Isolated gastrocnemius tightness

Management of insertional tendinopathy of the Achilles tendon

Posterior heel pain is common and disabling. Most cases respond to nonoperative treatment. The literature is confusing about the treatment rationale because many papers treat a variety of pathologies in the same way on an empirical basis. The authors critically review the literature with special reference to surgical treatment. The key to successful management of posterior heel pain is a proper understanding of the anatomy and pathological processes. Only then can appropriate treatment be recommended and proper advice about recovery times be offered to patients.

Isolated recession of the gastrocnemius muscle: the Baumann procedure

BACKGROUND

The Baumann procedure consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles. The goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle. Unlike the Vulpius procedure, the Baumann procedure truly isolates the lengthening site to the gastrocnemius muscle and does not lengthen the soleus muscle. The Baumann procedure has not previously been studied in cadaver specimens.

METHODS

The gastrocnemius and soleus muscles of 15 normal cadaver specimens had four sequential releases: a single gastrocnemius recession, a second gastrocnemius recession, a single soleus recession, and an Achilles tenotomy. Ankle dorsiflexion was measured with a goniometer initially, after each muscle recession, and after the tenotomy.

RESULTS

After the second gastrocnemius recession, the average increase in ankle dorsiflexion measured 14 degrees with the knee extended and 8 degrees with the knee flexed.

CONCLUSIONS

The Baumann procedure treats equinus contracture of the gastrocnemius muscle by improving ankle joint dorsiflexion. The procedure is indicated when the results of the Silfverskiöld test are positive.

The surgical management of equinus in the adult acquired flatfoot

Ankle joint equinus plays a significant role in the pathogenesis of adult and pediatric flatfoot. The surgical management of ankle equinus is a widely debated topic, and procedure selection is often based on surgeon preference because there is no consensus regarding the superiority of a single procedure. Gastrocnemius recession offers acceptable cosmesis and minimizes perceived weakness, yet requires increased operating time and is indicated only in mild to moderate contractures. Whereas tendo-achilles lengthening is efficient and technically undemanding, and one may achieve large amounts of required length, final length is sometimes unpredictable and may markedly decrease posterior muscle group strength.

Biomechanics and clinical analysis of the adult acquired flatfoot

The adult acquired flatfoot is a deformity that results from the loss of dynamic and static supportive structures of the medial longitudinal arch. The severity of the deformity is dependent upon the role of ligamentous disruption on the hindfoot that can be determined by careful clinical examination. Treatment of the adult flatfoot requires an understanding of the biomechanical effects of deforming forces, tendon dysfunction, ligament disruption, and joint sublaxation.

Stress fractures of the second metatarsal base occur in nondancers

Stress fractures of the base of the second metatarsal are common in ballet dancers and essentially are unreported in nondancers. We presumed base of the second metatarsal stress fractures in nondancers occur in a wide variety of individuals regardless of demographics, are highly associated with athletic activities, and have specific examination findings and poor clinical outcomes. Using a retrospective chart review, we identified 12 stress fractures at the base of the second metatarsal (nine patients) in nondancers. Our review suggests second metatarsal base stress fractures occur in nondancers in a diverse population, and nonoperative treatment provides limited success. Advanced radiographic study, specifically MRI, is useful to assist the early diagnosis and prognostication. All of the stress fractures were treated nonoperatively; six fractures (50%) developed nonunion and five underwent subsequent surgery. The surgery for nonunion provided successful outcomes; however, risk factors such as low bone mass and comorbidities may have played important roles in the prognosis.

Hallux valgus: demographics, etiology, and radiographic assessment

BACKGROUND

The purpose of the study was to preoperatively evaluate the demographics, etiology, and radiographic findings associated with moderate and severe hallux valgus deformities in adult patients (over 20 years of age) treated operatively over a 33-month period in a single surgeon's practice.

METHODS

Patients treated for a hallux valgus deformity between September, 1999, and May, 2002, were identified. Patients who had mild deformities (hallux valgus angle < 20 degrees), concurrent degenerative arthritis of the first metatarsophalangeal joint, inflammatory arthritis, recurrent deformities, or congruent deformities were excluded. When enrolled, all patients filled out a standardized questionnaire and had a routine examination that included standard radiographs, range of motion testing, and first ray mobility measurement. A chart review and evaluation of preoperative radiographs were completed on all eligible patients.

