Equinus: Clinical Podiatric Biomechanics and Surgery Spring 2024 PDF

EQUINUS Clinical Podiatric Biomechanics and Surgery Spring 2024 EQUINUS - Clinical Podiatric Biomechanics and Surgery EQUINUS Clinical Podiatric Biomechanics and Surgery Spring 2024 Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guideline...

EQUINUS Clinical Podiatric Biomechanics and Surgery Spring 2024 EQUINUS - Clinical Podiatric Biomechanics and Surgery EQUINUS Clinical Podiatric Biomechanics and Surgery Spring 2024 Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws CPMS Mission Statement: To educate a diverse group of highly competent and compassionate podiatric health professionals to improves lives in a global community. EQUINUS - Clinical Podiatric Biomechanics and Surgery EQUINUS Clinical Podiatric Biomechanics and Surgery Spring 2024 Disclosure Statement Dr. Kelly John, Assistant Professor, College of Podiatric Medicine and Surgery, Employed by Des Moines University, West Des Moines, Iowa. Disclosure: Financial— No relevant financial relationship exists. Nonfinancial— No relevant nonfinancial relationship exists. EQUINUS - Clinical Podiatric Biomechanics and Surgery EQUINUS - Clinical Podiatric Biomechanics and Surgery EQUINUS - Clinical Podiatric Biomechanics and Surgery How do you solve a problem like Equinus? WEST EAST Equinus is the root of all evil; makes other parts of the body do bad things. All Equinus should be fixed with a scalpel and the surgery should be on the schedule tomorrow. Equinus is BAD. Yes, Equinus is associated with “the wrong crowd”, but not always the intentional instigator. There are more nonviolent ways to rehabilitate the wayward contracted posterior compartment. Equinus isn’t necessarily good, but it’s not always so bad. EQUINUS - Clinical Podiatric Biomechanics and Surgery OBJECTIVES Identify the etiologies of equinus and describe the clinical examination of equinus. Identify the compensatory mechanism associated with equinus and its role in pathology of the foot. Identify the evidence for conservative and surgical treatment of equinus. EQUINUS - Clinical Podiatric Biomechanics and Surgery Equinus Clinically DEFINITION: Pes Equinus is a condition in which the upward bending motion of the ankle joint (dorsiflexion) is limited. Very UNCOMMON to have patient’s HPI: “I have equinus.” (Equinus vs Aquinas) Patient presents with other symptoms related to the equinus. We can treat the presenting symptoms with or without addressing the equinus component. Plantar fasciitis Calf cramping Tendinitis (Achilles’, posterior tibial) Metatarsalgia/ forefoot pain Flat foot Arthritis – ankle, midfoot Pressure sores in arch or ball of the foot Bunions Hammertoes Ankle pain Shin splints/ medial tibial stress syndrome Global warming… EQUINUS - Clinical Podiatric Biomechanics and Surgery Equinus = ankle joint dorsiflexion is limited The normal range for ankle joint dorsiflexion was established as 0 degrees to 16.5 degrees nonweightbearing. Baggett BD, Young G. Ankle joint dorsiflexion. Establishment of a normal range. J Am Podiatr Med Assoc. 1993 May;83(5):251-4. Motion of a reduced quantity has been referred to as 'equinus' and the widely accepted theory is that when equinus is present, an abnormal foot function occurs. For normal foot function and human ambulation, the amount of ankle joint dorsiflexion required is claimed to be 10 degrees. EQUINUS - Clinical Podiatric Biomechanics and Surgery Anatomy – Gastrocnemius = crosses 3 joints: knee, ankle, subtalar Soleus = crosses two joints: ankle and subtalar EQUINUS - Clinical Podiatric Biomechanics and Surgery Triceps Surae The triceps surae muscle is a three-headed muscle in the posterior compartment of the leg. It consists of two muscles, gastrocnemius and sole us. Along with the plantaris muscle, the triceps surae composes the superficial flexor group of the leg, which forms the bulk on the back of the calf. EQUINUS - Clinical