equinus management for improved patient outcomes

Equinus Non Surgical Management Module #3

Equinus Management for Improved Patient OutcomesByPatrick A. DeHeer, DPMFASPS, FACFAS

Disclosures

I am a principal of IQ Med

I am the inventor of The Equinus Brace

James Amis, MD Frontiers in Surgery 2016The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle"We are awakening to a new era of understanding the mechanics and function of the human foot and ankle. There is a simple, singular, usually silent, and remote cause for the majority of non-traumatic acquired foot and ankle pathology, and mechanically, it creates cumulative damage to the foot and ankle through leveraged forces. In short and in this authors opinion, equinus is the primary mechanical common denominator that leads to the majority of acquired non-traumatic foot and ankle problems by indirect leveraged means as well as direct forces along the posterior/plantar chain. There can be no more room for the standard thinking that these resultant foot and ankle problems arise just because we are getting older or we are obese or they are just random, or that an equinus contracture is only a part of the equation. Equinus is the equation."

Proper Evaluation of Equinus

Barouk & Barouk Foot Ankle Clin N Am 2014The Gastrocnemius: Clinical Diagnosis of Gastrocnemius Tightness



Morales-Munoz et al. FAI 2016Gastrocnemius Proximal Release in the Treatment of Mechanical Metatarsalgia: A Prospective Study of 78 Cases

Definition of Equinus

DiGiovanni et al JBJS 2002Patient GroupControl Group# Patients3434Males1816Females1618Average Age and Range47 (21 to 76)45(28 to 63)Average Weight and Range183 lbs.(104 to 345)171 lbs.(120 to 260)

Primary Diagnosis in Patient GroupNumber of PatientsMetatarsalgia7Mortons Foot13Idiopathic Lis Franc Arthrosis1Posterior Tibial Tendon Insufficiency 9Plantar Fasciitis3Stress Fracture 5th Metatarsa1

Purpose frequency of Equinus in symptomatic patient group and control group, and determine the reliability of clinical evaluation of Equinus

Examines two possible definitions of Equinus and confirmation of clinical diagnosis with Equinometer

DiGiovanni et al JBJS 2002It demonstrated that (1) patients with metatarsalgia or related forefoot and/or midfoot symptoms had less average maximal ankle dorsiflexion with the knee in extension than did a control population without foot symptoms, and (2) when the knee was flexed to 90 to relax the gastrocnemius, this difference was no longer present.

DiGiovanni et al JBJS 2002We have selected < 5 of maximal ankle dorsiflexion with the knee in full extension as our definition because it allowed us to diagnose the problem in those who were at risk (symptomatic patients) with fairly good reproducibility (76%) and, more importantly, we were able to reliably avoid (in 94% of the cases) unnecessary treatment of those who were not at risk (asymptomatic people).

How Frequent is Equinus?

Hill JAPMA 1995209 NP over 6 weeks26 deleted primary complaint did not fit into study guidelines (Nail, VP, etc.)6 of remaining 174 had normal AJ DF168 Equinus 3 Gastroc/165 GS9 to 85 y/o Mean = 48.2 y/oEquinus = < 3 AJ DF with KEFindings 96.5% of patients with foot or ankle pathology exhibited Equinus

Hill JAPMA 1995

Rearfoot Pain = 73Medial Foot Pain = 55Lateral Foot Pain = 21Mixed Group Pain = 19Heel Pain +/- Spur = 632nd Metatarsal Pain/Lesion = 20HM/HD of 4th/5th Digits = 8Complaints in 2 or 3 of GroupsAchilles Tendonitis = 3PTT or ATT = 15Peroneal Tendonitis = 7Heel or Calf Pain = 9Calf Muscle Pain = 3 HAV = 7Mortons Neuroma = 5Metatarsalgia = 5Retrocalcaneal Exostosis = 1Hallux Limitus = 3 Lateral Ankle Joint Capsulitis = 1PF + ATT = 1Sesamoiditis = 4Calcaneal Apophysitis = 1Collapsing Medial Arch = 3PF + ATT + Calf Strain = 11st MCJ Capsulitis/ Medial AJ Capsulitis/3rd Metatarsal Lesion = 1

Hill JAPMA 1995The podiatric physician should look beyond the specific complaint to diagnose the underlying cause. Frequently, ankle Equinus deformity will be at the root of the patients foot problem.Gastrocsoleus stretching was found to be an effective modality in treating a wide range of podiatric complaints where ankle Equinus is an underlying etiologic factor.