RESULTS

One-hundred and three of 108 (96%) patients (122 feet) with a diagnosis of moderate or severe hallux valgus (hallux valgus angle of 20 degrees or more)(70) qualified for the study. The onset of the hallux valgus deformity peaked during the third decade although the distribution of occurrence was almost equal from the second through fifth decades. Twenty-eight of 122 feet (23%) developed a deformity at an age of 20 years or younger. Eighty-six (83%) of patients had a positive family history for hallux valgus deformities and 87 (84%) patients had bilateral bunions. 15% of patients in the present series had moderate or severe pes planus based on a positive Harris mat study. Only 11% (14 feet) had evidence of an Achilles or gastrocnemius tendon contracture. Radiographic analysis found that 86 of 122 feet (71%) had an oval or curved metatarsophalangeal joint. Thirty-nine feet (32%) had moderate or severe metatarsus adductus. A long first metatarsal was common in patients with hallux valgus (110 of 122 feet; 71%); the mean increased length of the first metatarsal when compared to the second was 2.4 mm. While uncommon, the incidence of an os intermetatarsum was 7% and a proximal first metatarsal facet was 7%. The mean preoperative first ray mobility as measured with Klaue's device was 7.2 mm. 16 of 22 (13%) feet were observed to have increased first ray mobility before surgery.

CONCLUSIONS

The magnitude of the hallux valgus deformity was not associated with Achilles or gastrocnemius tendon tightness, increased first ray mobility, bilaterality or pes planus. Neither the magnitude of the preoperative angular deformity nor increasing age had any association with the magnitude of the first metatarsophalangeal joint range of motion. Constricting shoes and occupation were implicated by 35 (34%) patients as a cause of the bunions. A familial history of bunions, bilateral involvement, female gender, a long first metatarsal, and an oval or curved metatarsophalangeal joint articular surface were common findings. Increased first ray mobility and plantar gapping of the first metatarsocuneiform joint were more common in patients with hallux valgus than in the general population (when compared with historical controls).

The role of isolated gastrocnemius and combined Achilles contractures in the flatfoot

In the absence of bony deformity, ankle equinus is generally the result of shortening within the gastrocnemius-soleus complex. Restriction of ankle dorsiflexion as a proxy for equinus contracture has been linked to increased mechanical strains and resultant foot and ankle pathology for a long time. This entity has many known causes, and data suggest it can manifest as either an isolated gastrocnemius or combined (Achilles) contracture. Numerous disorders of the foot and ankle have been linked with such "equinus disease", and although some of these relationships remain controversial, a reasonably convincing relationship between equinus contracture and the development of flatfoot exists. What is still perhaps most misunderstood is the temporal association between these two pathologies, and hence higher levels of evidence are needed in the future to define more precisely the interplay between flatfoot deformity and gastrocnemius-soleus tightness.

Anatomical aspects of the gastrocnemius aponeurosis and its insertion: a cadaveric study

Anatomical variation in the attachment of the gastrocnemius muscle to the soleus muscle has not been studied previously. The gastrocnemius muscle may insert directly onto the tendinous superficial surface of the soleus; however, in most cases, the distal end of the gastrocnemius aponeurosis extends for a variable distance as a thin, tendinous sheet void of muscular attachments. Surgeons performing a gastrocnemius recession may target the exposed inferior portion of the aponeurosis that is not directly covered by muscle. This is the subject of this anatomical study. Fifty-three embalmed cadaveric specimens were dissected to measure the length of the gastrocnemius aponeurosis medially and laterally. Three aponeurosis length categories were subjectively developed according to the ease with which a surgeon might release the gastrocnemius from the soleus: long aponeurosis (minimum aponeurosis length greater than 10 mm; 53% of specimens); short aponeurosis (9%), and direct attachment of the gastrocnemius muscle to the soleus on the medial side, lateral side, or both (38%). The typical gastrocnemius aponeurosis in the sample was distinctly shorter medially and longer laterally. For aponeuroses in the long aponeurosis category, the median length medially was 22.5 mm and median length laterally was 51 mm. In the short aponeurosis category, median medial length was 5 mm and lateral length was 22 mm. The lateral length was 1.8 times greater than the medial length for the long aponeurosis and 5 times greater for the short aponeuroses. Understanding the variation of the gastrocnemius aponeurosis will aid the surgeon in choosing a recession technique, performing the procedure, and preventing iatrogenic complications.