Podiatric Biomechanics and Surgery Etiologies of Equinus Congenital Developmental Acquired Excessive pronation FF varus greater than 4 degrees Tarsal coalition Internal malleolar position Tight hamstring Limb length discrepancy Tonic spasm of triceps surae and Clonic spasm triceps surae (UMNL) Low lying soleus muscle Hip dysplasia Trauma Casting It may be a Chicken or the egg question EQUINUS - Clinical Podiatric Biomechanics and Surgery Clinical Exam of Equinus (sequelae of equinus) Toe walking Excessive or prolonged pronation; early heel off Forefoot pressure lesions Genu Recurvatum Hip flexion Lumbar lordosis Silfverskiold Test + EQUINUS - Clinical Podiatric Biomechanics and Surgery Clinical Exam of Equinus (sequelae of equinus) Hypermobile first ray – bunion or hallux limitus Hammer toes Plantar fasciitis Metatarsalgia Tendinopathy Patela-femoral syndrome Back pain EQUINUS - Clinical Podiatric Biomechanics and Surgery Genu Recurvatum and Pes valgus EQUINUS - Clinical Podiatric Biomechanics and Surgery Types of Equinus Gastrocnemius Gastroc-soleus Osseous Pseudoequinus A combination of the above EQUINUS - Clinical Podiatric Biomechanics and Surgery Types of Equinus Could you get an isolated Soleus equinus? Low lying soleus muscle belly Fibromatosis of the soleus muscle Very rare EQUINUS - Clinical Podiatric Biomechanics and Surgery The Silfverskiold Test The Silfverskiöld test can be used to differentiate gastrocnemius tightness from an Achilles tendon contracture by evaluating ankle dorsiflexion with the knee extended and then flexed. Technique The test is performed with the patient seated or in supine. Two hands are utilized to perform the technique, with one hand neutralizing and locking the subtalar (ST) joint and the other stabilizing the talonavicular (TN) joint and forefoot in order to isolate the ankle joint motion. Then the forefoot is supinated and foot is dorsiflexed with knee in full extension. Measurement is taken of the DF range. Then the test is repeated with the knee flexed at 90 degrees. EQUINUS - Clinical Podiatric Biomechanics and Surgery The Silfverskiold Test Gastroc Equinus Gastroc-Soleus Less dorsiflexion with a soft and spongy feel when the knee is extended is considered as an indication for gastrocnemius contracture. Equally limited dorsiflexion with the knee flexed and extended is considered as an indication for soleal equinus or an osseous block. EQUINUS - Clinical Podiatric Biomechanics and Surgery Osseous Equinus Osseous impingement of tibiotalar articulation or tib-fib Abrupt end to dorsal ROM –hard stop Not dependent on knee position Radiographic findings Reduced anterior joint space Squaring of talar neck Talar lipping, osteophytes Charger view Lateral projection with stressed dorsiflexion EQUINUS - Clinical Podiatric Biomechanics and Surgery Osseous Equinus EQUINUS - Clinical Podiatric Biomechanics and Surgery Pseudoequinus Actually 10º of dorsiflexion at ankle, but functionally need more because of a plantarflexed forefoot Forefoot loads earlier due to anterior cavus deformity Arched foot NWB, arch collapses WB Pseudoequinus describes the condition in which the forefoot equinus position uses up limited available ankle joint motion Does well with conservative treatment with accommodative EQUINUS - Clinical Podiatric Biomechanics and Surgery Examples of a combination of equinus types Hemophilic Equinus Contracture Hemarthrosis Recurrent synovitis Trauma with improper immobilization Casted plantarflexed Allowed to remain supine with ankle plantarflexion EQUINUS - Clinical Podiatric Biomechanics and Surgery Casting or splinting in plantarflexed position EQUINUS - Clinical Podiatric Biomechanics and Surgery Casting Plantarflexed – must appreciate that this is the narrowest part of the talus (in addition to Achilles’ tendon contracture) EQUINUS - Clinical Podiatric Biomechanics and Surgery How do you solve a problem like Equinus? Treatment includes