Evaluation and Treatment of Patients with Equinus Flashcards
1
Q
Equinus
A
- a fixed plantarflexed position
- inadequate dorsiflexion available
2
Q
what does the biomehcnaics community see equinus as
A
inadequate ankle joint dorsiflexion
3
Q
to some specialities, equinus is seen as
A
a fixed plantarflexed position
4
Q
for eqinus, when is foot function okay
A
-if the foot reaches a plantigrade position (gets the heel to the floor), foot function is fine
5
Q
what is the biomechanics community concered about
A
how the heel is able to reach the floor (compensation)
6
Q
what amount of dorsiflexion is required at the ankle
A
10’
7
Q
if a minimum of 10’ of dorsiflexion is not available, compensation will be required in order for
A
the heel to remain on the ground in midstance (or in order for the tibia to move forward on the foot)
8
Q
how is ankle joint dorsiflexion measured
A
- femoral condyles in frontal plane
- STJ in neutral position
- MTJ maxiamlly pronated
9
Q
how is the goniometer placed when measuring ankle joint dorsiflexion
A
ALWAYS placed on the lateral side of the ankle
10
Q
how do you determine the type of equinus
A
determine the difference in ROM of the ankle with the knee flexed vs. knee extended will help determine the type of equinus (Silverskiold test)
11
Q
why would you measure ankle joint dorsiflexion actively
A
- prevent firing of the gastroc-soleus complex when it is stretched
- may be a problem bc many pts will automatically pronate the STJ
12
Q
why should ankle joint dorsiflexion be measured passively
A
- maximum ankle joint dorsiflexion is required during gait at or slightly before heel lift
- extensors should not be firing at this point
13
Q
how can ankle equinus be classified
A
- by type
- by etiology
14
Q
what are the 4 general types of equinus
A
- gastrocnemius equinus
- soleal equinus
- ankle joint/bony equinus
- pseudoequinus = functional equinus
15
Q
gastrocnemius equinus is a result of
A
tight gastrocnemius
16
Q
what is ankle joint dorsiflexion with gastrocnemius equinus
A
ankle joint dorsi w/ knee flexed: >10
ankle joint dorsi/ knee extended: <10
17
Q
how do you compensated for a gastrocnemius equinus
A
knee flexion
18
Q
what is ankle joint dorsiflexion with a soleal equinus
A
ankle joint dorsi w/ knee flexed: <10
19
Q
a soleal equinus may also have what other influence
A
gastroc influence
20
Q
what is ankle joint dorsiflexion with a bony equinus
A
ankle joint dorsi w/ knee flexed: <10
21
Q
how do you distinguish btwn a bony and soleal equinus
A
- Feel of end ROM
- Tightness of Achilles Tendon
- Radiographic findings
22
Q
Bony vs. Soleal Equinus: Feel of end ROM
A
- spongy/soleal equinus if end ROM
- bony equinus if abrupt, solid end ROM
23
Q
Bony vs. Soleal Equinus: Tightness of Achilles tendon
A
- soleal equinus if taut Achilles tendon
- bony if not taught
24
Q
Bony vs. Soleal Equinus: Radiographic findings
A
forced dorsiflexion lateral view
25
what is pseudoequinus AKA
functional equinus
26
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
27
what type of foot is pseudoequinus found in
an anterior cavus, or anterior equinus foot type
28
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
29
pseudoequinus in the anterior cavus foot type, the FF is ---on the RF
plantarflexed
30
with pseudoequinus ankle joint dorsiflexion is required until
the heel is on the ground in stance phase
31
with pseudoequinus how much dorsiflexion is available for gait
none
32
what is a Silverskiold Test?
when you measure ankle joint dorsiflexion with the knee extended and with the knee flexed
33
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)
34
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
35
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
36
signs and symptoms of STJ pronation: Hypermobile 1st ray
- HPK sub hallux IPJ and/or sub 2nd metatarsal head
- hallux limitus
- hallux abductovalgus, etc
37
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
38
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
39
signs and symptoms of an abductory twist
- diffuse hyperkeratoses at the plantar aspect of the MT heads 2-4
- hallux abductovalgus
- achilles tendonitis
40
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
41
signs and symptoms of compensation by genu recurvatum
- may be asymptomatic
| - may have anterior or posterior knee pain
42
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
43
Signs and symptoms of an early heel lift
- increased FF symptoms (prolonged propulsive phase)
| - Achilles tendon problems
44
by shortening the stride length, what happens to the amount of dorsiflexion
is reduced
45
what is a shorten stride length associated with
- tight hamstrings
| - lower back problems
46
how does the knee compensated for a gastrocnemius equinus
knee flexes
47
what happens to ankle joint dorsiflexion as the knee flexes
dorsiflexion will be increased
48
signs and symptoms of knee flexion compensation
-promotes hamstring tightness leading to lower back pain
49
Etiologies of Gastrocnemius Equinus
1. Congenital (congenitally short)
2. Acquired (adaptation to gait changes, constant knee flexion, trauma)
3. Neurological (spastic disorder, a form of pseduoequinus)
50
Etiologies of Soleal Equinus
1. congenital
2. acquired
3. neurological (spasticity, a form of pseudoequinus)
51
Etiologies of Ankle Equnius
- primarily traumatic or arthritic
| - anterior and/or posterior exostoses
52
Etiologies of Pseudoequinus
-primarily associated with pes cavus
53
Indications to Heel lifts
-bony/pseudoequinus
54
why are heel lifts not indicated for soft tissue equinus
the deformity is maintained rather than treated
55
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
56
what materials are used for heel lifts
-firm material (Korex, or a high durometer crepe)
57
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
58
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
59
Equinus Treatment: Shoe Modification
- heel lift incorporated into the sole of the shoe for severe equinus
- consider a FF rocker
60
Etiologies of Equinus in Diabetic Patients
Generalized loss of flexibility
Motor neuropathy
Post-operative
61
what is a quick way to test for generalized loss of flexibility
prayer sign
62
loss of flexibility at the ankle joint can lead to
equinus
63
loss of flexibility at the fist MTPH can lead to
hallux limitus which may lead to retrograde STJ pronation
64
other etiologies of equnius in diabetic patients
- motor neuropathy
| - post operative
65
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
66
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
67
what is an example of a FF amputation
transmetatarsal amputation
68
what is the most significant complication of equinus in the diabetic pt, regardless of the etiology
change in plantar pressure
69
changes in plantar pressure can lead to
- ulcer formation
| - increase in deforming forces
70
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
71
deforming forces in diabetics can cause
charcot deformities
72
treatment of equinus in diabetic patients
- address the etiology
| - physical therapy (stretching and ROM exercises)
73
how do you treat complications of equinus in diabetic patients
- accommodate the eqinus deformity
| - limit the deforming forces (AFO, physical therapy)
74
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.