Role of toe flexor tendoscopy in management of an unusual cause of metatarsalgia

The purpose of this study is to describe an endoscopic approach to toe flexor tendons at the level of metatarsal head region. And this study is a kind of retrospective case series. Three patients with toe flexor tenosynovitis were evaluated after a follow-up of 2 years after toe flexor tendoscopy. One patient suffered from infective toe flexor tendosynovitis resulting from a penetrating injury and other two patients suffered from idiopathic focal toe flexor tenosynovitis. Pre-operative metatarsalgia subsided after toe flexor tendoscopy. No endoscopy-related complication was observed. Toe flexor tendoscopy can be an effective operative means in the management of focal toe flexor tenosynovitis.

Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases

To evaluate morbidity associated with surgical lengthening of the gastrocnemius, medical records were reviewed retrospectively for 126 patients (mean age, 49.7 years; range, 8-78 years) who had undergone open gastrocnemius recession. Ten patients had isolated recession; 116 had gastrocnemius recession with an additional foot or ankle procedure on the ipsilateral limb. During a mean follow-up period of 19 months (range, 6-50 months), all patients were examined for any postoperative complications associated with the recession. Complications were defined as the presence of postoperative infection, wound dehiscence, nerve problems, decreased muscle strength, scar problems, or calcaneus gait (overlengthening). Uncomplicated outcome was defined as absence of all these complications and return to regular activity, both occurring during a follow-up of at least 6 months. Postsurgical complications developed in 9 (6%) of the 126 patients: 6 (4%) had scar problems, 2 (1.33%) had wound dehiscence, 2 (1.33%) had infection, 3 (2%) had nerve problems, and 1 (0.67%) developed complex regional pain syndrome. No patient complained of either a limp or gait disturbance. Neither persistent decrease in muscle strength nor calcaneus gait was seen. These data suggest that the open gastrocnemius recession procedure has low associated morbidity.

An equinus deformity of the ankle accounts for only a small amount of the increased forefoot plantar pressure in patients with diabetes

Patients with diabetes mellitus may develop plantar flexion contractures (equinus) which may increase forefoot pressure during walking. In order to determine the relationship between equinus and forefoot pressure, we measured forefoot pressure during walking in 27 adult diabetics with a mean age of 66.3 years (sd 7.4) and a mean duration of the condition of 13.4 years (sd 12.6) using an Emed mat. Maximum dorsiflexion of the ankle was determined using a custom device which an examiner used to apply a dorsiflexing torque of 10 Nm (sd 1) for five seconds. Simple linear regression showed that the relationship between equinus and peak forefoot pressure was significant (p < 0.0471), but that only a small portion of the variance was accounted for (R(2) = 0.149). This indicates that equinus has only a limited role in causing high forefoot pressure. Our findings suggest caution in undertaking of tendon-lengthening procedures to reduce peak forefoot plantar pressures in diabetic subjects until clearer indications are established.

A mechanical equinometer to measure the range of motion of the ankle joint: interobserver and intraobserver reliability

BACKGROUND

Clinical measurement of passive dorsiflexion of the ankle joint is essential for the diagnosis of various pathologic conditions of the foot and ankle but is of unreliable precision with high interobserver variability in nonweightbearing tests. This work was designed to develop and test a precise, standardized, and reliable technique for measurement of passive and active ankle range of motion.

METHODS

The proposed measurement tool is composed of two mobile parallelograms, one attached to the tibia, the second one to the plantar surface of the foot. The parallelograms are connected with a hinge with an angular scale to measure the angle between the foot and tibia.

RESULTS

Interobserver correlation between clinical measurements for maximal passive foot dorsiflexion were 0.03 with knee extension and 0.38 with knee flexion, while for measurements with the proposed tool they reached 0.89 and 0.97, respectively, with a mean measurement error of 0.9 degrees. Intraobserver correlations reached values of r = 0.98 and 0.99.

CONCLUSIONS

The proposed tool allows measurement of the ankle range of motion with very high precision and reproducibility far superior to clinical measurements.

CLINICAL RELEVANCE

Precise measurement of ankle range of motion is clinically challenging. With the use of the proposed tool, measurement precision and reliability are decisively improved.

The effect of triceps surae contracture force on plantar foot pressure distribution

BACKGROUND

Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure.

METHODS

Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350 N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions.

