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Equinus casting?

Posted by josh s on 6/09/01 at hrmin (050314)

Has anyone heard of putting on a cast to resolve equinus?

A nurse friend asked her friend the orthopedist about treatments for equinus. He told her he sees it all the time and has good success with casting the foot/leg to stretch the calf musculature.

I've never found this treatment in all my searching and reading so I'm looking for any info or experiences.

Thanks Much!

Re: Equinus casting?

Dr. Biehler on 6/09/01 at 16:37 (050347)

If the purpose of the cast is just to stretch out the calf muscles, the night splint might be a more comfortable form of treatment. Dr. B.

Re: Equinus casting?

josh s on 6/10/01 at hrmin (050366)

Thanks Dr. B,

I've considered giving night casting a try before. Several concerns/questions:
As I understand it the equinus in my ankles has resulted in compensatory midfoot dorsiflexion hypermobility and a hypermobile first ray. In applying steady tissue remodeling type pressure to the lever of the foot in an effort to lengthen calf muscles, it seems to me that the already hypermobile and repetively stressed/injured tissues of the foot would give before the stiff and unyielding calves. Is this line of reasoning correct and is there any way to prevent this? A heavy tape job Scott style may protect the plantar structures, but as Scott says in his book, the tape seems to lose it's effectiveness after a short while.

I spoke to a pedorthist this week and he advised against lengthening surgery, having seen several disastrous overlengthenings. He recommended higher heeled shoes with rocker bottoms. I've aquired some Dansko clogs which definately allow proper 'tip over' as scott says but I need a long term resolution.

As I live in Minnesota, considering visiting the mayo clinic to take advantage of their reputation if possible. Will a bunch of orthopods and physiatrists be of any assistance in resolving equinus. Any opinions?

Re: Equinus casting?

laura on 6/10/01 at 22:36 (050414)

pardon me, but what exactly is 'equinus'??? thank you very much!

Re: what is

josh s on 6/10/01 at hrmin (050415)

Laura, 'ankle equinus' is in simplest terms the inability of the ankle joint to dorsiflex. That is, move the top of the foot closer towards the shin and knee. Scott discusses it as a factor of many if not most people's pf troubles. The experts have determined that ten degrees of dorsiflexion is necessary for normal walking motion. Scott discusses this in his book in the section about 'tipping over' the foot. Anything less than ten degrees of motion causes trouble.

In simple terms, the trouble consists of the foot trying to dorsiflex in the midfoot (the instep, the foot bones in front of the ankle) to compensate for the inability of the ankle to do so. The many ligaments and plantar fascia of the sole of the foot are designed to resist this movement which flattens the arches of the foot. As I understand it, this kind of stress can cause damage to these ligaments and plantar fascia. The breakdown of the midfoot is what is known as 'falling or fallen arches'.

One study found that ninety something percent of folks screened with foot touble associated with excessive pronation had some degree of ankle equinus. Ankle equinus is the reason many of us with plantar fasciitis are advised to stretch our calf muscles. The paragraph above illustrates why Scott relates in his book taping the arches of his feet while stretching his calves.

It can cause excessive pronation or be caused by excessive pronation. It can be present in people with flat feet and people with high arches.

Re: Equinus casting?

Julie on 6/11/01 at 01:10 (050418)

Laura, equine= horse. Think of a horse's hoof, and you'll have a better visual idea of equinus.

Re: Equinus casting?

laura on 6/11/01 at 06:58 (050426)

Thank you both!

Re: what is

JudyS on 6/11/01 at 12:18 (050452)

Josh, that is one of the best descriptions, and cause/effect explanations I've heard to date - thank you for putting it in easy-to-understand language.

Re: what is

wendyn on 6/11/01 at 13:15 (050453)

I really like your description too Josh. I have equinus and I still have a hard time understanding it. My mid foot has been collapsing since I was a kid - so that comment really seemed to fit. What I still don't get is really the 'why' behind all of it.

Re: Why what is?

josh s on 6/11/01 at hrmin (050464)

Wendyn, unfortunately I don't understand the 'why' behind it all either. I've been wondering since the incidence of excessive pronation and ankle equinus are found together why the profession has not focused on clear diagnostic and treatment protocols to resolve equinus.

My own experience has been made interesting with only two of three health care folks diagnosing me with it. In the literature, it is mentioned as important to check ankle range of motion with the foot in 'subtalar neutral' a nebulous place at best. You may recall the way your doctor attempted to balance your foot in between inversion and eversion when putting the plaster on to cast your foot for orthotics, this is 'subtalar neutral'. If the doctor lets the foot evert or pronate while checking range-o-motion it will appear that one has more dorsiflexion ability that actually present.

