Increased Ankle Dorsiflexion Research Articles

The effect of collateral ligament release on ankle dorsiflexion: An anatomical study

Ankle stiffness is a common complication after ankle fracture, reconstructive surgery or total ankle replacement, and the usual limitation is in dorsiflexion. There are few articles in the literature concerning this frequent problem, and furthermore they are not recent and tend to be controversial. The purpose of this anatomical study was to evaluate and quantify the effect of ankle collateral ligament release on dorsiflexion, specifically the amount of increase in ankle dorsiflexion following section of the two ligaments most often implicated in ankle stiffness: the deep posterior tibiotalar ligament (dPTTaL, or posterior deep deltoid) and the posterior talofibular ligament (PTaFL). We dissected 18 adult fresh cadaveric ankle joints, and with an electronic goniometer combined with an electronic dynamometer measured their mobility in dorsiflexion before and after transection of each ligament separately, and the two ligaments combined. The results showed a significant difference between the two groups of ankles with section of the dPTTaL resulting in a greater increase in ankle dorsiflexion than section of the PTaFL (mean 7.45° vs. 3.5°, respectively; p<0.001). Combined section of both ligaments improved the gain in ankle dorsiflexion more than isolated section of each ligament, but was not statistically significant (p=0.88). If after gastrocnemius recession or Achilles tendon lengthening persistent restriction remains in ankle dorsiflexion, the results of our study demonstrate that the next step should be release of the dPTTaL.

Interventions for increasing ankle range of motion in patients with neuromuscular disease

Reduced ankle dorsiflexion range of motion, or ankle equinus, is a common and disabling problem for patients with neuromuscular disease. Clinicians devote considerable time and resources implementing interventions to correct this problem although few of these interventions have been subject to rigorous empirical investigation. To assess the effect of interventions to reduce or resolve ankle equinus in people with neuromuscular disease. We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (August 2009), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2009), MEDLINE (1966 to August 2009), EMBASE (1980 to August 2009), CINAHL 1982 to August 2009), AMED (1985 to August 2009) and The Physiotherapy Evidence Database (PEDro) (1929 to August 2009). We searched the reference lists of identified articles and also contacted known experts in the field to identify additional or unpublished data. Randomised controlled trials evaluating interventions for increasing ankle dorsiflexion range of motion in neuromuscular disease. Outcomes included ankle dorsiflexion range of motion, functional improvement, foot alignment, foot and ankle muscle strength, health-related quality of life, satisfaction with the intervention and adverse events. Two authors independently selected papers, assessed trial quality and extracted data. Four studies involving 149 participants met inclusion criteria for this review. Two studies assessed the effect of night splinting in a total of 26 children and adults with Charcot-Marie-Tooth disease type 1A. There were no statistically or clinically significant differences between wearing a night splint and not wearing a night splint. One study assessed the efficacy of prednisone treatment in 103 boys with Duchenne muscular dystrophy. While a daily dose of prednisone at 0.75 mg/kg/day resulted in significant improvements in some strength and function parameters compared with placebo, there was no significant difference in ankle range of motion between groups. Increasing the prednisone dose to 1.5 mg/kg/day had no significant effect on ankle range of motion. One study evaluated early surgery in 20 young boys with Duchenne muscular dystrophy. Surgery resulted in increased ankle dorsiflexion range at 12 months but functional outcomes favoured the control group. By 24 months, many boys in the surgical group experienced a relapse of achilles tendon contractures. There is no evidence of significant benefit from any intervention for increasing ankle range of motion in Charcot-Marie-Tooth disease type 1A or Duchenne muscular dystrophy. Further research is required.