RESULTS

The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p<or=0.005). Increasing gastrocnemius force had similar results. Increasing triceps surae force from 0 to 21 lbs (93 N) increased average percent forefoot and midfoot force 59% and 38%, respectively, and reduced average percent hindfoot force 18%. Increasing gastrocnemius force from 0 to 18 lbs increased average percent forefoot and midfoot force 50% and 32%, respectively, and reduced average percent hindfoot force 16%. For a given triceps surae force, there was no statistical difference in pressure distribution noted between different combinations of gastrocnemius and soleus force.

CONCLUSIONS

In a static model, increased triceps surae or isolated gastrocnemius force shifted weightbearing plantar pressure from the hindfoot to the midfoot and forefoot. Similar results were noted whether the triceps surae force was applied through the gastrocnemius or soleus or both. The results of this study are consistent with the clinical association of triceps surae contracture with foot and ankle disorders including diabetic foot ulcers and metatarsalgia. The similar effects with triceps surae force application through the gastrocnemius or soleus suggest that patients with isolated gastrocnemius contractures may obtain similar clinical benefits with potentially less morbidity after gastrocnemius aponeurosis lengthening as compared to Achilles tendon lengthening.

Role of toe flexor tendoscopy in management of an unusual cause of metatarsalgia

The purpose of this study is to describe an endoscopic approach to toe flexor tendons at the level of metatarsal head region. And this study is a kind of retrospective case series. Three patients with toe flexor tenosynovitis were evaluated after a follow-up of 2 years after toe flexor tendoscopy. One patient suffered from infective toe flexor tendosynovitis resulting from a penetrating injury and other two patients suffered from idiopathic focal toe flexor tenosynovitis. Pre-operative metatarsalgia subsided after toe flexor tendoscopy. No endoscopy-related complication was observed. Toe flexor tendoscopy can be an effective operative means in the management of focal toe flexor tenosynovitis.

Evaluation of results of endoscopic gastrocnemius recession

BACKGROUND

Gastrocnemius recession is traditionally done as an open procedure. The aim of this retrospective study was to evaluate the safety and efficacy of gastrocnemius recession performed endoscopically.

METHODS

The procedure was done in 28 patients (17 men and 11 women), ranging in age from 16 to 72 years (average 47.57, SD 13.86) between January, 2001, and September, 2003. In three patients, the procedure was done bilaterally. Followup ranged from 4 to 36 months (average 22.00, SD 11.84). The procedure was done through a single medial or lateral portal using the 3M Agee Carpal Tunnel Release System (Micro Aire Surgical Instruments, Charlottesville, VA).

RESULTS

The initial incision for portal entry was at the wrong level in two of 31 procedures (6.5%), requiring a second incision. The recession could not be accomplished in one of 31 procedures (3.2%), so an open technique was used to complete transection of the gastrocnemius aponeurosis. One patient had a superficial wound infection (3.2%). There was no incidence of sural nerve or Achilles tendon damage. Analysis of results from a modified Olerud and Molander score using a paired student t-test revealed statistically significant improvement (p < or = 0.05) in pain, stiffness, swelling, and overall average score after the procedure.

CONCLUSION

The results of endoscopic gastrocnemius recession using the Agee Carpal Tunnel Release System have been encouraging, with limited morbidity. The technique proved both feasible and safe in this study.

Biomechanics of the first ray part V: The effect of equinus deformity. A 3-dimensional kinematic study on a cadaver model

The positional change of the medial column of the foot in closed kinetic chain with variable Achilles tendon tension was investigated in seven fresh frozen cadaver specimens using a 3-dimensional radio wave tracking system. The distal tibia and fibula and the intact ankle and foot and were mounted on a non-metallic loading frame. The frame allowed positioning of the foot to simulate midstance phase of gait while the tibia and fibula were axially loaded to 400 N. To record osseous motion, receiving transducers were attached to the first metatarsal, medial cuneiform, navicular, and talus. Movements of these bones in 3-dimensional space were measured as specimens were axially loaded and midstance motor function was simulated using pneumatic actuators. To simulate a progressive equinus influence, force was applied to the Achilles tendon at tensile loads of 0%, 30%, and 60% of predicted maximum strength during each test trial. Osseous positions and orientations were collected and analyzed in all three cardinal planes utilizing data recorded. As Achilles load increased, the position of the first metatarsal became significantly more inverted ( P < .05). Although not statistically significant, remarkable trends of arch flattening motion were detected in the distal segments of the medial column with varied Achilles load. Increased Achilles load reduced the influence of peroneus longus on the medial column.