strategies aimed at relieving the symptoms and conditions associated with equinus. In addition, the patient is treated for the equinus itself. Conservative Treatment of Equinus Surgical Treatment of Equinus EQUINUS - Clinical Podiatric Biomechanics and Surgery How do you solve a problem like Equinus? Notorious B.I.G. Equinus is associated with “the wrong crowd”, but not always the intentional instigator. There are more nonviolent ways to rehabilitate the wayward contracted posterior compartment. Equinus isn’t necessarily good, but it’s not always so bad. Night splint. The foot may be placed in a splint at night to keep it in a position that helps reduce tightness of the calf muscle. Heel lifts. Placing heel lifts inside the shoes or wearing shoes with a moderate heel takes stress off the Achilles tendon when walking and may reduce symptoms. Arch supports or orthotic devices. Custom orthotic devices that fit into the shoe are often prescribed to keep weight distributed properly and to help control muscle/tendon imbalance. Physical therapy. To help remedy muscle tightness, exercises that stretch the calf muscle(s) are recommended. Eccentric exercise being done daily is associated with improvement in pain and gaining mobility and foot dorsiflexion EQUINUS - Clinical Podiatric Biomechanics and Surgery Nonsurgical treatment options Only effective for soft tissue equinus No consensus on how long stretching session should occur and how long is the course of treatment – lifetime? Do heel lifts lead to more contracture? EQUINUS - Clinical Podiatric Biomechanics and Surgery How do you solve a problem like Equinus? 2Pac Equinus is the root of all evil; makes other parts of the body do bad things. All Equinus should be fixed with a scalpel and the surgery should be on the schedule tomorrow. Equinus is BAD. Heal with steel Increase the length of some or all of the components of the triceps surae (including the plantaris?) Isolated or in combination with other procedures How do you determine how much to lengthen? EQUINUS - Clinical Podiatric Biomechanics and Surgery Surgical Procedures to Reduce Equinus The triceps surae is divided into 5 levels (Lamm and et al). (1) Level 1, calcaneal tendon; (2) Level 2, starts in the common aponeurotic tendon of the soleus and gastrocnemius and finishes at the distal end of the soleus muscle; (3) Level 3, starts where the muscle bellies of the gastrocnemius merge to form the calcaneal tendon and finishes where the aponeuroses of the soleus and gastrocnemius merge (4) Level 4, comprises the medial and lateral bellies of the gastrocnemius; (5) Level 5, comprises the proximal insertion and tendons of the medial and lateral heads of the gastrocnemius EQUINUS - Clinical Podiatric Biomechanics and Surgery Surgical Procedures to Reduce Equinus EQUINUS - Clinical Podiatric Biomechanics and Surgery The Silfverskiold and Barouk Procedures: Level V Traditional Medial and Lateral Gastrocnemius Muscle Release Proximal release of the muscular heads of the gastrocnemius muscle. Isolated Medial Gastrocnemius Release: Barouk Modification Structures in the region: Popliteal artery/posterior tibial artery, popliteal nerve/tibial nerve, popliteal vein/greater saphenous vein EQUINUS - Clinical Podiatric Biomechanics and Surgery The Baumann Procedure Level IV A stepwise surgical approach to equinus release. This procedure is an intramuscular lengthening of the gastrocnemius alone or along with the soleus. The surgeon will initially incise the gastrocnemius. If there is an incomplete release, one can also incise the soleus to achieve maximum lengthening. This procedure was originally described with the patient in the prone position, which can inherently limit one’s ability to perform concomitant procedures to the foot and ankle. Why???? EQUINUS - Clinical Podiatric Biomechanics and Surgery How to position on the OR table EQUINUS - Clinical Podiatric Biomechanics and Surgery STRAYER