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Case of the Season #1

Patient: Male, 35 years old, 5’9″, 190 lbs

 

History and chief complaint

 

Patient’s feet have always bothered him, and he has “flat feet”. He has been treated by various practitioners and has been prescribed orthotics, but none of them were tolerable. Over the past 10 years he has developed persistent pain behind his knees in the popliteal fossa.

 

Clinical exam and observations

 

Patient has a low arch structure bilaterally, with motion in the subtalar and midtarsal joints mildly reduced. Ankle dorsiflexion 8 degrees bilaterally with knees extended and 11 degrees with knees flexed.

 

 

Visual gait examination

 

Patient has a heavy, plodding non-propulsive type of gait. His posture is slouching. Base of gait is about 4″ wide and the angle of gait is significantly abducted. Upon closer examination, it was observed that the patient had genu recurvatum that was masked by his stocky build.

 

Diagnosis

 

In this case, there is a presence of severe gastrocnemius equinus influence.

The bilateral low arch appearance indicates midtarsal joint oblique axis compensation. This provides additional dorsiflexion of the forefoot on the rearfoot that ultimately became “fixed”. This would tend of give a false over-estimation of the range of ankle dorsiflexion.

 

More compensation occurred bilaterally at the level of the knee in the form of hyperextension (recurvatum). This allows the heel to remain on the ground since the leg does not move forward over the foot. Instead, the leg stays posterior to the foot creating an obtuse angle between the foot and the leg, thus compensating for the reduced range of ankle dorsiflexion.

 

Finally, the patient even used the transverse plan to compensate for the lack of sagittal plane ankle dorsiflexion by abducting his feet. This helped to keep his heels on the ground as he literally rolled forward over his feet in a totally non-propulsive manner.

 

There was a lack of diagnostic acumen on the part of his previous practitioners, by failing to give appropriate weight to the patient’s persistent intolerance to various ordinary orthotic devices. This is a classic finding in patients who have gastrocnemius and other types of equinus deformities.

 

Treatment

 

What is the appropriate treatment for the patient with a suspected gastrocnemius equinus influence? Since it is extremely difficult to differentiate the functional from the structural, all suspected equinus patients should be given a course of calf muscle stretching before and after dispensing of the orthotics.

Achilles tendon stretch

The orthotics themselves may have heel raises applied initially to investigate their acceptance. A separate 1/8″ – 1/4″ removable heel lift may be used instead.  Monitoring of the functional equinus patient should demonstrate a definitive increase in the range of ankle dorsiflexion, and the heel raises should be reduced and ultimately removed as the deformity is reduced. When monitoring fails to show any increase in ankle dorsiflexion in compliant patients, the practitioner may properly make the judgement that the gastrocnemius equinus is structural. In this case, the surgical lengthening of the Achilles tendon may be considered is appropriate in the context of the patient’s age, foot structure, etc. Osseus equines deformities must be ruled out. If surgical intervention is not deemed to be appropriate, then orthotics with heel raises and/or shoes with heels are appropriate forms of therapy.

orthotic with heel lift
A heel lift can be added to any of our orthotics

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Biomechanical and Postural Considerations/ Orthotic Treatment By Joe Coletta, PTA,