The definition of equinus varies from less than 0° to less than 25° of dorsiflexion with the foot at 90° to the leg. Despite its pervasive nature and broad association with many lower-extremity conditions, the prevalence of ankle equinus is unclear. Furthermore, there are few data to suggest whether equinus is predominantly a bilateral finding or isolated to the affected limb only.
We conducted a prospective cohort study examining consecutive patients attending a single foot and ankle specialty practice. Participation involved an assessment of ankle joint range of motion by a single rater with more than 25 years of clinical experience. We defined ankle equinus as ankle joint dorsiflexion range of motion less than or equal to 0° and severe equinus as less than or equal to –5°. Patients who had previously experienced an Achilles tendon rupture, undergone posterior group lengthening (ie, Achilles tendon or gastrocnemius muscle lengthening), or had conservative or surgical treatment of equinus previously were excluded.
Of 249 included patients, 61% were female and 79% nondiabetic. The prevalence of ankle equinus was 73% [183 of 249], and nearly all of these patients had bilateral restriction of ankle joint range of motion (prevalence of bilateral ankle equinus was 98.4% [180 of 183] among those with equinus). We also found that ankle equinus was more common in patients with diabetes, higher body mass indexes (BMIs), or overuse symptoms.
The prevalence of ankle equinus in this sample was higher than previously reported, and nearly all of these patients had bilateral involvement. These data suggest that many people attending foot/ankle specialty clinics will have ankle equinus, and select groups (diabetes, increased BMI, overuse symptoms) are increasingly likely.
Angioleiomyomas are benign tumefactions that originate from smooth muscle in vascular structures and are difficult to definitively diagnose preoperatively. Although these lesions are rarely encountered in the foot, the lower extremity is the most common site of occurrence. An angioleiomyoma typically manifests as a small, painful, solitary, mobile lesion. This case report describes a lateral retromalleolar para–Achilles tendon insertional location for a moderately sized immobile solid tumefaction in the subcutaneous tissues. The lesion was nonpainful and progressively enlarged over 5 years. An excisional biopsy was performed, and the nodular lesion was subsequently diagnosed histopathologically as an angioleiomyoma. Owing to the ambiguous nature of the clinical findings, angioleiomyoma should be included in the differential diagnosis of lower-extremity soft-tissue manifestations.
The acute rupture of the tibialis posterior (TP) tendon, compared to an acute rupture of the Achilles tendon, is a quite uncommon disease to be diagnosed in the emergency department setting. In most cases symptoms related to a TP dysfunction, like weakness, pain along the course of the tendon, swelling in the region of the medial malleolus, and the partial or complete loss of the medial arch with a flatfoot deformity precede the complete rupture of the tendon. In this case report, we describe an acute rupture of the TP tendon following a pronation-external rotation injury of the ankle with no association of a medial malleolus fracture and with no history of a prior flatfoot deformity or symptoms.
Background: Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia. This prospective study examines the efficacy of extracorporeal shockwave therapy in the treatment of chronic Achilles tendon disorders.
Methods: Twenty-three patients (23 feet) were treated with extracorporeal shockwave therapy for Achilles tendinosis, insertional tendonitis, or both. Indications for treatment were a minimum of 6 months of conservative care, and a visual analog pain score > 5. The mean follow-up was 20 months (range, 4–35 months).
Results: Ninety-one percent (14 patients) were satisfied or very satisfied (23 patients) with treatment. Eighty-seven percent (20 patients) stated that extracorporeal shockwave therapy improved their condition, 13% (3 patients) said it did not affect the condition, and none stated that it made them worse. Eighty-seven percent (20 patients) stated they would have the procedure again if given the choice. Four months after extracorporeal shockwave therapy, the mean visual analog score for morning pain decreased from 7.0 to 2.3, and activity pain decreased from 8.1 to 3.1.
