Ankle Equinus Research Articles

Botulinum toxin type A injection increases range of motion in hip, knee and ankle joint contractures of children with cerebral palsy

This study aims to evaluate the clinical outcomes of children with spastic type cerebral palsy (CP) treated with botulinum toxin type A (BoNT-A) injection for lower limb contracture and the influence of age, gender, functional level and degree of initial contracture on treatment outcomes. Clinical records at pre-BoNT-A injection and post-BoNT-A injections of 153 sessions of a total of 118 consecutive children (67 boys, 51 girls; mean age 5.9±2.6 years; range, 2.5-16 years) were retrospectively evaluated. Degrees of pre- and post-injection contracture were evaluated. Post-injection supplemental casting for 10 days was recorded in all cases. Less than 20° of hip flexion contracture, more than 30° of hip abduction, a negative prone Ely test, less than 50° of popliteal angle and at least 5° of ankle dorsiflexion values at post-injection were accepted as sufficient clinical improvement. Sufficient post-injection range of motion (ROM) was observed in 80% of cases with hip flexion contracture, in 45% of cases with hip adduction contracture, in 84% of cases with knee flexion contracture and in 77% of cases with ankle equinus contracture. Prone Ely test that was positive in 60% of cases with knee extension contracture was negative at post-injection. Improvement in contractures were prominent in children with lesser degree initial contractures. Botulinum toxin type A injection increases ROM in hip, knee and ankle joint contractures in CP. Although age, gender and functional level may influence the clinical outcomes, pre-treatment level of contracture is the main determinant in improvement in ROM at post-injection.

Calf muscle stretching is ineffective in increasing ankle range of motion or reducing plantar pressures in people with diabetes and ankle equinus: A randomised controlled trial

BackgroundLimited ankle dorsiflexion, or equinus, is associated with elevated plantar pressures, which have been implicated in the development and non-healing of foot ulcer. A stretching intervention may increase ankle dorsiflexion and reduce plantar pressures in people with diabetes. MethodsTwo arm parallel randomised controlled trial from September 2016 to October 2017. Adults with diabetes and ankle equinus (≤5° dorsiflexion) were randomly allocated to receive an 8 week static calf stretching intervention or continue with their normal activities. Primary outcome measures were change in weight bearing and non-weight bearing ankle dorsiflexion and forefoot peak plantar pressure. Secondary outcome measures were forefoot pressure time integrals and adherence to the stretching intervention. Findings68 adults (mean (standard deviation) age and diabetes duration 67.4 (10.9) years and 14.0 (10.8) years, 64.7% male) were randomised to stretch (n = 34) or usual activity (n = 34). At follow up, no significant differences were seen between groups (adjusted mean difference) for non-weight (+1.3°, 95% CI:−0.3 to 2.9, p = 0.101) and weight bearing ankle dorsiflexion (+0.5°, 95% CI:−2.6 to 3.6, p = 0.743) or forefoot in-shoe (+1.5 kPa, 95% CI:−10.0 to 12.9, p = 0.803) or barefoot peak pressures (−19.1 kPa, 95% CI:−96.4 to 58.1, p = 0.628). Seven of the intervention group and two of the control group were lost to follow up. InterpretationOur data failed to show a statistically significant or clinically meaningful effect of static calf muscle stretching on ankle range of motion, or plantar pressures, in people with diabetes and ankle equinus.

Effect of Intermittent Serial Casting on Equinus Ankle Deformity in Children with Hemiplegic Cerebral Palsy