Serial night casting increases ankle dorsiflexion range in children and young adults with Charcot-Marie-Tooth disease: a randomised trial

Does 4 weeks of serial night casting followed by 4 weeks of stretching of the gastrocnemius and soleus improve ankle dorsiflexion range and other outcomes compared with no intervention in children and young adults with Charcot-Marie-Tooth disease? Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. 30 children and young adults with Charcot-Marie-Tooth disease and restricted ankle dorsiflexion range. The experimental group received 4 weeks of serial night casting followed by 4 weeks of weightbearing stretches. The control group received no intervention. Primary outcome was ankle dorsiflexion range; secondary outcomes included foot deformity, mobility, balance, falls, and self-reported activity limitations. Outcomes were measured at baseline, 4, and 8 weeks. By 4 weeks, serial night casting had increased ankle dorsiflexion range by a mean of 4 deg (95% CI 2 to 6) more in the experimental group than the control group. After a further 4 weeks of weightbearing stretches, the experimental group still had a mean of 3 deg (95% CI 0 to 5) more ankle dorsiflexion range than the control group. Other than reduced time to walk 10 metres at self-selected pace favouring night casting at 4 weeks, outcomes did not differ between groups at any time point. Two minor adverse events were reported in the experimental group. 4 weeks of serial night casting increased ankle dorsiflexion range compared with no intervention, but at 8 weeks there was no significant difference between groups.

The Acute Effects of Local Vibration Therapy on Ankle Sprain and Hamstring Strain Injuries

Aims: The purpose of this study was to determine if biomechanical muscle stimulation (BMS) applied directly to different segments of the body using the Swisswing® device results in acute improvements in range of motion and perceived stiffness in physically active adults with acute or subacute ankle sprain and hamstring strain injuries. Methods: Two separate groups of individuals with grade I or II ankle sprain (n = 5; 21.2 ± 1.9 years) or hamstring strain (Nn= 5; 20.6 ± 1.8 year) underwent 20 minutes of a controlled therapy consisting of ice, compression, and elevation, and 10 minutes of segmental BMS using the Swisswing® at 20 Hz. Ankle (dorsiflexion, plantar flexion, inversion, eversion), hamstring flexibility, and subjective ratings of stiffness were assessed prior to control treatment (baseline), post-control treatment, and post-Swisswing® treatment. Results: Relative to the post-control condition, Swisswing® treatment significantly (P < 0.03 for all) increased ankle dorsiflexion and eversion and hamstring flexibility, and significantly (P ≤ 0.05) decreased perceived ankle and hamstring stiffness. Conclusion: Segmental BMS therapy using the Swisswing® device appears to have significant acute benefits for improving flexibility and reducing perceived stiffness in healthy adults with ankle or hamstring injury. Future research is needed to determine the duration of these effects and if repeated periods of segmental BMS therapy aid in long-term injury recovery.

Effect of Medial Arch Support on Displacement of the Myotendinous Junction of the Gastrocnemius During Standing Wall Stretching

Controlled laboratory study. To examine the effects of standing wall stretching with and without medial arch support (WMAS versus WOMAS) on the displacement of the myotendinous junction (DMTJ) of the medial gastrocnemius, rearfoot angle, and navicular height in subjects with neutral foot alignment and pes planus. Standing wall stretching is often prescribed to increase ankle dorsiflexion range of motion for sports fitness and rehabilitation. However, the effect of standing wall stretching WMAS on DMTJ is unknown. Fifteen subjects with neutral foot alignment and 15 subjects with pes planus performed standing wall stretching under WMAS and WOMAS conditions. Measurements of DMTJ and rearfoot position were performed using ultrasonography and video imaging. Navicular height was measured using a ruler. Dependent variables were examined with a 2-way mixed-design analysis of variance. The 2 factors were foot type (neutral foot versus pes planus) and stretching condition (WMAS versus WOMAS). There were significant interactions of medial arch support by foot type for DMTJ, rearfoot angle, and navicular drop (P<.001). A post hoc paired t test showed that standing wall stretching in the WMAS condition significantly increased the DMTJ, compared to stretching in the WOMAS condition, in subjects with neutral foot (mean +/- SD, 9.6 +/- 1.6 versus 10.5 +/- 1.6 mm; difference, 0.9 mm; 99% CI: 0.4-1.4 mm) and in those with pes planus (10.0 +/- 1.8 versus 12.7 +/- 2.0 mm; difference, 2.7 mm; 99% CI: 1.9-3.5 mm) (P<.001). When comparing WOMAS and WMAS, the difference in DMTJ (1.8 mm; 99% CI: 0.9-2.7 mm) was significantly greater in subjects with pes planus than in those with neutral foot (P<.001). Standing wall stretching with medial arch support maintained subtalar joint neutral position and increased the length of the gastrocnemius in subjects with pes planus. When prescribing standing wall stretching, clinicians need to emphasize the use of medial arch support to effectively stretch the gastrocnemius in subjects with pes planus.