Hill JAPMA 1995Treating apparent biomechanical problems that have an underlying equinus deformity with rigid functional orthoses is a major reason for unsuccessful orthotic treatment.Equinus patients who receive orthoses as their sole treatment may not be capable of accepting orthotic control.A rigid orthotic will prevent the foot from pronating. The result is arch irritation from excess friction against orthoses.

The Equinus Dilemma You are not paying enough attention to it!!! Root et al The worst foot in the world is the one with the fully compensated equinus deformity.Johnson and Christensen Equinus deformity is the most profound causal agent in foot pathomechanics and is frequently linked to common foot pathology.Hill Equinus deformity is extremely prevalent, and it appears to be a primary causal agent in a significant proportion of foot pathology.

Pierre Barouk, MD - Foot Ankle Clin N Am 2014The Gastrocnemius: Introduction Looking for a retraction of the gastrocnemius should be an essential part of the foot and ankle examination for practitioners, not just surgeons. Even though the equinus has been recognized for 50 years as having an influence on the foot, only a few practitioners routinely search for it. The proportion of gastrocnemius tightness is high in the normal population, but it is significantly higher in populations that have foot and ankle problems. Why do we have short gastrocs? The evolution of the human race, especially walking at a certain pace and extending the knee, is probably one of the explanations. In addition to this, there is also the problem of sitting for long periods of time and the frequent use of high-heeled shoes. With this issue of Foot and Ankle Clinics of North America, you will gain a better understanding of how to recognize gastrocnemius tightness (the clinical Silfverskiold test is essential), how to treat it, and understand why it has an influence on many of the current pathologies that we see every day. Attaching some symptoms (calf cramps, lower limb instability, difficulty in walking without a heel, lumbar pain) to gastrocnemius tightness is essential to treating patients in a global manner. I hope you will be convinced of the importance of this, and no longer do without!

John Joseph Nutt, MDDiseases and Deformities of the Foot 1913

James Amis, MD - Foot Ankle Clin N Am 2014The Gastrocnemius: A New Paradigm for the Human Foot and Ankle Nutt stated, The chief characteristic of this condition is a shortening of the gastrocnemius and the soleus. This shortening is not enough to produce the deformity of equinous but limits dorsal flexion. What he essentially described in 1913 is the isolated gastrocnemius contracture. The biggest takeaway from Nutts work is the understanding of the ubiquitous source of calf contractures in otherwise normal humans, and he alludes to the mechanism of injury placed on the foot as a result.

James Amis, MD - Foot Ankle Clin N Am 2014The Gastrocnemius: A New Paradigm for the Human Foot and Ankle Origins of Calf Contracture Activity ChangesGeneral decreased activity as people ageMTU fail to reach maximal length regularlyLaw of Davis over time soft tissue contracts to the shortest length possibleSlow process for IGCRecent Changes in Activity bed rest, recovery from injury or surgeryAbrupt reduction in otherwise normal activityRelaxation of GSC leading to contracture (Law of Davis)Return to activity creates problems Quick process for IGCAthletes and Increased Activity Situations More at risk for contractureWhile running the gastrocnemius and hamstrings are not fully extended while the ankle is DFGradually muscles adapt to this shortened position (Law of Davis)Slow process for IGC