Conclusion: High-power extracorporeal shockwave therapy is safe, noninvasive, and effective, and it has a role in the treatment of chronic Achilles tendinopathy. (J Am Podiatr Med Assoc 98(6): 466–468, 2008)
Plantaris tendon disorders are a well-known source of midportion Achilles tendinopathy. Plantaris tendon thickening and fibrous tissue formation between the tendons are the histologic abnormalities that are typically observed. Surgical approaches (scraping of the Achilles medial and ventral paratendinous tissues and excision of the plantaris tendon) have already shown good clinical outcomes; despite this, the cost-benefit ratio of these interventions may be unfavorable, and their accessibility is limited. Percutaneous needle electrolysis is a minimally invasive ablative technique increasingly being considered for the treatment of tendinopathies and associated conditions. Herein we introduce a novel procedure to treat plantaris tendon–related midportion Achilles tendinopathy. The procedure starts with the ultrasound-guided insertion of an uncoated needle (diameter, 0.30–0.40 mm; length, 30 mm) between the plantaris and Achilles tendons. Subsequently, galvanic current (intensity, 2 mA) is locally transferred, which induces instant nonthermal electrochemical ablation of the intertendinous tissues in close proximity to the needle, finally debriding the plantaris tendon. To further promote its release, the second part of the procedure involves partial tenotomy of the lateral peripheral aspects of the plantaris tendon. Usually, the session does not exceed 30 min. Percutaneous needle electrolysis may be considered as a valid alternative to surgery. The outpatient procedure presented herein is, in fact, safe and quick to perform. In addition, long suspension of working or sporting activities after treatment is not required. Future investigations are needed to ascertain the short- and long-term therapeutic outcomes of plantaris tendon–related midportion Achilles tendinopathy treatment, in particular by comparing them with those obtained with other mini-invasive interventions.
Background: The purpose of this study was to determine whether magnetic resonance imaging findings are accurate and can be confirmed surgically.
Methods: Surgical correlation of preoperative magnetic resonance imaging findings of trauma to tendons and ligaments of the foot and ankle were retrospectively studied in 28 patients who had undergone surgical repair for tears of the Achilles tendon, posterior tibial tendon, peroneal tendons, collateral ligaments, and other pathology.
Results: This study corroborates that magnetic resonance imaging findings are confirmed surgically 83% of the time for tears of tendons and ligaments of the foot and ankle. Larger tendons (Achilles, posterior tibial tendon) have a 94% sensitivity and 6% specificity, respectively. Collateral ligament and high ankle sprains have a 73% sensitivity. There is a lower sensitivity of 57% for peroneus brevis and longus ruptures.
Conclusion: This study revealed that peroneal trauma can be an isolated event and in some cases can occur with other traumatic pathology such as collateral ligament tears. (J Am Podiatr Med Assoc 98(5): 370–373, 2008)
The intent of this study was to determine whether differences in function, walking characteristics, and plantar pressures exist in individuals after operative fixation of an intra-articular calcaneal fracture (HFX) compared with individuals with operative repair of an Achilles tendon rupture (ATR).
Twenty patients (ten with HFXs and ten with ATRs) were recruited approximately 3.5 months after operative intervention. All of the participants completed the Lower Extremity Functional Scale and had their foot posture assessed using the Foot Posture Index. Walking velocity was assessed using a pressure mat system, and plantar pressures were measured using an in-shoe sensor. In addition to between-group comparisons, the involved foot was compared with the uninvolved foot for each participant.
There were no differences in age, height, weight, or number of days since surgery between the two groups. The HFX group had lower Lower Extremity Functional Scale scores, slower walking velocities, and different forefoot loading patterns compared with the ATR group. The involved limb of both groups was less pronated.
The results indicate that individuals with an HFX spend more time on their involved limb and walk slower than those with an ATR. Plantar pressures in the HFX group were higher in the lateral forefoot and lower in the medial forefoot and in the ATR group were symmetrically lower in the forefoot.
Percutaneous Achilles tenotomy is an essential step in the Ponseti treatment of idiopathic clubfoot, with reported complications such as injury to the surrounding neurovascular structures and incomplete division of the Achilles tendon (AT). Knowledge of AT thickness would guide tenotomy blade insertion depth, obviating these related complications. We embarked on this study to ultrasonographically determine AT thickness at its different levels from the calcaneal insertion in children with idiopathic clubfoot.
