Understanding And Managing Equinus Deformities

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

   Equinus can be difficult to measure or assess clinically from practitioner to practitioner. As DiGiovanni points out, clinicians are accurate 97.2 percent of the time if equinus contracture is defined as less than 10 degrees of dorsiflexion.13 Accuracy falls to 77.8 percent if 5 degrees is the benchmark. From a pragmatic point, in addition to the vast amount of literature, which supports the need for 10 degrees of dorsiflexion at the level of the ankle joint for normal biomechanical function, clinicians would obviously be more accurate in assessing whether the patient has less than 10 degrees of dorsiflexion with the knee extended.

   Clinically, individual practitioners easily and accurately make the diagnosis but the assessment of the true number of degrees may vary widely with different practitioners. The description of the Silfverskiold maneuver has been well delineated for practitioners to determine what type of equinus is present. It is important to note that when there is no dorsiflexion available with the knee flexed and one has identified a bony block, there is almost always the need for posterior soft tissue release after surgical elimination of the bony impingement as the triceps surae are contracted.

   When it comes to surgical reconstruction for conditions such as hallux valgus, hammer digit syndrome, metatarsalgia, capsulitis, flatfoot, posterior tibial tendon insufficiency syndrome, Morton’s entrapment, hallux limitus/rigidus, plantar fasciosis, Charcot arthropathy, Achilles tendinosis/posterior or calcaneal exostosis, one should seriously contemplate a simultaneous gastrocnemius recession or even performing this prior to the planned surgical reconstruction.

   When it comes to complex forefoot deformity, it has been my experience that carefully planned serial surgery and performing the gastrocnemius recession as the primary procedure decreases the actual amount of surgical procedures and often completely eliminates the need for a second surgery. I recommend reassessment of the forefoot condition three to six months after superficial posterior compartment release. In many cases, the forefoot symptoms have resolved to the point where additional surgical procedures are simply not required or, if there is still pathology, there is a much lesser degree requiring less tissue disruption.

   This is well illustrated in the patient who has complaints of slightly contracted lesser digits, neuritic symptoms such as Morton’s entrapment in one or both interspaces, and a diffuse hyperkeratosis of the plantar forefoot.14 It is conservative, far simpler and less involved for the patient to undergo a minimally invasive endoscopic gastrocnemius recession. This allows full, immediate weightbearing in a boot in comparison to panmetatarsal osteotomies, multiple level procedures for lesser digital contracture and resection of a common plantar digital nerve or two.

   There is no comparison of the postoperative morbidity associated with each of these two different approaches. It is incredible how often the forefoot maladies just disappear a few months after a gastrocnemius recession. Often, the planned serial or staged surgical approach is simply not needed with reestablishment of normal forefoot and rearfoot biomechanical function. When one explains this concept to patients, they usually accept it readily.

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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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