James Amis, MD - Foot Ankle Clin N Am 2014The Gastrocnemius: A New Paradigm for the Human Foot and Ankle Origins of Calf Contracture Physiologic Changes of Muscle and Tendons Collagen (cross-linking) and connective tissue (less compliant and reduction in elastin) changes with agingMTU becomes locked into a shortened position (Law of Davis)Origins of Calf Contracture Genetics Subtle role in progressive contracture of connective tissueSome are more prone to muscle tightness than othersOrigin of Calf Contracture Bone/Muscle Growth MismatchBone grows faster than muscle during growth spurts Severs disease Tibia/Fiblua outpace GSC during growth resulting in Gastroc Equinus

James Amis, MD - Foot Ankle Clin N Am 2014The Gastrocnemius: A New Paradigm for the Human Foot and Ankle Origins of Calf Contracture Reverse EvolutionEvolved from quadrupeds to bipeds 2.2 to 3 million years ago bipedal gait was only used part-time prior to thatMorton JBJS 1924Schmidt J Exp Bio 2003Some leg muscles had to lengthen and others had to shorten, and the ankle had to DF 70 to get the heel on the ground and the foot plantigradeLengthen hip flexors, hamstrings, GSCShorten quadriceps, tibialis anteriorLater in evolutionary process hip flexors/hamstrings/GSC are the first to shorten (tighten) with aging Predilection pattern

James Amis, MD Frontiers in Surgery 2016The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle

James Amis, MD - Foot Ankle Clin N Am 2014The Gastrocnemius: A New Paradigm for the Human Foot and Ankle It has been postulated that epidemiologic factors, such as obesity, sedentary life style, medical comorbities, shoe wear, concrete floors, advanced age, female gender, and overuse issues, to name a few, are responsible for a variety of foot and ankle pathology. Although these factors might consistently coexist with a variety of foot and ankle problems and seem to have a causal relationship, it is my assertion that they have little if any direct relationship.The singular and real association of each of these epidemiologic factors is a contracture of the gastrocnemius muscle, which is camouflaged in this list. Most every other cause of these foot and ankle problems is likely mediated by contributing to the degree and/or rate of an already contracting gastrocnemius. These problems promote gastrocnemius tightness, which in time causes incremental damage to the foot and/or ankle.

Conditions Associated with Equinus Documented in the LiteratureHeel Spur Syndrome/Plantar FasciitisAchilles TendinopathyPosterior Tibial Tendon DysfunctionDiabetic Foot UlcersCharcot Neuropathy MetatarsalgiaMortons NeuromaLesser MPJ pathologies PDS, CapsulitisHallux ValgusHammer Digit SyndromeAnkle Fracture/SprainsSevers DiseasePediatric Flatfoot DeformityPoor Balance/Fall Risk Elderly Low Back PainAnkle Arthritis STJ Arthritis

1st Ray HypermobilityAdult Pes Plano ValgusHallux LimitusSesamoiditisLateral Column Syndrome/Foot PainFreibergs Infarction Forefoot CallusIliotibial Band SyndromeMedial Tibial Stress Syndrome/Shin SplintsPatellofemoral SyndromeChronic Ankle InstabilityTibial Stress FracturesOsteoarthritis Forefoot/MidfootMuscle StrainsGenu Recurvatum Arch PainAnterior Compartment SyndromeForefoot Nerve Entrapment

Medial Longitudinal ArchWhat structures stabilize it and what deform it?

Thordarson et al Clin Ortho 1995Study to evaluate the dynamic support of the human longitudinal arch by the leg muscles active in the stance phase of gait and by the plantar aponeurosis. Applied plantar loads of 350 N and 700 N; and with the ankle 10 plantarflexed with a load of 350 NMeasured angular displacement in sagittal plane (talus to 1st MT) and transverse plane (navicular to talus)

Thordarson et al Clin Ortho 1995Angular displacement in degrees recorded in sagittal plane between the first metatarsal and talus with positive values representing arch augmentation and negative values representing arch deformation.

Thordarson et al Clin Ortho 1995Angular displacement in degrees recorded in transverse plane between the navicula and talus with positive values representing adduction and negative values representing abduction.

