Category: Pathophysiology Introduction/Purpose: Gastrocnemius eqiunus has been associated with a wide range of foot and ankle pathologies in the literature, however, many still question it’s involvement or existence. A recent response in Foot & Ankle International pointed out an incorrect demonstration of the Silfverskold test in a prior study. With a growing body of literature supporting gastrocnemius equinus as a contributing factor in foot and ankle pain, why do many feel that it still does not exist? It was our hypothesis that unless the examination is performed correctly, the diagnosis can be missed and could be the potential cause for disbelief in its existence or effect on foot and ankle pain. We sought to demonstrate the difference in examination findings when performing the test correctly and incorrectly. Methods: Thirty consecutive patients with conditions associated with gastrocnemius equinus in the literature were included in the study. Each patient was consented and had a Silverskold test performed correctly by inverting and locking the subtalar joint as well as stabilizing the talonavicular joint in order to isolate the ankle joint. We then performed the exam incorrectly without stabilizing the same two joints, allowing motion through the ipsilateral hindfoot and midfoot joints. A long arm goniometer was used to measure the angles with each arm along the length of the fibula and fifth metatarsal. The senior author performed all of the examinations to maintain consistency. The angles were recorded for later review. Results: We found that when the subtalar and talonavicular joints were stabilized, there was almost fifteen degrees less dorsiflexion than when the same joints were not stabilized. The average dorsiflexion when performed in the correct manner was seventy-eight degrees, while the average dorsiflexion with the exam performed incorrectly was ninety-three degrees. Conclusion: We demonstrated that if the examination is not performed correctly, the equinus contracture could go undiagnosed as motion through the hindfoot and midfoot joints can alter the findings. It is important to understand and perform the technique correctly to evaluate for the contracture as it has been shown to be a contributing factor in many foot and ankle problems. If we standardize the examination, there may be less disagreement about its existence or affect on foot and ankle pain.
Isolated gastrocnemius equinus contracture has been associated with several foot and ankle pathologies within the literature. The Silfverskiöld test is commonly used to identify isolated gastrocnemius contracture, however, the proper technique for performing the test has been scrutinized. The purpose of this study was to determine if there is a clinical significance in the ankle dorsiflexion that is obtained when the examination is performed incorrectly with a single hand versus the correct two-hand technique. MethodsThirty consecutive new patients with conditions associated with gastrocnemius equinus were included in the study. The Silfverskiöld test was performed with a two-hand technique and a single-hand technique. The amount of dorsiflexion obtained with the knee in full extension was measured and recorded using an extendable goniometer for each technique, with the arms aligned with the fifth metatarsal and fibular head. ResultsThe average amount of dorsiflexion that was obtained with the two-hand technique with the knee in full extension was 76.3°±4.2°. When the one-hand technique was utilized the average amount of dorsiflexion obtained with the knee in full extension was 88.4°±4.2°. This was found to be statistically significant (p<0.01). ConclusionThis study demonstrates that if the Silfverskiöld test is not performed correctly, the diagnosis of an isolated gastrocnemius contracture could be underappreciated. Accordingly, it may be important to perform the test with two hands in order to neutralize the hindfoot, midfoot, and forefoot, so that the dorsiflexion motion is through the tibiotalar joint alone.
Virtual reality equipment is not only used to treat balance impairments but it is also used to measure and determine physical impairments through the use of physical performance tests. Virtual reality equipment is a reliable and valid tool for collecting physical performance data for the 5 × STS, FFR, TUG and 30-s stand test for healthy community-dwelling elders.
Category: Bunion Introduction/Purpose: An arch collapse model has been described for a multitude of foot and ankle problems that is based on a gastrocnemius equinus contracture producing a predictable collapse that has been described in five distinct phases. Previous studies have evaluated the presence of pes planovlagus in hallux valgus patients and concluded that this is a rare occurance. The Grand Rapids arch collapse model reviews adult foot pathology and believes there is a link between bunions and flatfeet. We wanted to evaluate patients with flatfeet and determine if they had an associated bunion deformity. Based upon the arch collapse model, there should be a significant number of flatfeet with an associated bunion deformity and our goal was to see if this proved to be true. Methods: We retrospectively reviewed the radiographs of patients diagnosed with a flatfoot based upon their ICD 9 and 10 codes in the senior author’s practice. For each patient, we used standard anteroposterior and lateral foot radiographs obtained on all new patients. Initially, we had 254 feet but had to exclude 93 feet due to inadequate radiographs, normal radiographs (normal meary’s angle and talonavicular coverage angle) or in patients who already had surgical procedures to the foot. This left 161 feet radiographs for review. We then measured the Meary’s angle on the lateral images and the talonavicular coverage angle, hallux valgus angle, intermetatarsal angle and sesamoid position on the anteroposterior radiographs. Results: Of the 161 feet that remained in the study, only 6 feet (3.7%) had no radiographic evidence of a bunion based upon sesamoid position, hallux valgus angle or the intermetatarsal angle. We did find a correlation with the severity of the flatfoot based upon the Meary’s angle and the talonavicular coverage angle with the severity of the bunion deformity defined by the sesamoid position, hallux valgus angle and the intermetatarsal angle. As the flatfoot got worse, the bunion did so as well. Conclusion: Our findings would seem to fit with the Grand Rapids arch collapse model. The hypermobility of the first ray that creates the bunion deformity then allows the arch to ultimately collapse. It also does not seem to contradict what has been found previously. Earlier studies showed a low association between patients with bunions who also had flatfeet. This would make sense as the deformity may not have progressed to the flatfoot yet. However, in our study the deformity has already progressed to a flatfoot and almost all have some radiographic evidence of a bunion.
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