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equinus with orthotics

Posted by joshs on 5/30/01 at hrmin (049413)

At the Langer Biomechanics website (www.ibguk.com/foot.htm) has this sentence at end of introductory paragraph: 'Patients with soft tissue equinus should be carefully screened before controlling devices are considered.'

Why?

Re: equinus with orthotics

Dr. Zuckerman on 5/30/01 at 23:22 (049426)

You need to screen for equinus period when doing a foot evaluation. Equinus can cause the pronatory compensation. I would think that boney equinus is much more important to rule out before precribing a controlling orthosis.

Re: equinus with orthotics

bg cped on 6/02/01 at 23:42 (049722)

You are right Dr Z, boney can be much more problematic. My opinion is that many orthotics that cant be tolerated is from too high medial arch and lack of rearfoot control/correction. Also tight h-cords that drive the midfoot collapse into the medial arch will have a low tolerance for orthotic if it does not have sufficient rearfoot control e.g. device with a high arch and little or no heel post or lift. Too much forefoot posting can also cause problems in this foot type

Re: equinus with orthotics

josh s on 6/04/01 at hrmin (049811)

Thanks,

I asked this question because of an article by a DC here: http://www.chiroweb.com/archives/12/15/20.html . A Dr. Keith Innes, describing a case of Equinus states: 'The patient will have a myriad of symptoms but the cause will be a loss of ten degrees of dorsiflexion. Early heel off and a torsioning into abduction of the twisted osteoligamentous plate of hte mid and forefoot is the first and most obvious sign. Because of the twisting effect of the lower limb the patient will appear to be a pronator and will most likely be given an orthotic to correct the illusionary pronation. Please note that even after the orthotic device is in place the patient will not be able to squat, in fact, the orthotic will have converged the axes of the transverse tarsal joints and locked up the midfoot. This will cause a lifetime of misery to the patient.'

The first DPM I saw diagnosed bilat. gastroc soleus equinus. He said the end feel was spongy as in a soft tissue restriction but did'nt know for sure. He noted upon gait analysis that I had an abductory twist at toe off. He also loaned me Valmassey's '...Biomechanics of Lower Extremity' which has a section on pediatric podiatry that describes the variations of equinus and the typical compensation strategies. Abductory twist and early heel lift/unlocked midtarsal joint were listed. This text recommended orthotic therapy and mentioned that if the equinus was truly congenital and thus unresolvable that either the patient would break orthotic device with midfoot collapse or would develop another compensation strategy such as early heel lift or genu recurvatum. If the equinus contraction was secondary to subtalar pronation, the orthotic, by controlling such pronation and preventing compensatory midfoot dorsiflexion by locking the transverse tarsal joints as described above would actually encourage or force the development of calf flexibility and resolve the equinus. This possibility was advocated by the doctor who prescribed my 1st set of orthotics.

Recently, searching the net I found various references outlining different strategies for accomodating equinus such as casting in a more pronated position, more arch fill, more flexible orthotic materials, etc. It seems with such strategies that the type of motion control necessary to force ankle dorsiflexion is not the goal. My spoke as though this was his Inent though he used a moderately flexible orthotic to accomplish it. Unfortunately he is now in the middle of the pacific and my new DPM does'nt think I have Equinus at all.

In my opinion the orthotic described above has not resolved my equinus(I tried Scott's flexion test with toes to wall today and came up four or five inches short of touching the wall unless I let my arches collapse and pronated into increased midfoot dorsiflexion). My desire is to resolve the equinus, I do not think I will be able to function at the level I would like unless I do.

At present am acting as my own physician which according to the proverb makes me a fool. Following the logic of Valmassey's book my six months of orthotic therapy with little apparent (to me) increase in ankle dorsiflexion would seem to indicate either congenital soft tissue equinus or a bony block. History of severe inversion sprain makes a blockage possible I suppose. This is of course assuming the orthotic was designed with enough control to achieve this.

The quotation above contains two statements I don't understand. The first is that the orthotic will cause a liftetime of misery for the patient. I wonder if he is describing the intolerance noted by bg cped for a device with too little rearfoot control. Could such a device cause a 'lifetime of misery for patient'? Apparently the author is describing the congenital or bony variety that Valmassey's text said would break the device (have you ever heard of that, it seems the foot would give first).My orthotics have not helped much thus far but I'm not sure if they could be causing me harm. If I'm careful to use a high enough heel that seems to help, but then there goes the orthotic forced dorsiflexion strategy. Stretching in my case as I've noted in other posts has not seemed to help, is there a more efficient way to determine the cause and the thus the proper resolution for an equinus.