The folks who study human walking with an eye for pain and disfunction have approximated that while standing on one leg with the other leg swinging forward, preparing to touch down, the stance leg is supposed to reach somewhere near 'subtalar neutral' about the moment that this ankle is reaching the necessary 10 deg. to pass the center of gravity forward over the toes, or 'tip' over as scott puts it. Those who have equinus cannot reach the ten degrees required and so the foot pronates or rolls inward (actually it simply stays pronated, as the foot intentionally pronates when it first touches down while walking)in order to allow the center of gravity to pass over. This is where the trouble begins.

The purpose of the foot to de-pronate or 'supinate' at this stage in the walking cycle is because we actually have two feet at the end of one ankle. The pronated foot pronates because when it does it becomes loose and mobile. This serves two major purposes. First, before cities and roads, the majority of our terrain was irregular. The pronated foot is a 'mobile adaptor' in that the bones are free to adjust to slopes, rocks, sticks, hidden depresions, etc. and still allow a smooth and effortless step forward. It is able to became this because the foot is like a linked chain, one end at the heel and the other at the toes. The pronated foot is a chain that has not been twisted, you can bend it and wiggle it freely. In reality the bones of the pronated foot are supported but supported loosely, like a bag of bones, by the powerful and many ligaments of the foot and tendons of the foot and lower leg.

Secondly, the pronated foot is designed to absorb shock. How it does this gets complicated and somewhat beyond me as it involves a rotation of the entire leg and a complex orchestration of simultaneous events from the foot on up the joints to at least the spine.

The second foot we posess is the supinated foot. During the walking cycle described above, as the foot swinging forward passes the leg that's planted the planted or stance foot begins to twist into supination. You can see this yourself if you stand and twist your whole body to the right, looking over your shoulder, leaving your feet planted but allowing the ankles to twist. When fully turned, the right foot is supinated (and the left is pronated). This supination movement twists the chain of foot bones and ligaments into a rigid, force transferring lever. This is necessary in order for the heel to rise and the ball of the foot and toes to push or pull backwards in order to tip us over to our next step.

With ankle equinus, this twisting into the rigid chain of the supinated foot either does not happen or happens too late. The result is a mobile untwisted chain, a bag of bones attempting to do the hard work of a rigid lever. It is incapable of doing this safely or efficiently. In order to avoid repetive stress or 'shear' forces from the attempt, our bodies wisely attempt various strategies to avoid it, at least to some degree. These can include hyperextending the knee, lifting the heel early, twisting the foot outward at the last moment in order to push off with the outside edge of the foot as in skating. These strategies all leave the foot open to some degree of shear stress and eventual trouble. Also, the midfoot can completely collapse, leaving a 'rocker bottom foot' which is painfully inefficient.

The biomechanists seem to focus mostly on walking, in the case of equinus I think other movements can actually be more harmful. Any motion requiring a squat or deep bend at knee and ankle can force compensatory pronation and stress to the midfoot. With someone with equinus, going up or down stairs will require the same compensations. Walking up a steep slope will be even worse. Then again the avoidance of squatting and crouching movements may cause equinus. I know few people who can squat as deeply or easily as the people of cultures without habitual use of chairs. People who can almost always display a powerful and graceful walk.

If one has an injury or predisposition toward excessive pronation this can cause equinus. I spoke to one DPM recently who expressed the opinion that all equinus is a result of excessive pronation. In this case the aquired equinus then goes on to contribute to the excessive pronation, making one of those awful circles.

Other causes mentioned in the literature include: heriditary contracture or shortness of the calf muscles/achilles (this is often seen in cerebral palsy), wearing high heeled shoes for years, habitual toe walking in children, a bony blockage in the front of the ankle joint, ankle trauma such as severe sprain can sometimes leave scar tissue that blocks the ankle joint, etc.

One podiatrist wrote recently about a manipulation (what chiropractors do) method to help equinus. This involves moving the bones of the ankle and of a small joint located on the outside of the knee (the proximal tibio-fibular articulation). Apparently this can improve the range of motion quite dramatically, though I've yet to find someone willing to do it.

My experience involves a reluctance or lack of interest on the part of health care persons to track the problem to it's cause and thus have a chance at resolution, which puzzles me. The profession tends, in my opinion, excessively towards accomodation of painful dilemmas rather than thorough and intelligent inquiry into history and cause and effect. I do not believe true healing or resolution is possible without finding the primary or original cause(s). Whether such pure causes are to be found is debatable. My opinion is that if the cause cannot be found the problem cannot be cured and hopefully vice versa.