Biomechanical and Anatomic Factors Associated with a History of Plantar Fasciitis in Female Runners

To compare selected structural and biomechanical factors between female runners with a history of plantar fasciitis and healthy control subjects. Cross-sectional. University of Delaware Motion Analysis Laboratory, Newark, Delaware; and University of Massachusetts Biomechanics Laboratory, Amherst, Massachusetts. Twenty-five female runners with a history of plantar fasciitis were recruited for this study. A group of 25 age- and mileage-matched runners with no history of plantar fasciitis served as control subjects. The independent variable was whether or not subjects had a history of plantar fasciitis. Subjects ran overground while kinematic and kinetic data were recorded using a motion capture system and force plate. Rearfoot kinematic variables of interest included peak dorsiflexion, peak eversion, time to peak eversion along with eversion excursion. Vertical ground reaction force variables included impact peak and the maximum instantaneous load rate. Structural measures were taken for calcaneal valgus and arch index during standing and passive ankle dorsiflexion range of motion. A significantly greater maximum instantaneous load rate was found in the plantar fasciitis group along with an increased ankle dorsiflexion range of motion compared with the control group. The plantar fasciitis group had a lower arch index compared with control subjects, but calcaneal valgus was similar between groups. No differences in rearfoot kinematics were found between groups. These data indicate that a history of plantar fasciitis in runners may be associated with greater vertical ground reaction force load rates and a lower medial longitudinal arch of the foot.

Effect of proprioceptive neuromuscular facilitation stretching on the plantar flexor muscle‐tendon tissue properties

Proprioceptive neuromuscular facilitation (PNF) stretching programs have been shown to be the most effective stretching technique to increase the range of motion (ROM). The objective of this study was to examine the mechanism of effect of PNF stretching on changes in the ROM. Sixty-two healthy subjects were randomized into two groups: a PNF stretching group and a control group. The PNF group performed a 6-week stretching program for the calf muscles. Before and after this period, all subjects were evaluated for dorsiflexion ROM, passive resistive torque (PRT) of the plantar flexors and stiffness of the Achilles tendon. The results of the study revealed that the dorsiflexion ROM was significantly increased in the PNF group (DeltaROMext: 5.97+/-0.671 degrees ; DeltaROMflex: 5.697+/-0.788 degrees ). The PRT of the plantar flexors and the stiffness of the Achilles tendon did not change significantly after 6 weeks of PNF stretching. These findings provide evidence that PNF stretching results in an increased ankle dorsiflexion. However, this increase in ROM could not be explained by a decrease of the PRT or by a change in stiffness of the Achilles tendon, and therefore can be explained by an increase in stretch tolerance.

Spatiotemporal and Kinematic Effect of Peroneal Nerve Stimulation Versus an Ankle-Foot Orthosis in Patients With Multiple Sclerosis: A Case Series

To compare the effect of a surface peroneal nerve stimulator (PNS) versus an ankle-foot orthosis (AFO) on spatiotemporal and kinematic parameters of gait in patients with multiple sclerosis. This was a case series design. Four subjects with multiple sclerosis and dorsiflexion weakness. Quantitative gait analysis with the use of (1) no device, (2) AFO, and (3) PNS as a single point-in-time assessment. Included walking speed, stride length, cadence, and double support time; kinematic parameters included peak pelvic obliquity during swing, peak contralateral hip abduction during stance, peak knee flexion and hip flexion during swing, ankle dorsiflexion at initial contact, and peak ankle internal rotation during swing. One-way analysis of variance was used to compare intrasubject performance under the 3 device conditions. The PNS significantly increased ankle dorsiflexion angle at initial contact, as compared with both no device and the AFO, in 3 of the 4 subjects. However, other spatiotemporal and kinematic gait parameters were more variably affected by the device conditions. With the exception of ankle dorsiflexion angle at initial contact, PNS and AFO have a variable effect on spatiotemporal and kinematic gait parameters in individual subjects with multiple sclerosis. Further studies are indicated to determine the clinical significance of intrasubject differences between device conditions.

