Abstract
The Silfverskiöld test has long been used as an important tool for determining the affected muscles of the triceps surae in patients with equinus deformity. However, the test may not reflect the altered interactions between the muscles of the triceps which are affected by spasticity. The purpose of this study was to compare the architectural properties of the triceps surae muscles complex using ultrasonography, between hemiplegic patients and typically-developing children. Specifically, we wished to examine any differences in the architecture of the three muscles with various angle configurations of the knee and ankle joints. Ultrasound images of the medial gastrocnemius, lateral gastrocnemius, and soleus were acquired from paretic (group I) and non-paretic (group II) legs of ten patients and the legs (group III) of 10 age-matched normal children. A mixed model was used to evaluate the differences in the measurements of muscle architecture among the groups and the effects of various joint configurations on the measurements within the muscles. Compared to the results of measurements in groups II and III, the fascicle length was not different in the medial gastrocnemius of a paretic leg but it was longer in the lateral gastrocnemius and shorter in the soleus; the pennation angle was smaller in both medial and lateral gastrocnemii and was not different in the soleus; and the muscle thickness was found to be reduced in the three muscles of the paretic leg. Contrary to the observations in both the medial and lateral gastrocnemii, the fascicle length was increased and the pennation angle was decreased in the soleus with an increase of knee flexion. Through the current simulation study of the Silfverskiöld test using ultrasonography, we found that the changes detected in the architectural properties of the three muscles induced by systematic variations of the position at the ankle and the knee joints were variable. We believe that the limited utility of the Silfverskiöld test should be considered in determining an appropriate operative procedure to correct the equinus deformity in patients with altered architecture of the muscles in conditions such as cerebral palsy, as the differing muscle architectures of the triceps surae complex may affect the behavior of the muscles during the Silfverskiöld test.
Highlights
An equinus gait is the most common abnormality seen in patients with cerebral palsy (CP)
The purpose of our study was to compare the architectural properties of the triceps surae muscles complex using ultrasonography, between the patients with spastic hemiplegic cerebral palsy (SHCP) and age-matched typically-developing children
On the basis of the findings obtained in the present study, we confirmed that the changes detected in the architectural properties of the three muscles of the triceps surae induced by systematic variations of the position at the ankle and the knee joints were variable to different degrees
Summary
An equinus gait is the most common abnormality seen in patients with cerebral palsy (CP). Conservative treatments are typically used first, most patients with an equinus deformity eventually require surgical correction, in which the calf muscles are lengthened based on the assumption that the ankle plantarflexors are abnormally shortened. The Silfverskiöld test (Figure S1) is commonly used as an important clinical tool for determining the affected muscles of the triceps in patients with equinus deformity [1,2]. When ankle dorsiflexion is facilitated by the bending of the knee joint (Silfverskiöld test-positive), surgery aiming to only lengthen the gastrocnemius muscle is required; otherwise (Silfverskiöld test-negative), surgeons typically lengthen the Achilles tendon with the assumption that both the gastrocnemius and soleus have been shortened. As such, lengthening of the tendo-achilles based on the suggestions by Silfverskiöld would change the ratio of muscle and tendon length and affect the competency of the plantar flexion–knee extension couple. Variable knee flexion angles may influence the excursion of the soleus through the action of the aponeurosis of gastrocnemius [6,7], resulting in difficulties in interpreting the findings of the test
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