Thordarson et al Clin Ortho 1995Study found that the plantar aponeurosis via dorsiflexion of the toes had the most significant arch-supporting function in the sagittal planeHuang et al Foot Ankle 1993 plantar fascia has a dynamic arch supporting functionDeland et al Foot Ankle 1992 had to divide the plantar fascia and calcaneonavicular ligament to create a flatfootMann Foot Ankle 1993 plantar aponeurosis is the most significant stabilizer of the arch The plantar fascia clearly has an important dynamic function..dividing this structure should be tempered by this data.

Thordarson et al Clin Ortho 1995The posterior tibial tendon was found to have consistent arch-supporting function at both load levels (350 N and 700 N) in the sagittal plane. It was also noted to adduct the forefoot in the transverse plane.Simultaneously tensioning the posterior tibialis, flexor digitorum longus, flexor hallucis longus, and peroneus longus was noted to have statistically significant, additive arch supporting function when compared to the posterior tibialis alone, suggesting that they all may have a small arch supporting function.

Thordarson et al Clin Ortho 1995The triceps surae was noted to have a significant arch-flattening with a 3.3 change in the sagittal plane at 350 N and an additional 3.7 flattening at 700 N.The achilles tendon tension was also noted to result in statistically significant abduction in the transverse plane at both these load levels.

Equinus Effect on Medial Column1st Metatarsal, 1st Cuneiform, Navicular, Talus

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Johnson & Christensen JFAS 1999Part I Role of PL

Johnson & Christensen JFAS 1999Part I Role of PL

Under the influence of PL the medial column functions as a series of linksPL is essentially creating an eversion "locking 1st ray Stabilization of the medial column Reciprocal supination of the rearfoot - midstance when PL is activeGray & Basmajian Anat Rec 1968 PL & plantar fasccia via windlass work together to prepare the foot for propulsionDeficit in either one results in a pathological situation

Johnson & Christensen JAFAS 2005Part V The Effect of Equinus Deformity

Johnson & Christensen JAFAS 2005Part V The Effect of Equinus DeformityIn clinical practice, the early destructive influence of equinus is often not appreciated. Instead, we are usually faced with the end result of equinus effectsThe authors strongly recommend careful clinical assessment and appropriate treatment of equinus in patients with biomechanical deformities affecting the first ray and midfoot.

Tricpes Surae Function During Gait


Basics of Human GaitStance PhaseInitial ContactLoading ResponseMidstanceHeel Rocker (R1)Ankle Rocker (R2) Tibia rotates forward to carry the passenger (body) forward over the ankle jointSmooth near end point declerationForefoot Rocker (R3)Terminal StancePre-SwingSwing Phase

James Amis, MD Frontiers in Surgery 2016The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and AnkleDirect ForcesGastrocnemius muscleGSC musculotendinous junctionAchilles tendonAchilles tendon insertion CalcaneusPlantar fasciaIndirect ForcesTightness of GSC 2nd Rocker limited Passenger (body) progress over planted foot Increased leveraged forces upon foot & ankleTighter the GSC Higher & earlier leveraged forces (bending force) on tension & compression sides of the foot & ankle increased stress & strain on the joints/ligaments/tendons pathology


Split Second Effect Ankle Joint Dorsiflexion Starts the last of midstance when swing phase foot starts to pass the stance foot Ends as stance heel lifts just prior to 3rd Rocker beginning Lasts approximately 120ms (1/10th second)Leveraged & direct forces act upon foot & ankle or start up gait (limping) developsStart up limp gait Rest & lack of calf tension Worsen calf tightness (Law of Davis)1000s steps/per over period of years occult, unrecognized, overuse of imbalance damage to foot & ankle


Split Second Effect Knee ExtensionIpsilateral knee extends fully as ankle ceased rotating due to GSC tightnessPulls the GSC even tighter at exactly the wrong time Increased direct & leveraged forces on foot & ankle 2 x force in the time


James Amis, MD Frontiers in Surgery 2016The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and AnkleIt appears that merely being human places us at risk of developing acquired non-traumatic foot and ankle problems. This damage is mediated through our unique anatomy and the gastrocnemius that tightens for a number of reasons (5).