The effects of neuromuscular electrical stimulation on clinical improvement in hemiplegic lower extremity rehabilitation in chronic stroke: A single-blind, randomised, controlled trial

Objective. In this study, the effectiveness of neuromuscular electrical stimulation (NMES) was evaluated in lower extremity rehabilitation in patients with chronic stroke.Method. The study enrolled 40 patients with chronic stroke. Twenty patients each were assigned to the treatment group and the control group. All patients received a conventional rehabilitation program for a 4-week period. In addition to this rehabilitation program, patients in the treatment group received NMES treatment for hemiplegic foot dorsiflexor muscles for 4 weeks, 5 days a week. The sessions were performed as one session per day and added to a total of 20 sessions. Clinical parameters were evaluated before and after the treatment.Results. Pre-treatment and post-treatment evaluations showed a significant increase in ankle dorsiflexion and a significant decrease in the level of spasticity in the treatment group (p < 0.05); however, there were no significant differences in the control group between the pre-treatment and post-treatment measures. Although Brunnstrom Stage, Rivermead leg and trunk score and Functional Independence Measurement motor subscore showed a significant improvement in pre- and post-treatment comparisons for both groups, the treatment group's scores were significantly higher than the control group (p < 0.05). Functional Ambulation Categories showed a significant improvement in both groups following the treatment; however, there was no significant difference between the two groups (p > 0.05).Conclusions. Use of NMES in hemiplegic foot dorsiflexion can contribute to the clinical improvement of patients when used in combination with rehabilitation programs.

Motor adaptation during dorsiflexion-assisted walking with a powered orthosis

A robotic ankle-foot orthosis (AFO) that provides powered assistance could adjust to varying gait dynamics much better than a rigid AFO. To provide insight into how humans would adapt to a powered AFO, we studied the response of neurologically intact subjects walking with an active dorsiflexion assist orthosis proportionally controlled by tibialis anterior electromyography (EMG). We examined the two mechanical functions of ankle dorsiflexors in gait (power absorption at heel strike and power generation at toe-off) by recruiting two groups of healthy subjects: Group One, called Continuous Control ( n = 5), had dorsiflexion assistance both at the initial heel contact and during swing; Group Two, called Swing Control ( n = 5), had the assistance only during swing. We hypothesized both groups of subjects would reduce tibialis anterior EMG amplitude with practice walking with the powered dorsiflexion assist. Ten healthy subjects were fitted with custom-made orthoses that included an artificial pneumatic muscle providing dorsiflexor torque. We collected lower body kinematics, EMG, and artificial muscle force while subjects walked on a treadmill for two 30-min training sessions. We found that subjects walked with increased ankle dorsiflexion by 9° but showed different adaptation responses of the two tibialis anterior EMG bursts. The first EMG burst around heel strike had ∼28% lower amplitudes ( p < 0.05) but the second EMG burst during swing had similar amplitudes. These results provide baseline data of EMG controlled dorsiflexion assist in neurologically intact humans that can be used to guide future studies on neurologically impaired individuals.

T.P.1.14 Interventions for increasing ankle flexibility in patients with neuromuscular disease: A Cochrane systematic review

