Key Insights On Managing Pediatric Equinus With Orthoses

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Robert Bielski, MD, encourages clinicians to narrow down the differential diagnosis of pediatric equinus by asking about the developmental history.
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Author(s): 
Guest Clinical Editor: Edwin Harris, DPM

The length of the orthosis depends on what one is treating and how severe the equinus is, according to Dr. Bielski. He typically will use a full-length (above calf) ankle-foot orthosis (AFO).

To effectively control equinus, orthoses should come just below the knee, according to Dr. Harris. “The lower the orthosis, the shorter its proximal lever arm. The shorter the lever arm, the less efficient it is in controlling the ankle joint,” he explains. Dr. Harris says stiffness in the proximal portion of the orthosis is another factor in control. The more forward the proximal medial and lateral trim lines, the stiffer the posterior portion of the orthosis becomes, according to Dr. Harris. He also notes the possibility of articulating the orthosis at the ankle to allow varying degrees of ankle motion, saying it is necessary to restrict plantarflexion to neutral in the control of equinus.

Q: What physical therapy techniques are available to help manage equinus deformity?
A:
Dr. Bielski thinks mild equinus does respond to manual stretching and older kids, and pre-teens can actively participate in a stretching program. In several patients, he has found that the tibialis anterior will show improved strength if he treats some of the equinus with physical therapy.

Dr. Harris also notes the effectiveness of regular stretching. “It becomes impractical and uneconomical to schedule a large number of physical therapy sessions to do stretching,” he cautions. “The therapist’s role in stretching is to train the parents to perform home stretching correctly and then supervise their performance regularly.”

Serial stretching casting can help increase the range of ankle dorsiflexion, says Dr. Harris. Although such a technique is most effective in children who cannot dorsiflex to a neutral position, he notes there are some risks to serial stretching casting. He says pressure sores can occur even in a perfectly applied cast, particularly in children with spasticity. Children with osteopenia secondary either to their disease or to disuse may sustain fractures during serial casting, notes Dr. Harris.

Dr. Keen’s recommendations for physical therapy depend on several factors. If she encounters a contracture in equinus without apparent hypertonia, Dr. Keen says serial stretch casting, followed by a home program of stretching and night splinting as well as gait training, can be very effective. In addition, clinicians should consider casting, night splinting, an AFO for daytime use and gait training in physical therapy for these patients.

If there is some good underlying active movement in the anterior compartment muscles after casting, Dr. Keen says subsequent active strengthening of these muscles is an important part of physical therapy as well. If there is some active movement but the child has a hard time learning how to get these muscles activated and moving, she may suggest electrical stimulation as a method of helping the child learn how it feels to activate the muscle. If there is mild weakness, kinesiotaping can provide a gentle dorsiflexion assist, according to Dr. Keen.

A physical therapist’s assessment serves as another document of the ranges of motion, says Dr. Harris, and it frequently identifies subtle alterations in tone that the physician may not recognize. Once one has achieved an acceptable range of motion, the physical therapist can further assist by training and strengthening the muscles in the anterior compartment.

Q: Are there any steps one should take before prescribing ankle foot orthoses for equinus?
A:
Attempting to force a contracted equinus foot into a neutral AFO can lead to a midfoot “break,” cautions Dr. Bielski. However, he notes stretching casts will often help get the ankle to neutral prior to AFO fitting. Dr. Bielski has also used nighttime splints (similar to plantar fasciitis splinting programs) that allow patients to stretch the Achilles at night.

Reduce contractures before fitting the AFO, says Dr. Keen, who looks for a passive range of motion (ROM) of at least 10 to 15 degrees at the ankle with the knee extended before recommending AFOs.

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