AbstractBackground: Equinus is the most common problem in ambulatory children with spastic hemiplegic cerebral palsy, which results in an unstable and inefficient gait pattern. Without proper management at an early stage, it can lead to permanent foot deformities.Aim of Study: The aim of this study was to evaluate the effect of serial casting on ankle range of motion, tone of the calf muscle and ankle kinematics during gait in children with spastic hemiplegic cerebral palsy.Material and Methods: Twenty-five spastic hemiplegic cerebral palsy children of both sexes (15 boys and 10 girls) participated in this study. Patients were selected at level I according to Gross Motor Function Classification System and the degree of spasticity ranged from 2 to 3 according to Modified Ashworth Scale with true equinus, with their mean age were 4.8±0.8 years. They were randomly assigned to two groups. The first group, 12 children, Group (A) who received a selected physical therapy program once a day/3 times a week for three successive weeks; while the second group, 13 children, Group (B) who received three consecutive casts for five days each and removed in the last two days in each week to conduct the same selected physical therapy program which conducted for the Group (A). Ankle range of motion was assessed by electronic goniometer, calf muscle spasticity was assessed by modified ashworth scale and ankle kinematics during gait was assessed by observational gait scale.Results: The results of the present study revealed that Group (B) showed statistically significant improvement in ankle range of motion, tone of calf muscle and ankle kinematics during gait (p=0.0001 for all) than those of the Group (A).Conclusion: Serial casting of equinus ankle deformity could improve ankle range of motion, tone of calf muscle and ankle kinematics during gait in children with spastic hemiplegic cerebral palsy.

Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet

BackgroundCongenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomy in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus [1]. Universal agreement is established about Ponseti technique as the initial management for this deformity. This preliminary study aims to investigate the possibility of having a braceable foot through a proposed accelerated Ponseti method by which, manipulations, 5 castings and Achilles tendon tenotomy are implemented in a week. MethodsThis study included 11 patients with 16severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. The method involves manipulation of the deformed foot, and 1st casting in one day, with the 2nd, 3rd, 4th, 5th castings in the 4th, 5th, 6th, 7th day post-manipulation. After the 4th cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients. Nonparametric tests were used for comparing the Pirani scores before starting the treatment and after removal of final cast. ResultsFive patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8–150days). All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, underwent the accelerated Ponseti technique. After removal of the three-week cast, the scores median was 0.59, (range 0–1.5), indicating a correction of the deformity and having braceable feet in all patients without experiencing any short-term complication. ConclusionsThe first step accelerated Pnoseti technique was found to be safe and effective for initial correction of severe idiopathic clubfoot deformity in children below three months of age , though it is an initial study that needs more studies with more follow up data.

Effects of eccentric exercise in pressure pain threshold in subjects with functional ankle equinus condition

Stretching exercises are widely used by the population before sporting activities. One of the most common technique is eccentric exercise. Here, we made a clinical examination of 98 subjects with equinus condition before activity and after 30 min of running (49 participants with previous eccentric exercise and 49 with no previously eccentric exercise). The clinical assessment of the Achilles tendon was based on the pressure pain threshold (PPT). We identified significant PPT changes between the previous eccentric stretching and the non-previous eccentric stretching group in the Achilles tendon evaluations. Based on our findings, we propose that subjects with equinus condition could use eccentric stretching in order to improve the Achilles tendon status.

The iPhone Measure app level function as a measuring device for the weight bearing lunge test in adults: a reliability study

BackgroundAnkle joint range of motion is a frequently assessed measure used by health care clinicians who manage lower limb pathologies to identify ankle equinus and/or other joint motion concerns that may negatively impact on function. The purpose of this study was to assess a new iPhone application (the level function of the ‘Measure application’), for measuring the weightbearing ankle lunge test in a healthy adult population (reliability) and measuring known angles (validity) when compared to a digital inclinometer.MethodsTo determine intra-rater reliability, inter-rater reliability and concurrent validity, 168 measures were conducted on 21 participants. Participants were preconditioned prior to assessment, and two experienced raters measured ankle dorsiflexion range of motion in the knee extended and knee flexed positions of the weight bearing lunge test, using an iPhone level function (of the Measure application) and a digital inclinometer in a randomised order, over two timepoints. Concurrent validity was also determined by comparison of measures of the two devices at known surface angles (0 and 15 degrees) in multiple planes. Reliability and validity were determined with intraclass correlation coefficients, concurrent validity was explored with the Bland Altman plot and an intraclass correlation coefficient. The Standard Error of the Mean and the minimal detectable change were also explored.ResultsThe intra-rater reliability using the iPhone and inter-rater reliability using the digital inclinometer, in the knee extended position, were ICC 0.85 respectively, indicating good reliability. All other intra-rater reliability and inter-rater reliability for both devices and both leg positions were over ICC 0.90, indicating excellent reliability. Concurrent validity between the two devices on a flat and known angle surface were ICC 1.0 (Limits of Agreement − 1.0 to 0.61), indicating excellent validity, with good validity demonstrated by a Bland Altman plot of all measures in all positions (ICC of 0.84 (Limits of agreement = − 4.51 to 6.49)).ConclusionThe use of the iPhone level measure, within the Measurement App has demonstrated to be an easy and reliable measurement tool to determine ankle joint dorsiflexion during the weightbearing lunge test in healthy adults.