Equinus Non Surgical ManagementWhat happens when a muscle is stretched over a period of time?How should stretching be done?How long each day should stretching be done?Is manual stretching effective?Are night splints the answer?Should you stretch both legs at the same time?Is there a need for maintenance therapy once the deformity has been corrected?

What happens when muscle is stretched over a period of time?

Konrad & Tilp Clinical Biomechanics 2014Study - analyze the effects of a short-term static stretching program on the functional and structural parameters of the plantar flexor muscletendon unit Stretching program Runners wall stretch4 30 s of static stretch per leg6 weeks

Konrad & Tilp Clinical Biomechanics 2014

Konrad & Tilp Clinical Biomechanics 2014

This study has shown that a six-week static stretching program of the calf muscles increases dorsiflexion RoM but has no effect on muscle and tendon tissue. Therefore, altered tolerance to stretching, possibly due to adaptations of nociceptive nerve endings, seems to be the main explanation for gains in RoM.

How Long Should Stretching Be Done Daily?

Stretching time per leg per dayReference(s)30 seconds1, 2, 31 minute2, 31 minute 20 seconds42 minutes1, 3, 5, 6, 7, 2 minutes 30 seconds9, 103 minutes11, 12, 134 minutes12, 145 minutes1, 158 minutes1610 minutes17, 1830 minutes19All night via night splint12, 20, 21, 22, 23, 24

