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Anke Equinus Contracture


- Discussion:
    - see: role of ankle and subtalar joint in gait
    - normally, during the transition from foot flat to heel off, the foot dorsiflexes as the body moves forward;
    - gait consequences of equinus contracture:
             - patient may adopt a toe to toe gait pattern or a toe to heel gait pattern (premature forefoot loading)
             - reduced propulsion
             - excessive knee hyperextension
             - excessive foot pronation which allows more dorsiflexion to occur at the subtalar joint;
             - reduced stride length of the opposite limb
             - reduced gait velocity
             - external rotation 
    - diff dx:
             - anterior ankle impingement
             - leg length descrepancy
             - hyperpronation of the foot
             - clubfoot
             - ankle equinus in CP
             - immobilization after trauma 

- Exam:
   - Silfverskiold test
          - normal ankle dorsiflexion:
                    - ankle dorsiflexion with knee extended (= 10 degrees of DF)
                    - with flexion of the knee there will be an additional 10 deg of DF (= 20 deg of DF);
          - isolated gastroc contracture: (usually seen in CP)
                    - equinus contracture with knee extended (20 degrees of plantarflexion);
                    - when the knee is flexed to 90 degrees, ankle dorsiflexion significantly improves (10 degrees of dorsiflexion).

- Heel Cord Stretching:
    - patient should be standing and facing wall w/ the feet internally rotated (which keeps heel flat on floor during stretch and which locks the subtalar joint);
           - this ensures that dorsiflexion motion occurs only at ankle joint;
    - care must be take to invert subtalar joint and forefoot before applying dorsiflexion stress;
           - this locks calcaneus under talus, ensuring that dorsiflexion occurs only at the ankle joint rather than dorsiflexion does not occur at the midfoot;

- Orthotics:
    - with a fixed equinus deformity, patients may do well with a heel-lift shoe insert;

Operative Treatment:
      - Baumann procedure:
              - consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles;
              - goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle;
              - truly isolates the lengthening to the gastrocnemius muscle
              - procedure is indicated when the results of the Silfverskiold test are positive. 

      - Vulpius procedure
              - superficial gastrocnemius-soleus recession includes an intramuscular lengthening of the soleus muscle
      - Strayer: 
              - distal gastrocnemius tenotomy, 3 cm proximal to the gastrocnemius-soleus aponeurosis;
              - gastroc and soleus are separated to allow the gastrocnemius tendon to retract proximally, which is then sutured to soleus

Biomechanics and Orthotics of the Foot in Athletes. Graves SC, Badwey TH, Graves KO. Oper Tech Sports Med. 1994;2(1):2-8.

Isolated Recession of the Gastrocnemius Muscle: The Baumann Procedure

Helical Cutting as a New Method for Tendon-Lengthening in Continuity

Lengthening of the Gastrocnemius-Soleus ComplexAn Anatomical and Biomechanical Study in Human Cadavers