilevel surgery.” The Journal of bone and joint surgery. ate of the Scholl College British volume 82.4 (2000): 535-540. of Podiatric Medicine 39 Svehlik, M., et al. “The Baumann procedure to correct equinus and is the Chief Resident gait in children with diplegic cerebral palsy: long-term results.” The of the St. Vincent India- Journal of bone and joint surgery. British volume 94.8 (2012): 1143- 149 napolis program. 1147. 40 Morales-Muñoz, Patricia, et al. “Proximal gastrocnemius release Dr. Lining is a graduate of the Kent State Col- in the treatment of mechanical metatarsalgia.” Foot & ankle interna- lege of Podiatric Medicine and is currently a sec- tional 37.7 (2016): 782-789. ond year resident at St. Vincent Indianapolis.

CME EXAMINATION

See answer sheet on pagE 151.

1) The triceps surae consists of the following 4) The zone of hypovascularity of the Achilles muscles: tendon is located: A) Gastrocnemius A) 4-5 cm proximal to the insertion of the B) Soleus tendon C) Plantaris B) 7 cm proximal to the insertion of the D) All of the above tendon C) 1 cm proximal to the insertion of the 2) The gastrocnemius crosses which of the tendon following joints? D) At the insertion of the tendon A) Knee B) Ankle 5) There is a gastrocnemius equinus when: C) Subtalar joint A) The ankle joint dorsiflexes greater than D) All of the above 90 degrees with the knee extended B) The ankle joint dorsiflexes less than 90 3) Which of the following is NOT an action of the degrees with the knee extended gastrocnemius? C) The ankle joint dorsiflexes greater than A) Dorsiflex the ankle joint 90 degrees with the knee flexed B) Supply power for propulsion D) b & c C) Flex the knee D) Plantarflex the ankle joint Continued on page 150 www.podiatrym.com SEPTEMBER 2019 | PODIATRY MANAGEMENT $ CME EXAMINATION PM’s Continuing

Medical6) ETheducation proximal pathology NOT associated with CME Program equinus is: A) Hamstring contractures Welcome to the innovative Continuing Education B) Quadriceps contractures Program brought to you by Podiatry Management C) Genu recurvatum Magazine. Our journal has been approved as a D) Lumbar lordosis sponsor of Continuing Medical Education by the Council on Podiatric Medical Education. 7) What percentage of plantar fasciitis cases was associated with equinus in the study by Patel Now it’s even easier and more convenient to and DiGiovanni? enroll in PM’s CE program! A) 95% B) 100% You can now enroll at any time during the year C) 83% and submit eligible exams at any time during your D) 50% enrollment period. CME articles and examination questions 8) Hill states that it is important to do which of from past issues of Podiatry Management the following when stretching the calf muscles: can be found on the Internet at http://www. A) Adduct the foot 10 degrees podiatrym.com/cme. Each lesson is approved 150 B) Abduct the foot 10 degrees for 1.5 hours continuing education contact hours. C) Keep the foot at 0 degrees Please read the testing, grading and payment D) Stretch for 30 seconds instructions to decide which method of participa- 9) Based on the study by Herzenberg and Lamm, tion is best for you. which of the following is most effective? Please call (631) 563-1604 if you have any A) A double gastrocnemius recession questions. A personal operator will be happy to B) A soleus recession assist you. C) A single gastroc recession each of the 10 lessons will count as 1.5 credits; D) A single gastroc with the addition of a thus a maximum of 15 CME credits may be earned single soleus recession during any 12-month period. You may select any 10

in a 24-month period. 10) A meta-analysis by Radford, et al. showed that calf muscle stretching provided: The Podiatry Management Magazine CME A) A decrease in ankle joint dorsiflexion B) No change in the amount of ankle program is approved by the Council on Podi- dorsiflexion achieved atric Education in all states where credits in C) An increase in ankle joint dorsiflexion instructional media are accepted. This article is D) An increase in knee flexion approved for 1.5 Continuing Education Contact Hours (or 0.15 CEU’s) for each examination successfully completed. See answer sheet on page 151. PM’s privacy policy can be found at http:// The author(s) certify that they have NO affiliations with or involvement in any organization or entity with podiatrym.com/privacy.cfm. any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; member- this CME is valid for CPME-approved credits ship, employment, consultancies, stock ownership, or other equity interest), or non-financial interest (such for three (3) years from the date of publication. as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materi- als discussed in this manuscript.

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Name ______Email Address______Please Print: First MI Last Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Zip for credit card______Note: Credit card is the only method of payment. Checks are no longer accepted. Signature______Email Address______Daytime Phone______State License(s)______Is this a new address? Yes______No______

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Enrollment Form & Answer Sheet (continued) Continuing

Medical Education

EXAM #7/19 Understanding Equinus: A 2019 Update (DeHeer, Camp, and Lining) Circle: 1. A B c D 6. A B c D 2. A B c D 7. A B c D 3. A B c D 8. A B c D 4. A B c D 9. A B c D 5. A B c D 10. a B c D

Medical Education Lesson Evaluation Strongly Strongly agree agree neutral Disagree disagree [5] [4] [3] [2] [1] 152 1) This CME lesson was helpful to my practice ____

2) The educational objectives were accomplished ____

3) I will apply the knowledge I learned from this lesson ____

4) I will makes changes in my practice behavior based on this lesson ____

5) This lesson presented quality information with adequate current references ____

6) What overall grade would you assign this lesson? ABCD

7) This activity was balanced and free of commercial bias. Yes _____ No _____

8) What overall grade would you assign to the overall management of this activity? ABCD

How long did it take you to complete this lesson? ______hour ______minutes What topics would you like to see in future CME lessons ? Please list : ______

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