ReferencesGrady, J. F., and A. Saxena. "Effects of stretching the gastrocnemius muscle." The Journal of foot surgery 30.5 (1990): 465-469.Youdas, James W., et al. "The effect of static stretching of the calf muscle-tendon unit on active ankle dorsiflexion range of motion." Journal of Orthopaedic & Sports Physical Therapy 33.7 (2003): 408-417.Zito, Michael, et al. "Lasting effects of one bout of two 15-second passive stretches on ankle dorsiflexion range of motion." Journal of Orthopaedic & Sports Physical Therapy 26.4 (1997): 214-221.Knight, Claudia A., et al. "Effect of superficial heat, deep heat, and active exercise warm-up on the extensibility of the plantar flexors." Physical Therapy 81.6 (2001): 1206-1214.Konrad, Andreas, and Markus Tilp. "Increased range of motion after static stretching is not due to changes in muscle and tendon structures." Clinical Biomechanics 29.6 (2014): 636-642.Ryan, Eric D., et al. "The time course of musculotendinous stiffness responses following different durations of passive stretching." journal of orthopaedic & sports physical therapy 38.10 (2008): 632-639.Nakamura, Masatoshi, et al. "Effects of a 4-week static stretch training program on passive stiffness of human gastrocnemius muscle-tendon unit in vivo." European journal of applied physiology 112.7 (2012): 2749-2755.Chadchavalpanichaya, Navaporn, Gulapar Srisawasdi, and Atchara Suwannakin. "The effect of calf stretching box on stretching calf muscle compliance: a prospective, randomized single-blinded controlled trial." Journal of the Medical Association of Thailand= Chotmaihet thangphaet 93.12 (2010): 1470-1479.Johanson, Marie A., et al. "The Effect of Subtalar Joint Position on Dorsiflexion of the Ankle/Rearfoot Versus Midfoot/Forefoot During Gastrocnemius Stretching." Foot & Ankle International 35.1 (2014): 63-70.Gajdosik RL, Vander Linden DW, Williams AK. Influence of age on length and passive elastic stiffness characteris- tics of the calf muscle-tendon unit of women. Phys Ther. 1999;79:827-838.Pratt, Kimberly, and Richard Bohannon. "Effects of a 3-minute standing stretch on ankle-dorsiflexion range of motion." trial 2 (2003): 0-85.Barry, Lance D., Anna N. Barry, and Yinpu Chen. "A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis." The Journal of foot and ankle surgery 41.4 (2002): 221-227.Kay, Anthony D., and Anthony J. Blazevich. "Moderate-duration static stretch reduces active and passive plantar flexor moment but not Achilles tendon stiffness or active muscle length." Journal of Applied Physiology 106.4 (2009): 1249-1256.Johnson, Eric G., et al. "Effect of a Static Calf MuscleTendon Unit Stretching Program on Ankle Dorsiflexion Range of Motion of Older Women." Journal of geriatric physical therapy 30.2 (2007): 49-52.Bohannon, R. W., D. Tiberio, and M. Zito. "Effect of five minute stretch on ankle dorsiflexion range of motion." J Phys Ther Sci 6 (1994): 1-8.Macklin, K., Aoife Healy, and Nachiappan Chockalingam. "The effect of calf muscle stretching exercises on ankle joint dorsiflexion and dynamic foot pressures, force and related temporal parameters." The Foot 22.1 (2012): 10-17.Guissard, Nathalie, and Jacques Duchateau. "Effect of static stretch training on neural and mechanical properties of the human plantarflexor muscles." Muscle & nerve 29.2 (2004): 248-255.Peres, Steven E., et al. "Pulsed shortwave diathermy and prolonged long-duration stretching increase dorsiflexion range of motion more than identical stretching without diathermy." Journal of athletic training 37.1 (2002): 43.Cheng, Hsin-Yi Kathy, Yan-Ying Ju, and Chun-Li Lin. "Design and validation of a dynamic stretch splint for plantar fasciitis." Medical engineering & physics 34.7 (2012): 920-928.Batt, Mark E., Jeffrey L. Tanji, and Nina Skattum. "Plantar fasciitis: a prospective randomized clinical trial of the tension night splint." Clinical Journal of Sport Medicine 6.3 (1996): 158-162.Porter, David, et al. "The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study." Foot & ankle international 23.7 (2002): 619-624.Evans, Angela. "Podiatric medical applications of posterior night stretch splinting." Journal of the American Podiatric Medical Association 91.7 (2001): 356-360.Roos, Ewa, Mikael Engstrm, and Bengt Sderberg. "Foot orthoses for the treatment of plantar fasciitis." Foot & ankle international 27.8 (2006): 606-611.Berlet, Gregory C., et al. "A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint." Orthopedics 25.11 (2002): 1273-1275.

Radford et al BJ Sports Med 2006Systematic review of the literature to determine whether static calf muscle stretching increases ankle dorsiflexion18 papers identified - 5 trials met inclusion criteria for review with 161 participants Ankle dorsiflexion was measured both actively and passively, weight-bearing and non- weight-bearing, and with the knee extended and flexedDuration between stretching and measurement was immediate in all trials, except for that of Youdas et al where participants were measured 6072 hours after stretchingFour of the trials ensured 100% compliance by supervising the stretches Youdas et al used log books instead showing 95% complianceAll results presented in this review are the effect of stretching alone compared with no stretching

Radford et al BJ Sports Med 2006

Radford et al BJ Sports Med 2006There was a general trend that the longer the stretch, the greater the increase in ankle dorsiflexion The only result that was not supported by the sensitivity analyses was the one for > 30 minutes of stretching. As only one trial was included in the sensitivity analysis of this intervention, it may be that the sensitivity analysis sample was underpowered (n = 45) to detect the effect that the primary analysis detected with greater sample power (n = 64).

Radford et al BJ Sports Med 2006CONCLUSION: Calf muscle stretches provide a small but statistically significant increase in ankle dorsiflexion, particularly after 530 minutes of stretching. However, it is unclear whether the change that occurs with stretching is clinically important. Therefore calf muscle stretching is recommended where a small increase in ankle range of motion is thought to be beneficial.

Does STJ Position Matter?