This prospective comparative study consisted of two groups of children 4 years and younger: a study group of patients with clubfoot requiring tenotomy and a control group. Both groups underwent ultrasonographic evaluation of their AT. The ultrasonographic data collected include AT thickness 1 and 2 cm from the calcaneal insertion of the AT, thickness of the thinnest portion of the tendon, and the distance of this thinnest portion from the calcaneal insertion.
Twenty-seven children with idiopathic clubfoot constituted the study group, and 23 children with no musculoskeletal deformity were enrolled in the control group. Mean ± SD AT thicknesses 1 and 2 cm from the calcaneal insertion in the study group were 2.4 ± 0.7 mm and 2.1 ± 0.7 mm, respectively, and in the control group were 2.5 ± 0.7 mm and 2.3 ± 0.7 mm, respectively. The average thickness of the thinnest portion of the AT along its length was 2 mm at 1.8 cm from the calcaneal insertion in both groups.
Safe and complete percutaneous tenotomy would most likely be achieved when performed 1.8 cm from the calcaneal insertion, where the corresponding average AT thickness of 2 mm would be a guide to determine the insertion depth of the tenotomy blade.
The diagnosis of Sever’s injury (apophysitis calcanei) has previously been partly based on radiographic findings in the calcaneal apophysis. Sclerosis and fragmentation have been supposed to represent signs of inflammation due to tractions from the Achilles tendon. The clinical findings, diagnostic criteria, and studied population are often poorly defined. We sought to define diagnostic criteria by analyzing clinical and radiographic characteristics in a population with Sever’s injury and to compare the findings with those of a control group of matched, symptom-free children.
We assessed 30 consecutive children with Sever’s injury with high levels of pain but high physical activity levels in sports activities and 15 pain-free matched controls.
One-leg heel standing showed 100% sensitivity; the squeeze test, 97%; and the palpation test, 80%. All three tests showed 100% specificity. All of the patients and controls showed increased density of the apophysis. Half of the pain-free controls showed fragmentation versus almost 90% of children with heel pain.
The diagnosis of Sever’s injury is clinical, not radiologic. Radiologic findings of increased density and fragmentation are found also in pain-free controls with high levels of physical activity and may, therefore, represent normal growth and development. We suggest that the diagnosis of Sever’s injury should be based on patient history and the results of two specific clinical tests. (J Am Podiatr Med Assoc 103(5): 361–368, 2013)
In the Ponseti technique, the residual equinus deformity is corrected with percutaneous tenotomy. This experimental study aimed to compare the safety and effectiveness of a large-gauge needle, a corneal knife, and a No. 11 blade in percutaneous achillotomy performed in rats.
Ninety Achilles tendons of 45 Sprague-Dawley rats were analyzed, following division into three study groups. In the study, group I (needle), group II (corneal knife), and group III (No. 11 blade) were compared on the basis of bleeding, incision length, requirement for primary suture, range of motion, and resulting neurovascular injury at day 0. Moreover, the groups were compared in terms of range of motion, macroscopic and microscopic adhesions, and tenocyte morphology at days 21 and 42 postoperatively.
On day 0, one suture was required in group III, whereas in groups I and II, no sutures were required. Postoperative bleeding was greater in group III and similar in groups I and II. Neurovascular injury was not observed in any of the groups. Three incomplete tenotomies were observed in group III and one incomplete tenotomy was observed in group II. Importantly, all tenotomies were complete in group I. In all groups, the range of motion was similar. The macroscopic adhesion score revealed high adhesion in group III (P = .009). According to Tang's criteria, microscopic adhesion was significantly higher on day 21 in group III compared with the other groups (P <0.001). No significant differences were observed in tenocyte morphology based on the Bonar criteria (P = .850).
In the results obtained from this animal study, we observed less bleeding, less adhesion, and less incomplete tenotomy in the large-gauge needle and corneal knife groups compared with the No. 11 blade group during the percutaneous Achilles tenotomy performed in rats.