I'm a bit confused why if equinus and excessive pronation troubles are so much entwined there is little focus on equinus. If a person has equinus with excessive pronation and one or more of the compensation strategies designed to accomodate it and thus an inefficient and aberrated walk, clearly the insertion of an orthotic, even with a heel lift will not provide the necessary information to the nervous system necessary to change a clumsy, painful walk into a biomechanically efficient one. The foundation of life (movement) is walking, without being able to do this effortlessly, our ability to live is much reduced. Surely treatment must include rehabilitation and medicine together in a connected and coherant way.

When children are screened for scoliosis, they aught to be screened for foot and lower extremity malalignment. I'm not sure if problems detected could be any more effectively treated in children than in us adults, but at least we could track the development of trouble and learn more about it. Podiatry needs an Einstein.

Re: Why what is?

Dr. Marlene Reid on 6/11/01 at 18:07 (050473)

There is a reason why eequinous and pronation are seen together. One causes the other and it has to do with ankle joint dorsiflexion being a part of both. If you have less dorsiflexion at the ankle (equinous), the foot compensates by producing dorsiflexion through pronation and vice versa. The reason PF occurs with equinous is because the fibers of the achilles tendon are connected loosely with those of the plantar fascia. The reason PF occurs with pronated feet is because of the constant pulling of the fascia. Hope this helps.

Re: Why what is?

wendyn on 6/11/01 at 23:05 (050491)

Wow Josh.

That is the most informed interesting write up on equinus I've ever seen. This a hobby of yours?

Mine is not a powerful and graceful walk.

My feet do twist funny to push off - and my feet point out too. I honestly do look like I walk like a duck.

There appears to be a heriditary component to the short calf muscles. My cousin and I used to comment on the women's legs in our family - fairly muscular with well defined very short calves. The good news is that they look good - the bad news is that don't work real well - but ALL of the women have the same legs.

I think you have hit on an interesting point with the squats. When I had my major flare up of TTS/Tendonitis and God knows what else - it was following A LOT of activity including Stairmaster, Step classes and aerobics. In some of the aerobics we did a lot of squats. The physio therapist who I saw later said that my legs and feet are absolutely not designed for stair master or ANY type of squats.

Where do you live Josh?

I was diganosed with the start of these foot problems when I was 11 - but the doctors never really did anything about it.

Re: Equinus casting?

Dr. Biehler on 6/09/01 at 16:37 (050347)

If the purpose of the cast is just to stretch out the calf muscles, the night splint might be a more comfortable form of treatment. Dr. B.

Re: Equinus casting?

josh s on 6/10/01 at hrmin (050366)

Thanks Dr. B,

I've considered giving night casting a try before. Several concerns/questions:
As I understand it the equinus in my ankles has resulted in compensatory midfoot dorsiflexion hypermobility and a hypermobile first ray. In applying steady tissue remodeling type pressure to the lever of the foot in an effort to lengthen calf muscles, it seems to me that the already hypermobile and repetively stressed/injured tissues of the foot would give before the stiff and unyielding calves. Is this line of reasoning correct and is there any way to prevent this? A heavy tape job Scott style may protect the plantar structures, but as Scott says in his book, the tape seems to lose it's effectiveness after a short while.

I spoke to a pedorthist this week and he advised against lengthening surgery, having seen several disastrous overlengthenings. He recommended higher heeled shoes with rocker bottoms. I've aquired some Dansko clogs which definately allow proper 'tip over' as scott says but I need a long term resolution.

As I live in Minnesota, considering visiting the mayo clinic to take advantage of their reputation if possible. Will a bunch of orthopods and physiatrists be of any assistance in resolving equinus. Any opinions?

Re: Equinus casting?

laura on 6/10/01 at 22:36 (050414)

pardon me, but what exactly is 'equinus'??? thank you very much!

Re: what is

josh s on 6/10/01 at hrmin (050415)

Laura, 'ankle equinus' is in simplest terms the inability of the ankle joint to dorsiflex. That is, move the top of the foot closer towards the shin and knee. Scott discusses it as a factor of many if not most people's pf troubles. The experts have determined that ten degrees of dorsiflexion is necessary for normal walking motion. Scott discusses this in his book in the section about 'tipping over' the foot. Anything less than ten degrees of motion causes trouble.