Johanson et al FAI 2013Materials & Methods27 participants 3 M : 23 FMean age = 31.3 years, SD = 10.7Five 30-second gastrocnemius stretching trials with STJ in pronation and supination Current or recent history of lower extremity chronic conditions associated with limited ankle dorsiflexion (30 minutes/day)Lack of follow though minimum of 6 weeksImproper stretching technique heel off ground, knee bent or not in full extension, STJ not in supination

Manual Stretching

Manual Stretching

Why Night Splints Fail



Why Dorsal Night Splint Fail

Ideal Equinus Bracing ConceptsExtend above the knee lock the knee into full extensionControllable ankle joint dorsiflexion prevent over stretching and allow for precision of treatmentSTJ supination engaging the Windlass mechanism to supinate the STJ creating DF primarily in the hindfoot and not in the midfoot, external rotation of the tibia allowing for full knee extension via the screw home mechanism

The Equinus Brace

Unilatereal vs. Bilateral StretchingDo you make 1 orthotic or 2 and why?

Manal et al J App Bio 2006

Optimal Pennation Angle of the Primary Ankle Plantar and Dorsiflexors: Variations With Sex, Contraction Intensity, and Limb

Manal et al J App Bio 2006

Taken together, and in light of our findings, it appears that the same pennation angle can be used for the right and left legs for the TA, LG, MG, and Sol muscles.

Macklin et al The Foot 2012L BaselineL 4 WeeksL 8 WeeksR BaselineR 4 WeeksR 8 WeeksAJ DF ()5(1)10(3)16(3)b5(1)10(3)15(3)bFPI3(2)3(3)4(1)4(2)3(2)3(2)PPP 1st MPJ kPa281.64 (84.21) 351.79 (84.28) 395.26 (137.57)c397.97 (146.19) 419.03 (130.23) 508.77 (181.87)cPPP 2nd MPJ kPa464.54 (172.36) 585.92 (204.13) 736.74 (251.94)b 401.10 (161.84) 477.49 (160.06) 621.97 (205.77)bPPP 5th MPJ kPa216.13 (64.34) 184.67 (74.32) 211.46 (85.75) 134.23 (62.84) 155.92 (63.15) 195.00 (69.74)c Max. Force (N/BW)1.21 (0.09) 1.30 (0.12) 1.34 (0.13) 1.18 (0.10) 1.22 (0.07) 1.39 (0.16)d

Stance Time (s)0.66 (0.04) 0.63 (0.04) 0.62 (0.04)a0.65 (0.04) 0.62 (0.04) 0.61 (0.03)aTime HC to HL (s)0.17 (0.02) 0.16 (0.03) 0.15 (0.02)c0.17 (0.02) 0.16 (0.02) 0.15 (0.03)c

a Significant difference between baseline and both week 4 and 8 (p 0.05). b Significant difference between all data collection sessions (p 0.05). c Significant difference between baseline and week 8 (p 0.05). d Significant difference between week 8 and both baseline and week 4 (p 0.05).

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Johanson et al FAI 2013

Why Proper Equinus Treatment Results In Improved Orthotic Outcomes

The Orthotic/Equinus War

The Orthotic/Equinus War

Shoe-Equinus Relationship

Shoe Drop

Shoe Drop

Recommended Regime Stretch 1 hour/day seated upright if hamstrings allowStretch bilateral lower extremities simultaneously even if only one side is symptomatic (i.e. right heel pain)Check monthly until 5 AJ DF with KE is reachedIf patient is athletic or has high physical lower extremity work demands maintenance therapy of 1 hour/week (make it a habit)

James Amis, MD Frontiers in Surgery 2016The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and AnkleThe isolated gastrocnemius contracture must be addressed as the definitive treatment for many if not the majority of non-traumatic acquired foot and ankle pathology. While treating the obvious foot or ankle problem is advisable and can be of great benefit to the patient, it must be considered only as adjunctive and palliative.

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equinus management for improved patient outcomes

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