Managing Equinus In Patients With Diabetes

Patrick DeHeer, DPM, FACFAS, and Brandon Borer, DPM

   In this study, the authors found a 10.3 percent rate of equinus in patients with diabetes. We think this is easily low because of the study authors’ definition of equinus. Remember, there is no standard definition of equinus. Patients with equinus also had a significantly longer duration of diabetes than those without equinus.

Assessing The Use Of Stretching And Night Splints

Clinicians can address equinus via either conservative care or surgical care. As with most pathological conditions, one should attempt conservative care initially. The two main forms of conservative care are manual stretching and bracing.

   In a meta-analysis, Radford and co-workers showed that calf muscle stretching provided a small but statistically significant increase in ankle joint dorsiflexion.11 Their analysis showed that 15 to 30 minutes per day provided the greatest amount of ankle joint dorsiflexion (3.03 degrees) for each of the three groups. In their study, Grady and Saxena had patients stretch once per day for 30 seconds, two minutes or five minutes with the knee extended over a six-month period of time.4 The increase in ankle joint dorsiflexion for each group was 2.15, 2.3 and 2.7 degrees respectively. These totals were not statistically significant but when one takes into account the minimal amount of daily stretching, the results are actually encouraging.

   In discussing the problems with manual stretching, Hill stated: “Active stretching requires detail in teaching the proper technique, and must be done at least four times a day at 5-minute to 8-minute sessions. The most serious mistakes patients make during their previous attempts at stretching are inadequate stretch time and abducted foot position during the stretch. It is critical that the foot be adducted 10 degrees during the stretching to lock the subtalar-midtarsal joints for maximum benefit at the calf.”13

   Night splints have long been the only mode of bracing for equinus treatment but there are several flaws with them. First, they are designed for patients to use at night while sleeping and the most common sleeping position with these braces is on the side with knees bent.

   This means that the gastrocnemius muscle is not stretching. Remember that as the gastrocnemius muscle crosses the knee and ankle both, it is most often the contracted structure. The adherence with night splints is also very poor based on my personal experience. These two factors lead to the mediocre results attributed to night splints as described in the Evans study, which showed only six of 20 patients achieving 10 degrees of dorsiflexion with the use of night splints.14

Can The EQ/IQ Brace Be A Viable Alternative To Night Splints?

The answer the lead author has developed to address ineffectual manual stretching and the failures of night splints is the EQ/IQ brace (IQ Med). Patients do not need to sleep in this brace. The lead author recommends using it 30 minutes in the morning and 30 minutes in the evening (15 minutes stretching the gastroc-soleus complex and 15 minutes stretching the soleus).

   The EQ/IQ brace has an above-the-knee extension with a hinge at the knee. The extension allows the knee to lock into extension to stretch the gastrocnemius muscle. The hinge can release to allow for ease of application and isolated stretching of the soleus. There is also a hinge at the ankle joint that allows the treating physicians to set exactly the amount of dorsiflexion they desire based on the patient’s biomechanical exam. (The lead author suggests maybe 5 degrees the first month and then going up to 10 degrees the second month and, if needed, 15 degrees the third month.) The hinge goes from -30 degrees to +30 degrees, in 5-degree increments.

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