Pes cavus deformity11/26/2022 Another way of measuring the alignment of the calcaneus is “calcaneal pitch,” where on a lateral view a line drawn along the base of the calcaneus should slant upward from the horizontal surface by 20 to 30 degrees. If measurement is desired, the angle between the longitudinal axis of the tibia and the calcaneus (measured along its base) ranges between 60 and 90 degrees ( Fig. Normally the calcaneus is dorsiflexed relative to the plantar surface of the foot. It is evaluated only on a lateral weight-bearing radiograph. Hindfoot equinus is the easiest concept of the three. Overall, several key principles should be applied to the management of equinus: (i) define whether the equinus is fixed or dynamic or a combination of both, (ii) avoid early surgery and continue with conservative management for as long as possible, (iii) remember that surgery for fixed equinus often needs to be combined with multilevel surgery at the hip or knee rather than being performed in isolation, and (iv) lengthening interventions at higher levels in the calf minimize detrimental effects on calf muscle power generation but give less correction of equinus. Procedures that lengthen the Tendo Achilles should be avoided in individuals with spastic diplegia who are less than 8 years, as they seem to have the highest rate of overcorrection with time ( Borton et al. Overall, the rate of overcorrection with time averaged only 1% of children with spastic hemiplegia, compared with 15% (range 0% to 41%) in children with spastic diplegia. The results also appeared better when early surgery was avoided, with the authors commenting that delaying surgical intervention to over the age of 6 years may significantly improve outcomes and reduce the risk of recurrent equinus and overlengthening. The authors did not calculate any effect sizes, but noted that the topographical distribution of cerebral palsy may well be the strongest determinant of outcome of the surgical intervention, with results being worse in children with bilateral involvement (diplegia). Overlengthening is particularly deleterious, impairing force generation by the calf and contributing to the development of crouch gait, with excessive ankle dorsiflexion and increased hip and knee flexion.Ī recent systematic review of the management of equinus found that most surgical studies provided low levels of positive evidence ( Shore et al. The major complications of surgery for equinus include both recurrence of deformity and overlengthening of the calf muscle. Surgical procedures can be carried out at different levels or zones in the calf muscle: zone 1 is the most proximal zone beginning proximal to the gastrocnemius heads, zone 2 represents the mid-portion between the Tendo Achilles and the gastrocnemius heads, and zone 3 is the Tendo Achilles ( Shore et al. As a result there is a large amount of published literature on the management of equinus, much of which is confusing for the reader. due to static contracture in the calf muscle).Įquinus overall is a very common and visible problem in children with cerebral palsy. due to increased tone in the calf muscle) or fixed (i.e. ‘True equinus’ in gait is either dynamic (i.e. ‘Apparent equinus’ is commonly seen in children with more proximal involvement at the hip and knee joints, and management should be directed at the hip and knee position rather than the ankle. the ankle is in plantarflexion) or ‘apparent equinus’, where the heels are off the ground but the ankle is at neutral position relative to the shank. Equinus posturing in gait, or toe walking, can be due to either ‘true equinus’ (i.e. a plantarflexed position of the ankle in gait), which may or may not reflect a lack of dorsiflexion at the ankle. However, the term ‘equinus’ is also often used to describe equinus posturing in gait (i.e. Susan Stott, in Management of Chronic Conditions in the Foot and Lower Leg, 2015 Equinus Deformityįixed equinus at the ankle is defined as the inability to dorsiflex the ankle passively to plantargrade with the hindfoot in subtalar neutral and the knee extended.
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