Effects of Compressive Stockings and Standard Stockings in Skin Temperature and Pressure Pain Threshold in Runners with Functional Ankle Equinus Condition.

Objective: To assess clinical differences in the Achilles tendons of runners with ankle equinus wearing either compressive or standard stockings. Design: Case–control study. Methods: In this study, we conducted clinical examinations of 98 sportsmen (runners) with equinus, before and after 30 min of running on a treadmill; 49 runners wore compressive stockings and 49 wore standard stockings. Clinical assessments of the runners’ Achilles tendons were based on the pressure pain threshold (PPT) and skin temperature analysis. Results: Achilles tendon evaluations identified significant differences in skin temperature modification and PPT between the compressive and standard stocking groups. Conclusions: Based on our findings, we propose that higher skin temperatures are associated with lower pressure pain thresholds in the Achilles tendons of runners with ankle equinus.

Slow velocity of the center of pressure and high heel pressures may increase the risk of Sever\u2019s disease: a case-control study

BackgroundThis study determined if the body mass index, dynamic plantar-pressures, plantar surface contact-area, velocity of the centre of pressure (COP), gastrocnemius equinus, and gastrocnemius soleus equines are related to calcaneal apophysitis (Sever’s disease) in athletic children.MethodsThis case-control study examined 106 boys enrolled in a soccer academy, including 53 with Sever’s disease and 53 age-matched healthy controls. The dynamic average and maximum peak plantar-pressures, plantar surface contact-area, and velocity of the COP were evaluated with a digital pressure sensor platform. Goniometry was used to measure the ankle dorsiflexion range of motion and thereby identify gastrocnemius equinus and gastrocnemius soleus equinus.ResultsParticipants with Sever’s condition had significantly higher BMI and peak plantar-pressures (maximum and average) at the heel (Cohen’s d > 3 for pressures) than the controls. Those with Sever’s disease also had significantly slower velocity of the COP (Cohen’s d > 3). Boys with Sever’s disease were also 8 times more likely to have bilateral gastrocnemius equinus than disease controls.ConclusionsHigh heel plantar pressure and low velocity of COP are related to Sever’s condition in boys, although it is not clear whether these factors predispose individuals to the disease or are consequences of the disease. Gastrocnemius ankle equinus could be a predisposing factor for Sever’s condition.

Prevalence of ankle equinus and correlation with foot plantar pressures in people with diabetes

BackgroundAn association between equinus and plantar pressure may be important for people with diabetes, as elevated plantar pressure has been linked with foot ulcer development. To determine the prevalence of equinus in community dwelling people with diabetes and to examine any association between presence of equinus and forefoot plantar pressures. MethodsBarefoot (Tekscan HR Mat™) and in-shoe (Novel Pedar-X®) plantar pressure variables, non-weight bearing ankle range of motion and neuropathy status were assessed in 136 adults with diabetes (52.2% male; 47.8% with neuropathy; mean (standard deviation) age and diabetes duration: 68.4 (11.5) and 14.6 (11.1) years respectively). FindingsEquinus, when measured as ≤5° dorsiflexion, was present in 66.9% of the cohort. There was a significant correlation between an equinus and barefoot (r = 0.247, p = 0.004) and in-shoe forefoot pressure time integrals (r = 0.214, p = 0.012) and in-shoe forefoot alternate pressure time integrals (r = 0.246, p = 0.004). Significantly more males (p < 0.01) and people with neuropathy (p = 0.02) or higher glycated haemoglobin levels (p < 0.01) presented with an equinus. InterpretationCommunity dwelling adults with diabetes have a high rate of ankle equinus which is associated with increased forefoot pressure time integrals and a two-fold increased risk of high in-shoe peak pressures. Clinical assessment of an ankle equinus may be a useful screening tool to identify adults at increased risk of diabetic foot complications.

Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons.

Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons. We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy. Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy. An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population. Level III-retrospective cohort.