In simple terms, the trouble consists of the foot trying to dorsiflex in the midfoot (the instep, the foot bones in front of the ankle) to compensate for the inability of the ankle to do so. The many ligaments and plantar fascia of the sole of the foot are designed to resist this movement which flattens the arches of the foot. As I understand it, this kind of stress can cause damage to these ligaments and plantar fascia. The breakdown of the midfoot is what is known as 'falling or fallen arches'.

One study found that ninety something percent of folks screened with foot touble associated with excessive pronation had some degree of ankle equinus. Ankle equinus is the reason many of us with plantar fasciitis are advised to stretch our calf muscles. The paragraph above illustrates why Scott relates in his book taping the arches of his feet while stretching his calves.

It can cause excessive pronation or be caused by excessive pronation. It can be present in people with flat feet and people with high arches.

Re: Equinus casting?

Julie on 6/11/01 at 01:10 (050418)

Laura, equine= horse. Think of a horse's hoof, and you'll have a better visual idea of equinus.

Re: Equinus casting?

laura on 6/11/01 at 06:58 (050426)

Thank you both!

Re: what is

JudyS on 6/11/01 at 12:18 (050452)

Josh, that is one of the best descriptions, and cause/effect explanations I've heard to date - thank you for putting it in easy-to-understand language.

Re: what is

wendyn on 6/11/01 at 13:15 (050453)

I really like your description too Josh. I have equinus and I still have a hard time understanding it. My mid foot has been collapsing since I was a kid - so that comment really seemed to fit. What I still don't get is really the 'why' behind all of it.

Re: Why what is?

josh s on 6/11/01 at hrmin (050464)

Wendyn, unfortunately I don't understand the 'why' behind it all either. I've been wondering since the incidence of excessive pronation and ankle equinus are found together why the profession has not focused on clear diagnostic and treatment protocols to resolve equinus.

My own experience has been made interesting with only two of three health care folks diagnosing me with it. In the literature, it is mentioned as important to check ankle range of motion with the foot in 'subtalar neutral' a nebulous place at best. You may recall the way your doctor attempted to balance your foot in between inversion and eversion when putting the plaster on to cast your foot for orthotics, this is 'subtalar neutral'. If the doctor lets the foot evert or pronate while checking range-o-motion it will appear that one has more dorsiflexion ability that actually present.

The folks who study human walking with an eye for pain and disfunction have approximated that while standing on one leg with the other leg swinging forward, preparing to touch down, the stance leg is supposed to reach somewhere near 'subtalar neutral' about the moment that this ankle is reaching the necessary 10 deg. to pass the center of gravity forward over the toes, or 'tip' over as scott puts it. Those who have equinus cannot reach the ten degrees required and so the foot pronates or rolls inward (actually it simply stays pronated, as the foot intentionally pronates when it first touches down while walking)in order to allow the center of gravity to pass over. This is where the trouble begins.

The purpose of the foot to de-pronate or 'supinate' at this stage in the walking cycle is because we actually have two feet at the end of one ankle. The pronated foot pronates because when it does it becomes loose and mobile. This serves two major purposes. First, before cities and roads, the majority of our terrain was irregular. The pronated foot is a 'mobile adaptor' in that the bones are free to adjust to slopes, rocks, sticks, hidden depresions, etc. and still allow a smooth and effortless step forward. It is able to became this because the foot is like a linked chain, one end at the heel and the other at the toes. The pronated foot is a chain that has not been twisted, you can bend it and wiggle it freely. In reality the bones of the pronated foot are supported but supported loosely, like a bag of bones, by the powerful and many ligaments of the foot and tendons of the foot and lower leg.

Secondly, the pronated foot is designed to absorb shock. How it does this gets complicated and somewhat beyond me as it involves a rotation of the entire leg and a complex orchestration of simultaneous events from the foot on up the joints to at least the spine.

The second foot we posess is the supinated foot. During the walking cycle described above, as the foot swinging forward passes the leg that's planted the planted or stance foot begins to twist into supination. You can see this yourself if you stand and twist your whole body to the right, looking over your shoulder, leaving your feet planted but allowing the ankles to twist. When fully turned, the right foot is supinated (and the left is pronated). This supination movement twists the chain of foot bones and ligaments into a rigid, force transferring lever. This is necessary in order for the heel to rise and the ball of the foot and toes to push or pull backwards in order to tip us over to our next step.