Introduction: Reduced ankle flexibility (ankle equinus) is frequently exhibited in individuals with neuromuscular disorders and is thought to occur due to a number of active and passive neurophysiological mechanisms. In neuromuscular disorders such as Duchenne muscular dystrophy and Charcot-Marie-Tooth disease the evolution of ankle equinus is predictable and can cause a number of disabling secondary complications. Clinicians such as physiotherapists, podiatrists and orthopaedic surgeons are therefore eager to provide interventions which aim to reduce or resolve ankle equinus, although many of these require considerable time, energy and resources to implement. Unfortunately, few of these interventions have been subjected to rigorous investigation and much of our clinical practice continues to be guided by expert clinical opinion. Methods: We conducted a systematic review with the Cochrane Collaboration Neuromuscular Disease Group to identify randomised or quasi-randomised controlled trials of interventions to increase ankle dorsiflexion range of motion in people of any age with ankle equinus due to neuromuscular disease. Electronic searches of databases including CENTRAL (The Cochrane library 2007 Issue 4) MEDLINE (1950–present), EMBASE (from 1980 to present), CINAHL (1982–present), AMED (1985–present), EBM Reviews: ACP Journal Club (1991–present) and PEDro (1929–present). We also contacted known experts in the field to identify additional published or unpublished data. The primary outcome measure was change in quantifiable level of ankle dorsiflexion range of motion. Secondary outcome measures included functional ability, foot alignment, foot and ankle muscle strength, health-related quality of life, patient satisfaction with the intervention and adverse events. Results: The results of our systematic review will presented at the 13th International World Muscle Society Congress, 2008. Conclusion: The results of this review will assist in providing information regarding the effectiveness of interventions to reduce or resolve ankle equinus in neuromuscular disease and will allow for ongoing evaluation of these interventions in the literature.

Effects of back loading on the biomechanics of sit-to-stand motion in healthy children

The goal of the present study was to determine the thus far unstudied effects of back loading on the kinematics and kinetics of sit-to-stand (STS) motion in healthy children. Fifteen children (8 boys, 7 girls, mean age 9.6 years, SD 1.2 years) were tested with no back load and with a back load of 10% and 20% of body weight, respectively. A motion analysis system was used with six infrared cameras and two force plates. Total STS duration did not change; however, differential effects were shown for the durations of its phases. Back loading increased ankle dorsiflexion yielding a greater maximal dorsiflexion angle. Effects on the knee angle were limited except for a significant decrease in final knee flexion. Initial and maximal hip flexion increased but final hip angle did not change. Initial backward pelvic tilt decreased and a shift to forward pelvic tilt occurred at an earlier stage of STS motion. Back loading affected trunk motion: maximal and final forward shoulder tilt increased. Maximal ankle and knee moments and powers increased; however, hip joint kinetics was not affected significantly. Therefore, while maintaining the general pattern of STS motion, participants showed selectively significant adjustments to back loading during its different phases. The main kinematic adjustments were increased trunk flexion and greater ankle dorsiflexion, while the major kinetic adjustment was increased knee extension moment. Increased back loading yielded more pronounced effects, primarily in the ankle. In sum, back loading substantially affected the biomechanics of STS motion even for the lower load level studied. This finding may be of clinical relevance for musculoskeletal disorders, but this needs to be examined.

The effect of community-prescribed ankle–foot orthoses on gait parameters in children with spastic cerebral palsy

To evaluate the efficacy of ankle foot orthoses (AFOs) prescribed in the community for children with cerebral palsy (CP). Fifty-six children (32 boys and 24 girls, mean age 8.9 years, range 4-17) who were diagnosed as having CP were enrolled. They were grouped according to the type of CP, diplegic (n = 38) and hemiplegic (n = 18). Three-dimensional gait analyses while patient were barefoot and with AFOs were obtained and analyzed. The spatio-temporal findings were the most significantly changed as a result of AFO use. In the hemiplegic group, stride length was 11.7% (p = 0.001) longer with AFOs in both affected (10.2%) and non-affected (12.4%) legs, and cadence was reduced by 9.7%; walking speed was not affected. In the diplegic group, stride length with AFOs was 17.4% longer compared to barefoot (p < 0.001) and walking velocity improved by 17.8% (p < 0.001); cadence was unchanged. AFOs also increased ankle dorsiflexion at initial contact in both groups. In the hemiplegic group, AFOs produced an average 9.4 degrees increase of dorsiflexion at initial contact (IC) on the affected side (p < 0.001) and 5.87 degrees on the unaffected side (p = 0.007), and an increase of 9.9 degrees (p < 0.001) dorsiflexion at swing, on the affected side. In the diplegic group, dorsiflexion at IC was increased by 13.4 degrees on the right side and 7.8 degrees on the left side (p = 0.05; p > 0.001, respectively) and an increase of 6 degrees (p = 0.005) at swing. In the hemiplegic group of patients, knee flexion at initial contact on the affected side was reduced by 8.5 degrees (p = 0.032) while in the diplegic group we found no influence. The number of patients that reached symmetry at initial double support tripled (from 5.6 to 16.7%) with the use of AFOs. Our results showed that the use of AFOs improves spatio-temporal gait parameters and gait stability in children with spastic cerebral palsy. It has a lesser effect on proximal joint kinematics. Children with spastic hemiplegia display greater improvement than those with spastic diplegia.

