May 2012

Is There An Increased Prevalence Of Equinus In Patients With Diabetes?

By Brian McCurdy, Senior Editor

A study recently published in the Journal of the American Podiatric Medical Association speculates that equinus may occur more frequently than previously reported in patients with diabetes.

   Researchers conducted a prospective pilot study of 102 outpatients, 43 of whom had diabetes. Patients underwent standard lower extremity exams and researchers used a biplane goniometer to measure their ankle joint range of motion. The study authors defined equinus as ankle dorsiflexion measured at 0 degrees or less.

   The study notes that among the overall study population, 24.5 percent of patients had equinus. Among those with diabetes, 37.2 percent had equinus while 15.3 percent of the non-diabetic patients had equinus, according to the study. Authors noted that patients with diabetes in the study had a threefold risk of equinus in comparison to those without diabetes and those with peripheral neuropathy had a 2.8 times greater risk of equinus. The authors noted that although they cannot prove causality, there was a significant association between equinus and ulceration as patients with diabetes had a fourfold risk of ulceration in comparison to those without the disease.

   When managing equinus in patients with diabetes, study author Robert Frykberg, DPM, suggests that some effective strategies would include screening, therapeutic footwear and stretching.

   Patrick DeHeer, DPM, notes that stretching has been effective for patients with equinus but patients typically do not do manual stretching correctly or for long enough. Therefore, he does not recommend it. Patients with diabetes will have a tendency to recontract and therefore require an ongoing maintenance therapy to keep them stretched, according to Dr. DeHeer, a Fellow of the American College of Foot and Ankle Surgeons, who is in private practice at Hoosier Foot and Ankle in Carmel, Ind.

   “We have cut down the amputation rates significantly with three major preventative care programs: routine diabetic foot care, diabetic foot exams periodically, and diabetic shoes and orthoses,” says Dr. DeHeer. “However, we are missing one final piece of the puzzle that is equally important and that is adequate stretching.”

   When equinus is present on examination and the patient has recalcitrant or recurrent ulcerations, Dr. Frykberg recommends considering either a gastrocnemius recession or a tendo-Achilles lengthening. However, he cautions against doing these procedures routinely if there are no associated clinical sequelae.

   Should this study make DPMs more vigilant about the effects of equinus in patients with diabetes? Dr. Frykberg says podiatric physicians should recognize the prevalence of equinus, which was higher than previously recognized, and the association of equinus with ulcerated patients. He adds that one should thoroughly assess equinus, especially in patients with neuropathy and a history of ulceration.

   “It does not mean that all patients should have routine lengthening procedures performed since this could lead to other serious consequences such as calcaneus deformities and heel ulcerations,” cautions Dr. Frykberg, who is the Chief of the Podiatry Section and Podiatric Residency Director at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix.

   “We all know equinus is a significant pathology producer of the foot and leg but often ignore treating that component of the pathology and focus only on the symptomatic area,” says Dr. DeHeer. “I am not sure why this is but my feeling is because there is not an adequate way of treatment.”

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