With ankle equinus, this twisting into the rigid chain of the supinated foot either does not happen or happens too late. The result is a mobile untwisted chain, a bag of bones attempting to do the hard work of a rigid lever. It is incapable of doing this safely or efficiently. In order to avoid repetive stress or 'shear' forces from the attempt, our bodies wisely attempt various strategies to avoid it, at least to some degree. These can include hyperextending the knee, lifting the heel early, twisting the foot outward at the last moment in order to push off with the outside edge of the foot as in skating. These strategies all leave the foot open to some degree of shear stress and eventual trouble. Also, the midfoot can completely collapse, leaving a 'rocker bottom foot' which is painfully inefficient.

The biomechanists seem to focus mostly on walking, in the case of equinus I think other movements can actually be more harmful. Any motion requiring a squat or deep bend at knee and ankle can force compensatory pronation and stress to the midfoot. With someone with equinus, going up or down stairs will require the same compensations. Walking up a steep slope will be even worse. Then again the avoidance of squatting and crouching movements may cause equinus. I know few people who can squat as deeply or easily as the people of cultures without habitual use of chairs. People who can almost always display a powerful and graceful walk.

If one has an injury or predisposition toward excessive pronation this can cause equinus. I spoke to one DPM recently who expressed the opinion that all equinus is a result of excessive pronation. In this case the aquired equinus then goes on to contribute to the excessive pronation, making one of those awful circles.

Other causes mentioned in the literature include: heriditary contracture or shortness of the calf muscles/achilles (this is often seen in cerebral palsy), wearing high heeled shoes for years, habitual toe walking in children, a bony blockage in the front of the ankle joint, ankle trauma such as severe sprain can sometimes leave scar tissue that blocks the ankle joint, etc.

One podiatrist wrote recently about a manipulation (what chiropractors do) method to help equinus. This involves moving the bones of the ankle and of a small joint located on the outside of the knee (the proximal tibio-fibular articulation). Apparently this can improve the range of motion quite dramatically, though I've yet to find someone willing to do it.

My experience involves a reluctance or lack of interest on the part of health care persons to track the problem to it's cause and thus have a chance at resolution, which puzzles me. The profession tends, in my opinion, excessively towards accomodation of painful dilemmas rather than thorough and intelligent inquiry into history and cause and effect. I do not believe true healing or resolution is possible without finding the primary or original cause(s). Whether such pure causes are to be found is debatable. My opinion is that if the cause cannot be found the problem cannot be cured and hopefully vice versa.

I'm a bit confused why if equinus and excessive pronation troubles are so much entwined there is little focus on equinus. If a person has equinus with excessive pronation and one or more of the compensation strategies designed to accomodate it and thus an inefficient and aberrated walk, clearly the insertion of an orthotic, even with a heel lift will not provide the necessary information to the nervous system necessary to change a clumsy, painful walk into a biomechanically efficient one. The foundation of life (movement) is walking, without being able to do this effortlessly, our ability to live is much reduced. Surely treatment must include rehabilitation and medicine together in a connected and coherant way.

When children are screened for scoliosis, they aught to be screened for foot and lower extremity malalignment. I'm not sure if problems detected could be any more effectively treated in children than in us adults, but at least we could track the development of trouble and learn more about it. Podiatry needs an Einstein.

Re: Why what is?

Dr. Marlene Reid on 6/11/01 at 18:07 (050473)

There is a reason why eequinous and pronation are seen together. One causes the other and it has to do with ankle joint dorsiflexion being a part of both. If you have less dorsiflexion at the ankle (equinous), the foot compensates by producing dorsiflexion through pronation and vice versa. The reason PF occurs with equinous is because the fibers of the achilles tendon are connected loosely with those of the plantar fascia. The reason PF occurs with pronated feet is because of the constant pulling of the fascia. Hope this helps.

Re: Why what is?

wendyn on 6/11/01 at 23:05 (050491)

Wow Josh.

That is the most informed interesting write up on equinus I've ever seen. This a hobby of yours?

Mine is not a powerful and graceful walk.

My feet do twist funny to push off - and my feet point out too. I honestly do look like I walk like a duck.

There appears to be a heriditary component to the short calf muscles. My cousin and I used to comment on the women's legs in our family - fairly muscular with well defined very short calves. The good news is that they look good - the bad news is that don't work real well - but ALL of the women have the same legs.

I think you have hit on an interesting point with the squats. When I had my major flare up of TTS/Tendonitis and God knows what else - it was following A LOT of activity including Stairmaster, Step classes and aerobics. In some of the aerobics we did a lot of squats. The physio therapist who I saw later said that my legs and feet are absolutely not designed for stair master or ANY type of squats.

Where do you live Josh?

I was diganosed with the start of these foot problems when I was 11 - but the doctors never really did anything about it.