Isolated Recession of the Gastrocnemius Muscle: The Baumann Procedure

The Baumann procedure consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles. The goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle. Unlike the Vulpius procedure, the Baumann procedure truly isolates the lengthening site to the gastrocnemius muscle and does not lengthen the soleus muscle. The Baumann procedure has not previously been studied in cadaver specimens. The gastrocnemius and soleus muscles of 15 normal cadaver specimens had four sequential releases: a single gastrocnemius recession, a second gastrocnemius recession, a single soleus recession, and an Achilles tenotomy. Ankle dorsiflexion was measured with a goniometer initially, after each muscle recession, and after the tenotomy. After the second gastrocnemius recession, the average increase in ankle dorsiflexion measured 14 degrees with the knee extended and 8 degrees with the knee flexed. The Baumann procedure treats equinus contracture of the gastrocnemius muscle by improving ankle joint dorsiflexion. The procedure is indicated when the results of the Silfverskiöld test are positive.

The effect of trunk flexion on able-bodied gait

This study examined the effect of sagittal trunk posture on the gait of able-bodied subjects. Understanding the effect of trunk posture on gait is of clinical interest since alterations in trunk posture often occur with age or in the presence of spinal pathologies, such as lumbar flatback. Gait analysis was conducted on 14 adults walking at self-selected slow, normal, and fast walking speeds while maintaining three trunk postures: upright, and with 25 ± 7° and 50 ± 7° of trunk flexion from the vertical. During trunk-flexed gait, subjects adopted a crouch posture characterized by sustained knee flexion during stance and an increase in ankle dorsiflexion and hip flexion angles. During stance, these kinematic adaptations produced a posterior shift in the positions of the trunk and pelvis, which helped to offset the anterior shift in the trunk mass that occurred with trunk flexion. In this way, kinematic adaptations may have been used to maintain balance by shifting the body's center of mass to a position similar to that of upright walking. These changes in lower limb joint kinematics created a phase lag in the position of the hip joint center relative to that of the ankle joint center in the sagittal plane. Alterations in the sagittal alignment of the hip and ankle joint positions were associated with a phase lag in the vertical position, velocity, and acceleration of the body's center of mass (BCOM) relative to upright walking. Since the vertical ground reaction force (GRF v) is proportional to the vertical acceleration of the BCOM, significant changes were also seen in the GRF v during trunk-flexed gait. In summary, kinematic adaptations necessary to maintain dynamic balance altered the trajectory and acceleration of the BCOM in the vertical direction, which was reflected in the GRF v. The results of this study may help clinicians better understand the nature and impact of compensatory mechanisms in patients who exhibit trunk-flexed postures during gait.

Die endoskopische Verlängerungsoperation des Musculus gastrocnemius zur Behandlung des Gastrocnemius equinus

Endoscopic gastrocnemius recession is a new technique to treat gastrocnemius equinus. Smaller incisions and the ability to perform the technique in a supine position are purported advantages. This study was designed to evaluate the results and possible complications of this new technique. 47 patients undergoing 54 endoscopic gastrocnemius recessions were followed in a prospective study. Pre-operative criteria were a lack of ankle dorsiflexion with the knee extended to create a 90 degrees relationship of the foot to the leg in symptomatic patients. Pre- and postoperative ankle dorsiflexion were assessed, as were complications such as infection, nerve injury, haematoma, over-lengthening and poor cosmesis. Mean age of the patients was 49.4 years. Post-operative follow-up from the index procedure was 27 months (range: 12 - 62 months). Pre-operative dorsiflexion was - 8 +/- 4 degrees; post-operative this improved significantly to 7 +/- 4 degrees (p = 0.00001). Most patients had additional reconstructive procedures. There were no infections; six limbs had lateral foot or leg dysaesthesia, one haematoma, one over-lengthened gastrocnemius while six limbs has an unacceptable cosmesis (due to tenting of the skin). Two diabetic patients required additional Achilles tendon lengthening in subsequent surgery. Patients with pre-operative dorsiflexion of - 10 degrees or more had an untoward result, but this was not statistically significant (p = 0.13). Lateral foot dysaesthesia was observed more often in patients having a combined procedure with calcaneal osteotomy (p = 0.03). The endoscopic gastrocnemius recession procedure can significantly increase ankle dorsiflexion, but has potential complications including lateral dysaesthesia (11 %), and unacceptable cosmesis (11 %) as the most common. Modifications to the technique may be needed. Overall, the endoscopic technique appears promising in decreasing gastrocnemius contracture.

