Managing Equinus In Patients With Diabetes

Author(s): 
Patrick DeHeer, DPM, FACFAS, and Brandon Borer, DPM

   We as podiatrists measure everything from X-ray angles to forefoot varus position. Yet we slap on a night splint and tell our patients to pull as tight as they can. This makes no sense to us. We should have more control and precision over the treatment of this condition.

   The lead author has made this brace ambulatory with a negative heel rocker sole, which allows ambulation with a fixed dorsiflexed position. The rocker soles are going to be removable and come in different soles to match the amount of ankle joint dorsiflexion (i.e. 5, 10 and 15 degrees). There is an adjustable wedge that goes under the hallux to engage the windlass mechanism. These wedges come in various degrees (i.e. 35, 50 and 65 degrees) and Velcro to the foot bed. The lead author has made varying degrees of wedges to allow for those with hallux limitus or rigidus. The femoral and tibial uprights are adjustable for leg and thigh length, and the physician should set the uprights. Finally, the standard foot beds will fit a small/medium size foot, but one can replace the foot bed with an extended version that will fit a large/extra-large size.

   Most manual stretching is recommended to last about 30 minutes per day.11 However, the lead author believes an hour a day is reasonable from an adherence standpoint in comparison to six to eight hours at night while disturbing the patient’s sleep. The ambulatory component of the brace is also important. The lead author foresees patients getting dressed in the morning and then putting on the brace and stretching while performing their morning rituals. A similar scenario would play itself out for the evening stretching.

   A final consideration is that this is not a brace patients will be able to buy at a drug store or on the Internet. The lead author has had patients complain about the expense of a night splint when they can find the same thing for about 20 percent of the price of the brace. This is a technical device that a physician must set, monitor and adjust. This brace will have a significant positive impact on the practice management component of your practice. Most importantly, it will provide you with a better way to treat the equinus deformity, the most significant producer of foot and ankle pathologies.

What You Should Know About Tendo-Achilles Lengthening And Gastrocnemius Recession

The surgical approach to equinus is well documented in the literature and mainly focuses on two different procedures, the tendo-Achilles lengthening (TAL) or gastrocnemius recession.

   The TAL approach most surgeons commonly utilize is the Hoke triple hemisection. This procedure employs three stab incisions starting 1 cm proximal to the insertion of the gastroc-soleus complex with two medial incisions and one lateral incision between the two medial incisions. One would section the tendon through the central portion and incise in the respective direction of the stab incisions. The tendon then slides to a lengthened position. This procedure is not without potential complications such as under-lengthening or, much worse, over-lengthening.

   The gastrocnemius recession is one of my favorite procedures and is well documented in the literature.15 I prefer the Baumann intramuscular approach to lengthening of the gastrocnemius aponeurosis. This provides controlled, sequential lengthening. Place the incision at the medial aspect of the calf midway between the posterior calf and anterior border of the tibia. The incision is typically 3 to 4 cm long and one deepens this to the level of the deep fascia. Incise the fascia revealing the gastrocnemius and soleus muscle bellies. Use a finger to identify the natural separation between the aponeurosis of the two muscles and insert a speculum to spread them apart.

   With the patient’s foot dorsiflexed and the knee extended, use a long-handled #15 blade to cut the proximal portion of the gastrocnemius aponeurosis including the intramuscular septum. This is a complete release from lateral to medial. If one notes inadequate dorsiflexion, I recommend a second more distal release (1 cm distal to the initial release) over a soleus recession based on the study by Herzenberg and Lamm.15

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