The subtle cavus foot, "the underpronator"

Subtle cavus foot deformity is ubiquitous, yet it continues to be commonly missed. Simple physical examination maneuvers can provide information that allows well-planned nonoperative care and selection of operative procedures to correct the underlying cause as well as presenting pathology.

Salvage of the neuropathic foot by using bone resection and tendon balancing: a retrospective review of 10 patients

Medical records were retrospectively reviewed for 10 patients (mean age, 48.7 years) who had a chronic, recurrent neuropathic forefoot ulceration or osteomyelitis in the presence of an abnormal metatarsal parabola. Two patients had multiple lesser metatarsal osteomyelitis, 3 patients had chronic ulceration in the presence of an abnormal metatarsal parabola, and 5 patients had previous lesser ray resection or metatarsal head resection. None of the patients had signs of skin breakdown under the first metatarsal. All of the patients were treated with a combination gastrocnemius recession, peroneus longus to peroneus brevis tendon transfer, and resection of the second through fifth metatarsal heads to decrease plantar forefoot pressure and preserve the first ray without increasing the risk of ulceration under the first metatarsal head. All patients achieved a healed plantigrade foot without ulcer recurrence, transfer callus development, or contralateral foot breakdown at a mean follow-up of 14.2 months. Postsurgical complications consisted of dehiscence of various incision sites on 3 individual patients and one local reaction to antibiotic-impregnated beads. This preliminary study suggests that this combination of reconstructive procedures may provide an alternative method of foot salvage to panmetatarsal resection and transmetatarsal amputation.

Endoscopic gastrocnemius recession: preliminary report on 18 cases

A technique of endoscopic gastrocnemius recession was evaluated. Fifteen patients undergoing 18 procedures were prospectively studied with a minimum follow-up of 1 year. There were 9 women and 6 men (mean age, 44.1 +/- 22.6 years). One patient had an isolated recession; the others had various adjunctive flatfoot or reconstructive procedures. Pre- and postoperative ankle dorsiflexion was evaluated, as was the amount of time before patients could perform a single-leg heel raise postoperatively. The mean preoperative ankle dorsiflexion with the knee extended was -8.7 degrees +/- 3.5 degrees , which improved from a mean 14.9 degrees at 3 months postoperatively to a mean 6.2 degrees +/- 2.6 degrees . At 12 months postoperatively, this value was 3.6 degrees +/- 1.8 degrees , a net postoperative improvement of 12.6 degrees (P < .00001). Patients were able to perform a single-leg heel raise on an average of 13.0 +/- 6.0 weeks. Complications were mostly related to lateral foot dysesthesia in the distribution of the sural nerve (N = 3). Furrowing of the medial leg was noted in 1 patient. No hematomas or neuromas associated with the portal sites were found. These results show endoscopic gastrocnemius recession to be an acceptable method of lengthening the gastrocnemius complex.

Hyperpronation and foot pain: steps toward pain-free feet

Primary care physicians often see patients who have foot pain. Although foot disorders may have many diagnostic possibilities, the majority can be explained via the pathologic biomechanics of hyperpronation and the resulting changes in the kinetic chain. Four common problems often associated with hyperpronation are plantar fasciitis, posterior tibial tendon dysfunction, metatarsalgia, and hallux valgus. Interventions that seek to reduce hyperpronation and strengthen foot muscles are often recommended for treating foot pain.

Dorsal mobility and first ray stiffness in patients with diabetes mellitus

BACKGROUND

Limited joint mobility in diabetic patients has been identified as a risk factor in the development of plantar ulcers. We examined dorsal mobility and passive first ray stiffness in patients with diabetes and investigated the relationship between first ray mobility and ankle joint dorsiflexion.

METHODS

Forty individuals were studied: 20 with diabetes (mean estimated duration of 16 +/- 10 years) and 20 matched controls. Dorsal first ray mobility was measured using a mechanical device. Force-vs-dorsal mobility displacement values were collected at 10 N increments to a load limit of 55 N. Ankle joint dorsiflexion motion was measured with a goniometer. The "prayer sign," a clinical indicator of limited joint mobility, was evaluated in each patient. Subjects were separated into the two groups for data analysis.

RESULTS

Patients in the diabetic group had more stiffness and less dorsal first ray mobility than the control group (p <.05). In particular, patients with a positive prayer sign had significant first ray stiffness (p <.05). Patients with diabetes also had less ankle dorsiflexion (p <.05).