Radiographic Evaluation of Idiopathic Clubfeet Undergoing Ponseti Treatment

Background: The Ponseti method for treatment of idiopathic clubfeet involves the use of serial casts, percutaneous Achilles tenotomy in most cases, and bracing with an abduction orthosis to prevent relapse. Although Ponseti recommended evaluation of the infant clubfoot strictly by palpation, many orthopaedic surgeons still rely on radiographs for decision-making during treatment. The aim of this study was to document with radiographs the effect of percutaneous Achilles tenotomy as described by Ponseti. Methods: We conducted a study of idiopathic clubfeet treated, at two centers, with the Ponseti method, including percutaneous Achilles tenotomy. Cast treatment was started within three weeks after birth, and radiographs were made before and after the tenotomy. Lateral radiographs with the foot in maximal dorsiflexion at the ankle were made for all patients, and anteroposterior radiographs of the foot were made at one center. The lateral tibiocalcaneal angle, the anteroposterior talocalcaneal angle, and the lateral talocalcaneal angle were measured on the radiographs. Foot dorsiflexion at the ankle was evaluated clinically. The results from both centers were evaluated separately and in combination. Results: Lateral dorsiflexion radiographs that showed the foot and ankle were evaluated for eighty-seven clubfeet, and anteroposterior radiographs that showed the foot were evaluated for sixty-five clubfeet. The mean improvement in the lateral tibiocalcaneal angle after the tenotomy was 16.9°. The mean change in the anteroposterior talocalcaneal angle was 2.1°, and the mean change in the lateral talocalcaneal angle change was 1.4°. The mean increase in clinically measured dorsiflexion after the tenotomy (in sixty-five feet) was 15.1°. Only the lateral tibiocalcaneal angle and dorsiflexion as measured clinically changed significantly after the Achilles tenotomy (p < 0.05). When the results at each center were analyzed separately, they were found to be nearly identical. Conclusions: The increase in the lateral tibiocalcaneal angle after Achilles tenotomy is essentially the same as the increase in ankle dorsiflexion seen on clinical examination. The anteroposterior and lateral talocalcaneal angles are not influenced significantly by the tenotomy. Radiographs confirmed that the additional dorsiflexion obtained from the percutaneous Achilles tenotomy is true dorsiflexion occurring in the ankle and hindfoot and not in the midfoot. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Radiographic Evaluation of Idiopathic Clubfeet Undergoing Ponseti Treatment

