Cath Lab Digest

Although equinus has been recognized for centuries, are podiatrists failing to consider it as a possible contributing factor in heel pain cases? In a provocative article, these authors combine their insights with a review of the literature and speculate about the emerging role of endoscopic gastrocnemius recession in treating complex heel pain cases.

     Equinus is one of the earliest published topics when it comes to surgery of the lower extremity. However, there still remains considerable controversy within podiatric medicine and surgery in regard to the recognition and treatment of equinus.

     Equinus is the number one risk factor for the development of heel pain.¹ Plantar fasciosis is the foot pathology most commonly associated with gastrocnemius equinus. ²

     While a recent online Podiatry Today survey on equinus and heel pain was not a scientifically constructed questionnaire, it does provide some interesting information on how our profession is dealing with this condition. Out of the 267 respondents who completed the survey, nearly 22 percent said they diagnose equinus in less than 10 percent of heel pain cases. Yet over 84 percent of the respondents almost always recommend calf stretching exercises for patients with heel pain. More than half of the respondents never surgically treat equinus. Only 1.5 percent surgically treat equinus greater than 50 percent of the time.

     Although heel pain can be complex and difficult to treat, there is a tendency to assume that we know everything about heel pain. We also often hear the podiatric dogma that 90 percent of heel pain cases “resolve with the most minimal of treatment.” ³ This type of individual and profession-wide complacency may lead to less than desirable results in many cases for any foot condition, especially complex heel pain.

     In July 2007, Rocco and colleagues reported a 93.6 percent cure rate with gastrocnemius recession in patients with isolated chronic plantar fasciitis (fasciosis). ⁴ They reported no significant complications and even reported success in patients with BMIs of greater than 30. In the senior author’s opinion, this is a very significant and important advancement for treating plantar heel pain.

     In combination with the existing body of knowledge regarding the relationship between plantar heel pain and equinus, the work by Rocco and colleagues may have application to other foot pathology. With integration into advanced surgical training residency programs, we will likely see more emphasis placed on the diagnostic and therapeutic considerations of a tight gastrocnemius.

A Closer Look At The Connection Between Equinus And Heel Pain

There is still some debate as to how we define equinus and what is normal. Ten degrees of dorsiflexion and 20 degrees of plantarflexion of the ankle are considered the minimum amount necessary for normal range of motion during gait. ⁵ There is still skepticism on whether equinus contributes
biomechanically to any foot condition. However, Subotnick is credited with the statement that equinus “is the greatest symptom producer in the foot.” ^6,7

     Subotnick had the incredible understanding and courage to state in his 1971 article that one needs to treat the gastrocnemius contracture in patients with forefoot manifestations in addition to the surgical correction of the forefoot pathology. ⁷ In children with cerebral palsy, Holstein observed the development of hallux valgus in the foot with equinovalgus with no evidence of the deformity prior to walking. ⁸

     The three greatest risk factors for developing plantar fasciosis are: limitation of ankle joint dorsiflexion (equinus), obesity and the amount of time spent weightbearing. ¹ Equinus is the single biggest risk factor with a 23.3-fold odds ratio for the development of plantar fasciosis in comparison with the control group, which had at least 10 degrees of dorsiflexion. ¹