Level III Distal recession of the gastrocnemius aponeurosis EQUINUS - Clinical Podiatric Biomechanics and Surgery STRAYER Distal recession of the gastrocnemius aponeurosis EQUINUS - Clinical Podiatric Biomechanics and Surgery Modified Strayer: posterior medial approach EQUINUS - Clinical Podiatric Biomechanics and Surgery Modified Strayer: Endoscopic EQUINUS - Clinical Podiatric Biomechanics and Surgery Vulpius and Baker Level II Distal recession of the gastrocnemius aponeurosis EQUINUS - Clinical Podiatric Biomechanics and Surgery Baker vs McGlamry and Fulp Level II McGlamry and Fulp Distal recession of the gastrocnemius aponeurosis Baker – tongue on distal flap EQUINUS - Clinical Podiatric Biomechanics and Surgery White, Hoke, and Z Procedures – Level I Z lengthening EQUINUS - Clinical Podiatric Biomechanics and Surgery White Procedure – Level I White described a percutaneous technique based the apparent rotation of the Achilles tendon. White stated the tendon rotated laterally approximately 90 degrees. Therefore, he recommended the anterior 2/3 of the tendon be severed distally, about 2.5cm proximal to the insertion into the calcaneus with a second incision placed 6 cm proximal to the first and the medial 2/3 of the tendon EQUINUS - Clinical Podiatric Biomechanics and Surgery Z- Lengthening Procedure – Level I Z- lengthening can be in sagittal plane or frontal plane Open procedure or percutaneous Sagittal Z will have a medial piece and a lateral piece Frontal Z with have anterior piece and a posterior piece EQUINUS - Clinical Podiatric Biomechanics and Surgery Distal Z Lengthening Distal Z Lengthening of Achilles’ Tendon EQUINUS - Clinical Podiatric Biomechanics and Surgery Hoke Achilles Lengthening Procedure – Level I Common for diabetic forefoot ulcers or TMA Reduces excessive forefoot pressure “Triple stab”- minimal incision “More Medial” EQUINUS - Clinical Podiatric Biomechanics and Surgery Percutaneous Tendo-Achilles Lengthening EQUINUS - Clinical Podiatric Biomechanics and Surgery Percutaneous Tendo-Achilles Lengthening 2 cm, 5cm, 8 cm PTAL or TAL More Medial Plantaris Tendon EQUINUS - Clinical Podiatric Biomechanics and Surgery Percutaneous vs. Open Surgical Correction of Soft-Tissue Ankle Equinus Contracture Monica H. Schweinberger, DPM, AACFAS, Thomas S. Roukis, DPM, PhD, FACFAS* Limb Preservation Service, Vascular/Endovascular Surgery Service, Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Avenue, MCHJ-SV, Tacoma, WA 98431, USA Clin Podiatr Med Surg 25 (2008) 571–585 EQUINUS - Clinical Podiatric Biomechanics and Surgery So why not just do the surgery? “There is nothing we can’t make worse with surgery” Weigh the risks and benefits What happens if you overlengthen? What about the sural nerve? How long is the recovery? Do I have to be NWB? Can I drive? EQUINUS - Clinical Podiatric Biomechanics and Surgery Complete Transection – Planned or Unplanned The distal Achilles tendon techniques affect both the gastrocnemius and soleus and they weaken the whole muscle complex. Complete transection of the tendon can lead to crouching, calcaneus gait and weakening at the knee and hip. EQUINUS - Clinical Podiatric Biomechanics and Surgery Published in Annals of Anatomy 2015 Anatomical variations of the formation and course of the sural nerve: A systematic review and meta-analysis. P. K. RamakrishnanB. Henry K. Tomaszewski Variations of the Sural Nerve SCN – sciatic nerve CPN – common peroneal nerve TN – tibial nerve PCN – peroneal communicating nerve MSCN – medial sural cutaneous nerve LSCN – lateral sural cutaneous nerve SN – sural nerve LDCN – lateral dorsal cutaneous nerve EQUINUS - Clinical Podiatric Biomechanics and Surgery EQUINUS - Clinical Podiatric Biomechanics and Surgery Undergraduate: St. Ben’s & St. Cloud State 10 miles apart EQUINUS - Clinical Podiatric Biomechanics and Surgery IF YOU DON’T KNOW, NOW YOU KNOW EQUINUS - Clinical Podiatric Biomechanics and Surgery