The second puzzling quoted statement is that pronation in the equinus patient is illusory and is actually the abductory twist. The DPM mentioned above told me that the abductory twist was in compensation for the hyperpronation, that the foot was pronating so far that it had to twist into supination/abduction in order to get off the ground. I've since read it described in different terms but still rearfoot pronation is a component. Strangely my present DPM remarked that I did not have as much pronation as he expected, though that could be result of walking performance style which cannot be sustained once gone from doctors office. Maybe here the DC author is wrong. Is'nt rearfoot hyperpronation always present with an unlocked midtarsal joint in gait?

Reading this it occurs to me that I've become unhealthily obsessed with biomechanics. However in present circumstances I feel I must search for the primary cause(s) of my troubles in order to real long term solutions.

Re: equinus with orthotics

Scott R on 6/04/01 at 08:28 (049822)

Josh, let me see if I understand correctly. When you stand facing a wall so that your toes touch the bottom of the wall your knees do not touch the wall when you squat?

Re: equinus with orthotics

wendyn on 6/04/01 at 13:15 (049861)

Mine do not either. I tried this as one of your data base tests and gave myself a whole lot of increased pain afterwards.

I have also been diagnosed with 'Gastroc equinus contracture'.

Re: equinus with orthotics

wendyn on 6/04/01 at 13:35 (049865)

Hmm - just tried it now and I seem to be able to do it. Can you repost somewhere the instructions you'd given before for this? I think there was something in there that was different from what I am doing now.

Re: equinus with orthotics

josh s on 6/04/01 at hrmin (049869)

Yes Scott, just as it's shown in your book. I can get close to touching if I allow my ankles and knees to roll inward (valgus) and pronate, which tends to bring forth pain in plantar fascia and deeper in medial arch.
The first time this became problematic was when I was nineteen and began studying tai chi chuan which really requires the kind of flexibility exhibited in your second wall crouch illustration. I compensated by rolling in and developed patella problems and then foot trouble.

Re: equinus with orthotics-sqatting

josh s on 6/04/01 at hrmin (049875)

Scott, just re-read your question. As far as sqatting, which is the subtitle of the article I quoted, I cannot squat with heels on the ground. In your semi-squat test If I allow my heels to leave the ground I could touch knees to wall. If I allowed inward collapse at ankles I maybe could squat but then I'd be resting completely on inside edges of feet and heel which attempted feels unsafe for feet and knees.

Re: equinus with orthotics

Dr. Zuckerman on 5/30/01 at 23:22 (049426)

You need to screen for equinus period when doing a foot evaluation. Equinus can cause the pronatory compensation. I would think that boney equinus is much more important to rule out before precribing a controlling orthosis.

Re: equinus with orthotics

bg cped on 6/02/01 at 23:42 (049722)

You are right Dr Z, boney can be much more problematic. My opinion is that many orthotics that cant be tolerated is from too high medial arch and lack of rearfoot control/correction. Also tight h-cords that drive the midfoot collapse into the medial arch will have a low tolerance for orthotic if it does not have sufficient rearfoot control e.g. device with a high arch and little or no heel post or lift. Too much forefoot posting can also cause problems in this foot type

Re: equinus with orthotics

josh s on 6/04/01 at hrmin (049811)

Thanks,

I asked this question because of an article by a DC here: http://www.chiroweb.com/archives/12/15/20.html . A Dr. Keith Innes, describing a case of Equinus states: 'The patient will have a myriad of symptoms but the cause will be a loss of ten degrees of dorsiflexion. Early heel off and a torsioning into abduction of the twisted osteoligamentous plate of hte mid and forefoot is the first and most obvious sign. Because of the twisting effect of the lower limb the patient will appear to be a pronator and will most likely be given an orthotic to correct the illusionary pronation. Please note that even after the orthotic device is in place the patient will not be able to squat, in fact, the orthotic will have converged the axes of the transverse tarsal joints and locked up the midfoot. This will cause a lifetime of misery to the patient.'

The first DPM I saw diagnosed bilat. gastroc soleus equinus. He said the end feel was spongy as in a soft tissue restriction but did'nt know for sure. He noted upon gait analysis that I had an abductory twist at toe off. He also loaned me Valmassey's '...Biomechanics of Lower Extremity' which has a section on pediatric podiatry that describes the variations of equinus and the typical compensation strategies. Abductory twist and early heel lift/unlocked midtarsal joint were listed. This text recommended orthotic therapy and mentioned that if the equinus was truly congenital and thus unresolvable that either the patient would break orthotic device with midfoot collapse or would develop another compensation strategy such as early heel lift or genu recurvatum. If the equinus contraction was secondary to subtalar pronation, the orthotic, by controlling such pronation and preventing compensatory midfoot dorsiflexion by locking the transverse tarsal joints as described above would actually encourage or force the development of calf flexibility and resolve the equinus. This possibility was advocated by the doctor who prescribed my 1st set of orthotics.

