Evaluation and Treatment of Patients with Equinus Flashcards
Equinus
- a fixed plantarflexed position
- inadequate dorsiflexion available
what does the biomehcnaics community see equinus as
inadequate ankle joint dorsiflexion
to some specialities, equinus is seen as
a fixed plantarflexed position
for eqinus, when is foot function okay
-if the foot reaches a plantigrade position (gets the heel to the floor), foot function is fine
what is the biomechanics community concered about
how the heel is able to reach the floor (compensation)
what amount of dorsiflexion is required at the ankle
10’
if a minimum of 10’ of dorsiflexion is not available, compensation will be required in order for
the heel to remain on the ground in midstance (or in order for the tibia to move forward on the foot)
how is ankle joint dorsiflexion measured
- femoral condyles in frontal plane
- STJ in neutral position
- MTJ maxiamlly pronated
how is the goniometer placed when measuring ankle joint dorsiflexion
ALWAYS placed on the lateral side of the ankle
how do you determine the type of equinus
determine the difference in ROM of the ankle with the knee flexed vs. knee extended will help determine the type of equinus (Silverskiold test)
why would you measure ankle joint dorsiflexion actively
- prevent firing of the gastroc-soleus complex when it is stretched
- may be a problem bc many pts will automatically pronate the STJ
why should ankle joint dorsiflexion be measured passively
- maximum ankle joint dorsiflexion is required during gait at or slightly before heel lift
- extensors should not be firing at this point
how can ankle equinus be classified
- by type
- by etiology
what are the 4 general types of equinus
- gastrocnemius equinus
- soleal equinus
- ankle joint/bony equinus
- pseudoequinus = functional equinus
gastrocnemius equinus is a result of
tight gastrocnemius
what is ankle joint dorsiflexion with gastrocnemius equinus
ankle joint dorsi w/ knee flexed: >10
ankle joint dorsi/ knee extended: <10
how do you compensated for a gastrocnemius equinus
knee flexion
what is ankle joint dorsiflexion with a soleal equinus
ankle joint dorsi w/ knee flexed: <10
a soleal equinus may also have what other influence
gastroc influence
what is ankle joint dorsiflexion with a bony equinus
ankle joint dorsi w/ knee flexed: <10
how do you distinguish btwn a bony and soleal equinus
- Feel of end ROM
- Tightness of Achilles Tendon
- Radiographic findings
Bony vs. Soleal Equinus: Feel of end ROM
- spongy/soleal equinus if end ROM
- bony equinus if abrupt, solid end ROM
Bony vs. Soleal Equinus: Tightness of Achilles tendon
- soleal equinus if taut Achilles tendon
- bony if not taught
Bony vs. Soleal Equinus: Radiographic findings
forced dorsiflexion lateral view
what is pseudoequinus AKA
functional equinus
what is pseudoequinus
the actual ankle joint dorsiflexion may be adquate, but it is being “used up” for purposes other than allowing the tibia to move anteriorly over the foot
what type of foot is pseudoequinus found in
an anterior cavus, or anterior equinus foot type
pseudoequinus can be associated with neuromuscular etiologies such as
- no limitation with measurement but spasticity may cause the patient to function as if equinus were present
- weak extensor group may be overpowered by the posterior group (will eventually lead to posterior tightness)
- weak posterior group may eventually lead to increased calcaneal inclination ankle and pes cavus deformity
pseudoequinus in the anterior cavus foot type, the FF is —on the RF
plantarflexed
with pseudoequinus ankle joint dorsiflexion is required until
the heel is on the ground in stance phase
with pseudoequinus how much dorsiflexion is available for gait
none
what is a Silverskiold Test?
