Understanding And Managing Equinus Deformities

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Author(s): 
Stephen L. Barrett, DPM, MBA, FACFAS

What One Survey Revealed About Equinus Diagnosis And Treatment

For example, several years ago Podiatry Today ran a survey on the diagnosis and treatment of equinus (see http://tinyurl.com/43peeqc ). Two hundred sixty-nine people completed the survey. Only 5.58 percent (17 respondents) never made the diagnosis of equinus. Two hundred fifty-four (94.42 percent) of the 269 respondents diagnosed the condition monthly with 97 (36 percent) making the diagnosis more than 10 times per month, 59 (22 percent) six to 10 times per month, and 98 (36 percent) diagnosing the condition one to five times per month.

   However, when asked “How often do you surgically treat equinus?,” 147 respondents replied “never” (54.65 percent) while 113 responded “yes” in 25 percent or less of their cases.

   Clearly, there is still a huge conceptual abyss that exists today between the recognition of and the surgical treatment of equinus as evidenced by this small sample of foot surgeons. Ninety-seven percent make the diagnosis but only 54 percent surgically treat the condition, sometimes very infrequently. There are several reasons for this in light of the compelling widespread clinical evidence and the amount of literature, which strongly supports the biomechanical relationship between the lack of ankle joint dorsiflexion and the development of pedal pathology.

A Closer Look At The Prevalence And Impact Of Equinus

First, let us again take a look at the prospective study by DiGiovanni and colleagues to see how prevalent equinus is in patients with foot pathology.1 The authors assessed a control group of 34 patients who never had foot pathology and 34 patients who presented with “isolated” forefoot or midfoot pain. They screened 1,000 patients to get this 34 due to their exclusion criteria. The researchers excluded any patient with neuroma or neurological conditions, any hindfoot or ankle pathology or a myriad of other reasons.

   The authors found that if they used less than 10 degrees of dorsiflexion with the knee extended as normal, 88 percent of the patients with pathology had equinus in comparison to 44 percent in the control group.1 When using only 5 degrees or less as the “normal” dorsiflexion, 65 percent of the pathology group had equinus versus 24 percent of the control group.

   What would the numbers be if their selection criteria were not based on isolated foot pathology but included global pathology? It is very likely the percentage of patients with pathology and equinus would be higher than 88 percent.

   In support of this contention is a prospective study of 174 consecutive patients out of 209 who met the selection criteria.3 They were subdivided into the following groups: rearfoot pain, medial foot pain, lateral foot pain and mixed etiology pain. Of the 174 patients, 168 (97 percent) had less than 3 degrees of dorsiflexion.

   Perhaps the greatest reason that gastrocnemius equinus, or all equinus for that matter, is undertreated is simply because of our current paradigm of surgical training and understanding. In a 2008 Podiatry Today article I co-authored, I related an interview I had with Thomas Sgarlato, DPM.4 Dr. Sgarlato had shared the following:

    “… in 1963, Root was doing tendo-Achilles lengthenings and McGlamry was doing tongue in groove gastrocs while I discovered you could just release the medial gastroc. Podiatry was in the dark ages then and we did not have the tools to react to it (equinus) … The problem is training. If more podiatric surgeons were trained to do the technique, and especially with the endoscopic approach that we did not have, more people would be helped.” (See www.podiatrytoday.com/what-role-does-equinus-play-in-heel-pain )

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Neal M. Blitz, DPM, FACFASsays: May 14, 2011 at 7:41 pm

I am not sure that endoscopic gastroc recessions should be termed "gastroc recessions." They are really gastrosoleal recessions.

Anatomically, the gastroc muscles form an muscular-free aponeurosis that inserts onto the soleus aponeurosis and together form the Achilles. The muscular free portion of the gastroc is termed the "gastroc run-out." In some cases, there is no run-out and the gastroc muscle inserts directly on the soleus aponeurosis.

Nonetheless, if you transect deep to muscle, then both the gastroc and soleus aponeurosis have been transected.

The clinical effect is unclear, but the anatomy is the anatomy.

Neal M. Blitz, DPM, FACFAS
Chief of Foot Surgery & Associate Chairman of Orthopaedics
Bronx-Lebanon Hospital Center
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References:

Blitz NM, Eliot DJ. Anatomical Aspects of the Gastrocnemius Aponeurosis and its Muscular-Bound Portion. A Cadaveric Study. Part II. J Foot Ankle Surg 47(6):533-40, 2008

Blitz NM, Rush SM. The Gastrocnemius Intramuscular Aponeurotic Recession. A Simplified Method of Gastrocnemius Recession. J Foot Ankle Surg 46(2):133-8, 2007

Blitz NM, Eliot DJ. Anatomical Aspects of the Gastrocnemius Aponeurosis and its Insertion. A Cadaveric Study. J Foot Ankle Surg 46(2):101-8, 2007

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