Recently, searching the net I found various references outlining different strategies for accomodating equinus such as casting in a more pronated position, more arch fill, more flexible orthotic materials, etc. It seems with such strategies that the type of motion control necessary to force ankle dorsiflexion is not the goal. My spoke as though this was his Inent though he used a moderately flexible orthotic to accomplish it. Unfortunately he is now in the middle of the pacific and my new DPM does'nt think I have Equinus at all.

In my opinion the orthotic described above has not resolved my equinus(I tried Scott's flexion test with toes to wall today and came up four or five inches short of touching the wall unless I let my arches collapse and pronated into increased midfoot dorsiflexion). My desire is to resolve the equinus, I do not think I will be able to function at the level I would like unless I do.

At present am acting as my own physician which according to the proverb makes me a fool. Following the logic of Valmassey's book my six months of orthotic therapy with little apparent (to me) increase in ankle dorsiflexion would seem to indicate either congenital soft tissue equinus or a bony block. History of severe inversion sprain makes a blockage possible I suppose. This is of course assuming the orthotic was designed with enough control to achieve this.

The quotation above contains two statements I don't understand. The first is that the orthotic will cause a liftetime of misery for the patient. I wonder if he is describing the intolerance noted by bg cped for a device with too little rearfoot control. Could such a device cause a 'lifetime of misery for patient'? Apparently the author is describing the congenital or bony variety that Valmassey's text said would break the device (have you ever heard of that, it seems the foot would give first).My orthotics have not helped much thus far but I'm not sure if they could be causing me harm. If I'm careful to use a high enough heel that seems to help, but then there goes the orthotic forced dorsiflexion strategy. Stretching in my case as I've noted in other posts has not seemed to help, is there a more efficient way to determine the cause and the thus the proper resolution for an equinus.

The second puzzling quoted statement is that pronation in the equinus patient is illusory and is actually the abductory twist. The DPM mentioned above told me that the abductory twist was in compensation for the hyperpronation, that the foot was pronating so far that it had to twist into supination/abduction in order to get off the ground. I've since read it described in different terms but still rearfoot pronation is a component. Strangely my present DPM remarked that I did not have as much pronation as he expected, though that could be result of walking performance style which cannot be sustained once gone from doctors office. Maybe here the DC author is wrong. Is'nt rearfoot hyperpronation always present with an unlocked midtarsal joint in gait?

Reading this it occurs to me that I've become unhealthily obsessed with biomechanics. However in present circumstances I feel I must search for the primary cause(s) of my troubles in order to real long term solutions.

Re: equinus with orthotics

Scott R on 6/04/01 at 08:28 (049822)

Josh, let me see if I understand correctly. When you stand facing a wall so that your toes touch the bottom of the wall your knees do not touch the wall when you squat?

Re: equinus with orthotics

wendyn on 6/04/01 at 13:15 (049861)

Mine do not either. I tried this as one of your data base tests and gave myself a whole lot of increased pain afterwards.

I have also been diagnosed with 'Gastroc equinus contracture'.

Re: equinus with orthotics

wendyn on 6/04/01 at 13:35 (049865)

Hmm - just tried it now and I seem to be able to do it. Can you repost somewhere the instructions you'd given before for this? I think there was something in there that was different from what I am doing now.

Re: equinus with orthotics

josh s on 6/04/01 at hrmin (049869)

Yes Scott, just as it's shown in your book. I can get close to touching if I allow my ankles and knees to roll inward (valgus) and pronate, which tends to bring forth pain in plantar fascia and deeper in medial arch.
The first time this became problematic was when I was nineteen and began studying tai chi chuan which really requires the kind of flexibility exhibited in your second wall crouch illustration. I compensated by rolling in and developed patella problems and then foot trouble.

Re: equinus with orthotics-sqatting

josh s on 6/04/01 at hrmin (049875)

Scott, just re-read your question. As far as sqatting, which is the subtitle of the article I quoted, I cannot squat with heels on the ground. In your semi-squat test If I allow my heels to leave the ground I could touch knees to wall. If I allowed inward collapse at ankles I maybe could squat but then I'd be resting completely on inside edges of feet and heel which attempted feels unsafe for feet and knees.