The Ponseti method for treatment of idiopathic clubfeet involves the use of serial casts, percutaneous Achilles tenotomy in most cases, and bracing with an abduction orthosis to prevent relapse. Although Ponseti recommended evaluation of the infant clubfoot strictly by palpation, many orthopaedic surgeons still rely on radiographs for decision-making during treatment. The aim of this study was to document with radiographs the effect of percutaneous Achilles tenotomy as described by Ponseti. We conducted a study of idiopathic clubfeet treated, at two centers, with the Ponseti method, including percutaneous Achilles tenotomy. Cast treatment was started within three weeks after birth, and radiographs were made before and after the tenotomy. Lateral radiographs with the foot in maximal dorsiflexion at the ankle were made for all patients, and anteroposterior radiographs of the foot were made at one center. The lateral tibiocalcaneal angle, the anteroposterior talocalcaneal angle, and the lateral talocalcaneal angle were measured on the radiographs. Foot dorsiflexion at the ankle was evaluated clinically. The results from both centers were evaluated separately and in combination. Lateral dorsiflexion radiographs that showed the foot and ankle were evaluated for eighty-seven clubfeet, and anteroposterior radiographs that showed the foot were evaluated for sixty-five clubfeet. The mean improvement in the lateral tibiocalcaneal angle after the tenotomy was 16.9 degrees . The mean change in the anteroposterior talocalcaneal angle was 2.1 degrees , and the mean change in the lateral talocalcaneal angle change was 1.4 degrees . The mean increase in clinically measured dorsiflexion after the tenotomy (in sixty-five feet) was 15.1 degrees . Only the lateral tibiocalcaneal angle and dorsiflexion as measured clinically changed significantly after the Achilles tenotomy (p < 0.05). When the results at each center were analyzed separately, they were found to be nearly identical. The increase in the lateral tibiocalcaneal angle after Achilles tenotomy is essentially the same as the increase in ankle dorsiflexion seen on clinical examination. The anteroposterior and lateral talocalcaneal angles are not influenced significantly by the tenotomy. Radiographs confirmed that the additional dorsiflexion obtained from the percutaneous Achilles tenotomy is true dorsiflexion occurring in the ankle and hindfoot and not in the midfoot. Therapeutic Level IV.

Percutaneous Achilles tendon lengthening: A cadaver-based study of failure of the triple hemisection technique

Background and purpose Modern descriptions of the percutaneous triple hemisection technique for Achilles tendon lengthening do not take into account the axial twist in the ligament. We were concerned that technical failures of the lengthening technique might occur more often than has been reported, and analyzed the results of the triple hemisection technique in cadaveric tendons in quantitative and qualitative terms, focusing on insufficient or complete tenotomies.Methods We performed a percutaneous triple hemisection of the Achilles tendon in 20 legs from adult cadavers, and measured the increase in ankle dorsiflexion in degrees, the length of the cuts in mm, and the depth of the cuts as a percentage of the total diameter of the tendon. Failure of the hemisection was defined as a sliding gap of ≤ 2 mm and/or a cut depth of ≤ 25% or < 75%.Results 21 of the 60 hemisections failed. These failures occurred in 12 of the 20 legs, and included 1 complete tendon rupture and 3 near-ruptures with only a few connecting fibers left.Interpretation Our findings support our hypothesis that technical failures in the triple hemisection procedure occur more often than acknowledged. Despite the scarce but good clinical results described in children, we suggest performing this technique as an open procedure, especially in cases where the boundaries of the tendon are less easily palpable (adults, obese children), and to use the largest possible distance between the hemisections.

Gait analysis role in long-term rehabilitation program in stiff-legged gait

The purpose was to determine the effects of a gastrocnemius stretching program on passive ankle dorsiflexion range of motion and ankle dorsiflexion and time-to-heel-off during the stance phase of gait.This study was a randomized-control trial design.The study was conducted in a biomechanical laboratory setting.Nineteen volunteers (17 women and 2 men, mean age=30.3 years; SD=9.8 years), with less than 8° of passive ankle dorsiflexion range of motion bilaterally and a history of lower extremity overuse injury were randomly assigned to the experimental (n=11) or control group (n=8).The experimental group participated in a static gastrocnemius stretching program of five repetitions held for 30-s, two times daily, for 3 weeks. The control group received no intervention.Passive ankle dorsiflexion range of motion and ankle dorsiflexion and time-to-heel-off during the stance phase of gait were measured before and after the intervention.The experimental group had significantly greater passive dorsiflexion range of motion at post-test than the control group on both the right (p=0.000) and left (p=0.002) sides. Ankle dorsiflexion and time-to-heel-off during the stance phase of gait were not different among group, time, or foot (p>0.05).A gastrocnemius stretch performed two times daily, for 3 weeks increased passive ankle dorsiflexion, but did not alter ankle dorsiflexion or time-to-heel-off during the stance phase of gait. Thus, when an increase in ankle dorsiflexion or time-to-heel-off during the stance phase of ambulation is a clinical goal, it is unlikely to result from the stretching regimen used in this study.