when you measure ankle joint dorsiflexion with the knee extended and with the knee flexed
what is the purpose of a Silverskiold Test
- used to determine the type of equinus
- can determine the type of posterior lengthening procedure to be done (gastroc, Recession vs. TAL)
methods of compensation for equinus
Subtalar joint pronation Abductory twist Genu recurvatum/knee hyperextension Early heel lift Knee flexion Shortened stride length Out-toed gait
- ***compensation may also occur as a combination of any or all of the above
- **signs and symptoms associated with equinus are dependent upon the method of compensation
STJ Compensation
- as the STJ pronates, the MTJ has more pronation available
- to compensate for equinus, STJ pronation allows for increased dorsiflexion at the OMJA
signs and symptoms of STJ pronation: Hypermobile 1st ray
- HPK sub hallux IPJ and/or sub 2nd metatarsal head
- hallux limitus
- hallux abductovalgus, etc
signs and symptoms of STJ pronation: excessive pronation
-plantar fasciitis
-posterior tibial tendon dysfunction
-hammer digit syndrome
-increased lordotic curve/low back pain
internal rotation of the tibia/patellar femoral syndrome
generalized leg fatigue, etc
how do you compensation by abductory twist
As the tibia moves over the foot in midstance, ankle joint dorsiflexion is required. If the ankle joint dorsiflexion is inadequate, the STJ will pronate
If the STJ pronation is inadequate or absent, the foot may abduct. This occurs by the heel moving inward on a fixed FF
signs and symptoms of an abductory twist
- diffuse hyperkeratoses at the plantar aspect of the MT heads 2-4
- hallux abductovalgus
- achilles tendonitis
why does genu recurvatum/knee hyperextension occur
-if the STJ and MTH are at their end ROM and the knee is still posterior to the ankle, body momentum may still carry the torso forward
signs and symptoms of compensation by genu recurvatum
- may be asymptomatic
- may have anterior or posterior knee pain
Why does early heel off compensation occur
As the tibia moves over the foot, a point is reached where all of the STJ and MTJ range of motion has been used
Tension is increased on the Achilles tendon or a bony block has ben reached, and the heel comes up
Signs and symptoms of an early heel lift
- increased FF symptoms (prolonged propulsive phase)
- Achilles tendon problems
by shortening the stride length, what happens to the amount of dorsiflexion
is reduced
what is a shorten stride length associated with
- tight hamstrings
- lower back problems
how does the knee compensated for a gastrocnemius equinus
knee flexes
what happens to ankle joint dorsiflexion as the knee flexes
dorsiflexion will be increased
signs and symptoms of knee flexion compensation
-promotes hamstring tightness leading to lower back pain
Etiologies of Gastrocnemius Equinus
- Congenital (congenitally short)
- Acquired (adaptation to gait changes, constant knee flexion, trauma)
- Neurological (spastic disorder, a form of pseduoequinus)
Etiologies of Soleal Equinus
- congenital
- acquired
- neurological (spasticity, a form of pseudoequinus)
Etiologies of Ankle Equnius
- primarily traumatic or arthritic
- anterior and/or posterior exostoses
Etiologies of Pseudoequinus
-primarily associated with pes cavus
Indications to Heel lifts
-bony/pseudoequinus
why are heel lifts not indicated for soft tissue equinus
the deformity is maintained rather than treated
How much of a heel lift is used to treat equnius
- Most commonly, begin with ¼ inch
- Must be used bilaterally unless also addressing a limb length discrepancy
- Must consider how much a shoe will be able to handle
- References vary as to 3/8, ½ or 5/8 inch but it is highly dependent upon the individual heel counter
what materials are used for heel lifts
-firm material (Korex, or a high durometer crepe)
Equinus Treatment: Stretching
- often an adjunct to other treatments
- limited to the soft tissue forms of equinus (gastrocnemius equinus or soleal equinus)
- “wall push-ups” are most common - important to avoid external rotation at the hip/abduction of the foot
how do you adjust functional orthoses to treat equnius
Allow for some pronation by:
- cast the foot slightly pronated
- increase the plaster arch fill on the positive
- do not fully post to the deformities
- use a less rigid shell material
Equinus Treatment: Shoe Modification
- heel lift incorporated into the sole of the shoe for severe equinus
- consider a FF rocker
Etiologies of Equinus in Diabetic Patients
Generalized loss of flexibility
Motor neuropathy
Post-operative
what is a quick way to test for generalized loss of flexibility
prayer sign
loss of flexibility at the ankle joint can lead to
equinus
loss of flexibility at the fist MTPH can lead to
hallux limitus which may lead to retrograde STJ pronation
other etiologies of equnius in diabetic patients
- motor neuropathy
- post operative
describe motor neuropathy
First the intrinsic foot muscles causing destabilization of the digits and resultant hammer digit syndrome
Next , the anterior muscle group is affected, causing decreased deceleration of forefoot loading in the contact phase of gait as well as no longer adequately opposing the plantarflexors
many FF amputation results in loss of what
Many of the forefoot amputations result in loss of function of the extensors and possibly the deep flexors resulting in the Achilles tendon being unopposed. As a result, these feet are likely to progress to significant equinus deformity
what is an example of a FF amputation
transmetatarsal amputation
what is the most significant complication of equinus in the diabetic pt, regardless of the etiology
change in plantar pressure
changes in plantar pressure can lead to
- ulcer formation
- increase in deforming forces
ulcer formation
may occur from direct increase in plantar pressure or as a result of compensation for the equinus causing an increase in plantar pressure
deforming forces in diabetics can cause
charcot deformities
treatment of equinus in diabetic patients
- address the etiology
- physical therapy (stretching and ROM exercises)
how do you treat complications of equinus in diabetic patients
- accommodate the eqinus deformity
- limit the deforming forces (AFO, physical therapy)
what are surgical considerations for treating equinus in diabetic patients
Tendo-Achilles lengthening may be indicated to allow more normal dorsiflexion and reduce the forefoot pressures.