Rupture Spontanee Du Tendon D’achille Sur Terrain Diabetique : A Propos Du Cas

Achilles Tendon Rupture (ATR) is a frequently described lesion in sports traumatology. It can occur following certain chronic or systemic diseases. We reported a case of a 48-year-old woman, a teacher by profession, who was consulting for lameness. Anamnesis found during a walk, a brutal sensation of blow on the heel with cowardice and sharp pain at the elective point imposing upon the resting of the patient. Clinical examination noted an increased spontaneous dorsiflexion of the affected ankle, depression corresponding to the tendon continuity solution, and a positive Thompson test. The diagnosis of Achilles Tendon Rupture was made. The patient was operated 2 weeks later by open surgery. A simple suture kept by a plaster splint was performed (the ankle in equinus). Functional rehabilitation was done for 6 weeks, and walking was allowed at the 6th week. In the absence of minimally invasive surgery, conventional surgery can provide good results in case of spontaneous Achilles Tendon Rupture at the cost of rigorous monitoring of the patient.

Validation of a weight bearing ankle equinus value in older adults with diabetes

BackgroundAccurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion < 30°) in unimpaired cohorts, and secondly to investigate any clinical effects this degree of ankle dorsiflexion restriction has on forefoot plantar pressure variables in older adults with diabetes.MethodsAnkle dorsiflexion was measured using a Lunge test with the knee extended in young adults without diabetes (YA) and older adults with diabetes (DA). In-shoe and barefoot plantar pressure was recorded for the DA group. Spearman’s correlation was calculated to determine any association between the presence of ankle equinus and plantar pressure variables in the DA group. DA group differences in people with and without an equinus were examined.ResultsA weight bearing equinus of < 30°, assessed in a lunge using an inclinometer placed on the anterior tibia, falls within the restricted range in young unimpaired cohorts. In the DA group this degree of ankle restriction had a fair and significant association with elevated barefoot forefoot peak pressure (r = 0.274, p = 0.005) and pressure-time integrals (r = 0.321, p = .001). The DA equinus group had significantly higher barefoot peak pressure (mean kPa (SD): 787.1 (246.7) vs 652.0 (304.5), p = 0.025) and pressure-time integrals (mean kPa (SD): 97.8 (41.6) vs 80.4 (30.5), p = 0.017) than the DA non equinus group.ConclusionsWe support a preliminary weight bearing ankle equinus value of < 30°. This value represents a restricted range in young adults and is correlated with increased forefoot plantar pressure variables in older adults with diabetes. Mean population weight bearing ankle dorsiflexion data presented here for older adults with diabetes, will allow use of the more functional Lunge test with knee extended in research and clinical practice.

Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus?

Conservative “functional” management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus-corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio-first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon.

An Analysis of Leg Muscle Stretch Using 3D Digital Image Correlation

Sural region is called as the bottom heart of the body since it is essential for the maintenance of venous circulatory adequacy during upright posture and activity. Previous research has found that ankle joint equinus can lead to foot pathologies. The paper presents a generic methodology to compute the strain pattern in the Sural and calcaneal region during leg dorsiflexion experiment. In the experiment, the subject is made to stand on an inclination plane and images are captured at varying angular inclinations. Strain plots obtained after comparison indicates the strain distribution in the posterior compartment of sural and calcaneal regions. The experiment is then repeated for four other participants and the trends are observed. VIC-3D is used to determine the strain distribution on two important superficial components of the leg region, namely the Sural and calcaneal regions, subjected to varied degrees of foot dorsiflexion. The experiment is extremely important as the primary knowledge gained will assists us to generate muscle-tendon units which can result into better understanding of the force and energy production. Moreover, this exercise can be used to regulate the blood circulation and avoid the syndrome mentioned above.

Infrared thermography applied to lower limb muscles in elite soccer players with functional ankle equinus and non-equinus condition.

