Equinus

Equinus is a condition of the foot and ankle that refers to a tight Achilles tendon.  The Achilles tendon is composed of the tendons of two muscles – the gastrocnemius and the soleus.  Together, these two muscles form the strongest tendon in the entire body, which inserts into the calcaneus (heel bone). 

The Achilles tendon can become tight in one of several ways.  Spastic equinus is the oldest recognized form of equinus, and is seen as a result of upper motor neuron disease.  This may include cerebral palsy, stroke, or spinal trauma and disease.  Congenital equinus refers to equinus typically caused by a shortened Achilles tendon, which is present at birth.  This may result in prolonged toe walking in the developing pediatric patient. 

Most commonly, equinus is an acquired deformity, due to a tightness of the gastrocnemius muscle, the soleus, or both.  This tightness develops over time, and can be worsened by wearing high-heeled shoes, being casted for a lengthy period of time, or from overuse without stretching.  Bony equinus can also present, which is a block of both that prevents the ankle from dorsiflexing, or moving upwards. 

Equinus is possibly the most common cause of foot pathology.  When the Achilles tendon is tight, the body compensates for this in order to bring the heel to the ground.  This is often done by pronating at the subtalar joint, which is the joint located just below the ankle.  This extra pronation can lead to a number of foot problems, such as  plantar fasciitis, flatfoot, tendintis, arthritis, bunions, hammertoes, ankle pain, and a number of other conditions.  Thus, equinus is not necessarily a painful problem, but the compensation for it can cause several painful problems. 

Treatment of equinus should begin with an aggressive stretching program to address the tightness of the Achilles tendon.  Because of it’s relationship to the plantar fascia, the two structures forming a type of sling around the calcaneus, plantar fascia stretches are often incorporated as well.  Combined with the use of orthotics to maintain foot structure when walking, conservative treatment is often helpful for those with equinus.  Heel lifts may also be used to address some of the compensation for equinus at the subtalar joint, as it effectively lessens the amount of space that must be compensated for. 

Occassionally surgery may be necessary if the equinus is not relieved with conservative measures, and is causing significant foot pathology.  Surgery may involve lengthening of the Achilles tendon itself, or lengthening of either the gastrocnemius muscle, the soleus muscle, or both.  These procedures are often combined with foot procedures such as flatfoot or bunion correction, as they are often indicated as the deforming force in a foot deformity.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Surgery for Lateral Ankle Stabilization

Chronic ankle sprains are a problem that plagues many individuals. Once the ligaments of the ankle have been compromised, they are subject to repeat injury. A person with chronic ankle sprains will often report an initial injury, possibly one that was never treated. There is usually constant swelling and pain at the ankle, and a feeling of instability, as if the ankle might give out at any time.

Chronic ankle instability can develop from damage to the nerve endings in the ligaments responsible for proprioception. Proprioception is the body’s ability to know where a particular part lies in space. Repetitive or chronic injury to the ankle ligaments can damage the proprioceptors in the ankle, leading to that feeling of instability. A person with chronic ankle injuries may also have attenuated, stretched out, and weakened ligaments, particularly of the lateral ankle.

Most commonly, the ligament that is damaged is the anterior talo-fibular ligament, or the ATFL. The calcaneofibular ligament (CFL) or posterior talo-fibular ligament (PTFL) may also be involved, as well as the extensor retinaculum, peroneal tendons, or the joints in the area such as the calcaneocuboid, tarso-metatarsal joints, subtalar joint, or the ankle joint itself. In high ankle sprains, the tibiofibular syndesmosis may also be injured.

Conservative care for chronic ankle injury revolves around protecting the ankle with high-top shoes or braces. These devices may work well in some individuals, but fail to offer enough support in others. In particular, high-performance athletes may be candidates for surgical repair of the ligaments if and when conservative therapy fails.

Surgery for lateral ankle instability focuses on reconstructing the lateral ankle and adding stability to the joint. There are a number of different techniques to do this. Most frequently, cases of chronic ankle instability are due to injury of the ATFL, or a combination of the ATFL and CFL. Depending on the extent of the injury, various procedures may serve to reconstruct and/or repair these ligaments.

Several procedures exist that use the peroneus brevis tendon, the extensor retinaculum, or both to reconstruct the ATFL and/or the CFL. These procedures may involve drilling a small hole in the tip of the fibula or the talus, and re-routing the tendon through the holes. When done correctly, this can add significant stability to the ankle joint.

Another technique involves using soft tissue from another part of the body, such as the tensor fascia lata in the hip and thigh, as a graft to reconstruct the ligaments. Cadaveric grafts or synthetic materials may also be used.

Many variables play into the decision-making of the surgeon and patient. The goals of the patient and the surgeon should be clearly communicated, as well as possible complications of the surgery and shortfalls that may exist. Lateral ankle reconstruction may not be an option for some patients, such as those with systemic conditions that may complicate the surgery or postpone healing. A thorough discussion should be had with a foot and ankle surgeon to assess the situation.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com