Gastrocnemius-soleus equinus (GSE) is a foot-ankle complaint in which the extensibility of the gastrocnemius (G) and soleus muscles (triceps surae) and ankle are limited to a dorsiflexion beyond a neutral ankle position. The asymmetric forces of leg muscles and the associated asymmetric loading forces might promote major activation of the triceps surae, tibialis anterior, transverses abdominal and multifidus muscles. Here, we made infrared recordings of 21 sportsmen (elite professional soccer players) before activity and after 30 min of running. These recordings were used to assess temperature modifications on the gastrocnemius, tibialis anterior, and Achilles tendon in GSE and non-GSE participants. We identified significant temperature modifications among GSE and non-GSE participants for the tibialis anterior muscle (mean, minimum, and maximum temperature values). The cutaneous temperature increased as a direct consequence of muscle activity in GSE participants. IR imaging capture was reliable to muscle pattern activation for lower limb. Based on our findings, we propose that non-invasive IR evaluation is suitable for clinical evaluation of the status of these muscles.

ANALYSIS AND PLANNING OF HINDFOOT DEFORMITY CORRECTION IN SAGITTAL PLANE

Background. The disadvantage of the known methods of analysis and planning of hindfoot deformities in the sagittal plaBackground. Long bone deformity planning is well established. However, there are not well described methods of analysis and planning of hindfoot deformities in the sagittal plane. Such planning is made even more difficult with concomitant deformation of the midfoot and/or ankle contracture or malpositioned arthrodesis. The aim of our study was to develop a universal method of analysis and planning of the calcaneus correction, based on the normally derived reference lines and angles.Methods. We analyzed 65 standing lateral foot films in normal adults, 23-54 years old were analyzed. We drew the talus joint line (points “a” and “b” – Line 1). We drew a second line, (Line 2) the calcaneal line, which starts at the back of the calcaneal tuberosity (point “d”), drawn perpendicular to a line from top to bottom of the calcaneal tuberosity. The intersection of the calcaneal line and the talar joint line form point (c) anteriorly. We measured lines ab, ac and cd, and their ratios: ac/ab, and cd/ab.Results. Talar joint line (Line 1) and calcaneal line (Line 2) intersect at a point (c), forming an angle 15.2° (±3.4°). The ratio ac/ab = 2.56 (± 1.1). The ratio cd/ab = 4.59 (±1.0). These ratios are constants for calculating the idealized joint lines for deformity planning. For deformity cases, draw Line 1, the talar joint line ab. Extend that line anteriorly to (c), which is a distance ab×2.56 from point (a). From (c), draw an idealized calcaneal line, Line-2, at an angle 15° to Line 1. Place (d) on this line, at a distance ab×4.59 from point (c). Next, draw the deformed calcaneal line (Line 3) and point (d1 ) where it exits the calcaneal tuberosity. Use the same technique and landmarks as for drawing the normal calcaneal line. The intersection of Lines 2 and 3 is the apex of the deformity. Rotate the piece containing Line 3 around this apex, until it is collinear with Line 2, and (d) is coincident with (d1 ).Conclusions. We describe the normal sagittal plane relationships between the hindfoot (calcaneus – talus). This normative data is used for planning sagittal plane hindfoot deformity corrections. It can be used for hindfoot deformities analysis and correction planning. It is independent of ankle joint equinus or malpositioned ankle arthrodesis, which can be considered as separate deformities.

A pilot investigation into the relationship between static diagnosis of ankle equinus and dynamic ankle and foot dorsiflexion during stance phase of gait: Time to revisit theory?

BackgroundAlthough the clinical assessment of ankle dorsiflexion has traditionally been measured utilising various goniometric means, the validity of this static examination has never been investigated. Since any impairment in ankle flexibility is likely to result in injuries, it is imperative that the correct examination technique is conducted. Hypothesis/PurposeTo determine whether a clinical diagnosis of ankle equinus, or limited ankle dorsiflexion, correlates with a decreased dorsiflexion range of movement of the foot and ankle during gait. MethodsTwenty participants with a clinical diagnosis of ankle equinus underwent optoelectronic motion capture utilising the Rizzoli foot model. Participants were divided into two groups, Group A with <−5° of dorsiflexion and Group B with −5° to 0° of ankle dorsiflexion. ResultsParticipants in Group B had a mean dynamic ankle dorsiflexion angle of 13.9°, while those in Group A had a mean dorsiflexion angle of 4.4°, resulting in a significant difference (p=0.004) between the two groups. Likewise, foot mean dynamic dorsiflexion angle of Group B was 17.13° and Group A 8.6° (p=0.006). ConclusionThere is no relationship between a static diagnosis of ankle dorsiflexion at 0° with dorsiflexion during gait. On the other hand, those subjects with less than −5° of dorsiflexion during static examination did exhibit reduced ankle range of motion during gait.

Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes.

Ankle distraction is an alternative to ankle arthrodesis or total ankle arthroplasty in younger patients with arthritis. Ankle distraction involves the use of external fixation to mechanically unload the ankle joint, which allows for stable, congruent range of motion in the setting of decreased mechanical loading, potentially promoting cartilage repair. Adjunct surgical procedures are frequently done to address lower-extremity malalignment, ankle equinus contractures, and impinging tibiotalar osteophytes. Patients can bear full weight during the treatment course. The distraction frame frequently uses a hinge, and patients are encouraged to do daily range-of-motion exercises. Although the initial goal of the procedure is to delay arthrodesis, many patients achieve lasting clinical benefits, obviating the need for total ankle arthroplasty or fusion. Complications associated with external fixation are common, and patients should be counseled that clinical improvements occur slowly and often are not achieved until at least 1 year after frame removal.

Current conservative management and classification of club foot: A review.

Clubfoot, known as congenital talipes equinovarus, is one of the complex paediatric foot deformity with the incidence of 1 in every 1000 live births. It consists of four complex foot abnormalities such as forefoot adductus, midfoot cavus, and hindfoot varus and ankle equinus. There are a number of surgical techniques (soft tissue releases, arthrodesis) used to correct clubfoot. However currently the conservative management (manipulation, serial casting, and braces) of clubfoot is considered as the best choice and it is widely accepted among orthopaedists. Clubfoot treated with surgical techniques might suffer various complications such as soft tissues contractures, neurovascular complications, infections, and shortening of the limbs. Although conservative method is generally considered as an effective method, it is still challenging to cure clubfoot in advance stages. Also, the classification of the initial severity of clubfoot is essential to evaluate the outcome of the treatment. In this review, the aim is to review the different types of conservative method and the assessment of clubfoot severity.

Treatment of Clubfoot Using the Ponseti Method.

The Ponseti method consists of a specific technique of manipulation of the clubfoot deformity, followed by the application of a plaster cast with the foot in the corrected position. A percutaneous tenotomy of the Achilles tendon is done prior to the final cast to gain complete correction in most patients. Bracing with a foot abduction orthosis is necessary to minimize relapse of the deformity. The method begins with the Ponseti manipulation and consists of the following steps: (1) Identify the head of the talus by palpation. (2) Supinate the forefoot to eliminate the cavus deformity and create a normal-appearing arch. (3) Abduct the forefoot with the vector of force parallel to the sole of the foot while using the lateral head of the talus as the fulcrum and maintaining the reduction of the cavus deformity. (4) This manipulation is followed by the application of an above-the-knee cast with the foot in the corrected position. (5) The manipulation and casting steps are repeated every 5 to 7 days until the foot is abducted approximately 50° from the frontal plane of the tibia. (6) In most patients (60% to >90%), a percutaneous tenotomy of the Achilles tendon is necessary to correct the residual ankle equinus after gaining full abduction of the foot with the manipulations. (7) The final cast is applied and worn for three weeks. (8) After removal of the final cast, the patient is managed with bracing with a foot abduction orthosis for 23 hours per day for 3 months. Bracing at night and during nap time is recommended until the child is 4 to 5 years old. The cavus deformity is eliminated after the application of 2 or 3 casts by the simple positioning maneuver. Abduction of the forefoot in the plane of the sole of the foot while using the head of the talus as the fulcrum results in the correction of the midfoot adduction deformity simultaneously with the hindfoot varus and the subtalar component of the equinus deformity. After full abduction is obtained, the cavus, adduction, and subtalar varus and equinus deformities are all completely corrected. The only residual deformity is the ankle equinus. Most feet require a percutaneous tenotomy to fully correct the ankle component of the equinus. The tenotomy can be performed as an outpatient procedure under local anesthetic without the need for sedation. If the foot can be dorsiflexed to >15° (without midfoot breach), a tenotomy is unnecessary. This manipulation allows complete correction of almost all idiopathic clubfeet in 4 to 7 sessions. Long-term follow-up (mean, 34 years; range, 25 to 42 years) has shown that clubfeet treated with the Ponseti method function as well as normal feet with respect to pain and level of activity.