CONCLUSION

Patients with diabetes have more stiffness and less first ray mobility and less ankle dorsiflexion than those without diabetes. The presence of a positive prayer sign correlates with stiffness and loss of first ray mobility. Soft-tissue stiffness may contribute to the development of foot ulcers in diabetic patients with neuropathy.

The effect of ankle position on the exam for first ray mobility

PURPOSE

The clinical assessment of first ray motion in the sagittal plane, as originally described by Morton, is difficult to quantify. Different reports have shown inconsistent values and variability between the manual exam and examination using an external measuring device. The authors hypothesize that when performing a manual examination for evidence of increased first ray motion, the magnitude of first ray mobility varies as the position of ankle dorsiflexion/plantarflexion varies.

METHODS

Using an external caliper (a modified Klaue device), the authors quantified first ray motion in reference to variable ankle positions in a group of normal patients, a group of patients with untreated moderate and severe hallux valgus, a group who had undergone a successful metatarsophalangeal joint arthrodesis for hallux valgus, and a small group who had previously undergone a plantar fasciectomy. A total of 119 feet (109 patients) were measured. In addition to first ray motion, radiographic data were compared between groups.

RESULTS

With the ankle in the neutral dorsiflexion position, the mean first ray motion was 4.9 mm for the control group, 7.0 mm for the hallux valgus group, 4.4 mm for the metatarsophalangeal fusion group, and 7.7 mm for the plantar fasciectomy group. There was a significant decrease (p < .05) in first ray motion when the ankle was moved to the dorsiflexed position for all four groups. There was a significant increase in first ray motion when the ankle was moved to the plantarflexed position (p < .01) for all groups except the plantar fasciectomy group. No significant difference in first ray motion was observed for the plantar fasciectomy group between the neutral and plantarflexed ankle positions (p < .05).

CONCLUSION

The exam for first ray mobility is influenced by the position of the ankle and may explain the discrepancy between the manual exam and measurement with an external device. Recommendations for the manual exam of first ray mobility are given.

Evaluation of Morton's theory of second metatarsal hypertrophy

BACKGROUND

Originally introduced by Morton, the concept of hypertrophy of the medial cortex and the entire shaft of the second metatarsal as an objective sign of increased mobility of the first ray has not been subjected to much scrutiny. The goal of the current study was to assess the clinical relevance and reliability of radiographic measures of hypertrophy of the second metatarsal in relation to mobility of the first ray, pes planus, and tightness of the gastrocnemiussoleus in both control subjects and patients with diagnosed disorders of the forefoot.

METHODS

Four study groups of forty-three subjects each were evaluated. The cohort included an asymptomatic control group as well as three groups made up of patients with symptoms and a diagnosis of hallux valgus, hallux rigidus, or interdigital neuroma. Mobility of the first ray (as measured with a device and method described by Klaue et al.), arch height, and ankle dorsiflexion were measured on physical examination. Plain weight-bearing radiographs and previously established equations were used to determine hypertrophy and the length of the second metatarsal, and the hallux valgus and first-second intermetatarsal angles were measured on plain radiographs as well.

RESULTS

There was no significant difference between the control and symptomatic groups with regard to the values for hypertrophy of the second metatarsal. The patients with hallux valgus deformity had significantly greater mobility of the first ray (p < 0.001) compared with the controls. No correlation was found between values for hypertrophy of the second metatarsal and mobility of the first ray, the length of the first metatarsal, pes planus, or restricted ankle dorsiflexion. No correlation was found between mobility of the first ray and either pes planus or restricted ankle dorsiflexion. A weak correlation (r = 0.4) was noted between increased mobility of the first ray and the hallux valgus angle.

CONCLUSIONS

Our findings do not support Morton's concept that medial cortical hypertrophy and increased shaft width of the second metatarsal are associated with increased mobility of the first ray or relative shortness of the first metatarsal. In addition, hypertrophy of the second metatarsal was not associated with either pes planus or restricted ankle dorsiflexion. We found the practice of using hypertrophy of the second metatarsal as an indicator of mobility of the first ray to be unreliable, and thus we consider it to be an inappropriate indication for arthrodesis of the first metatarsocuneiform joint in the treatment of hallux valgus deformity.

Fractures of the navicular

Generally, large or significantly displaced intra-articular navicular fractures are treated best by surgical intervention. Open reduction and internal fixation of these injuries allow anatomic restoration of adjacent joint surfaces and preservation of length and stability along the medial column of the foot; intervention must not disrupt the already tenuous blood Supply of the tarsal navicular because of the associated risks of avascular necrosis and nonunion. The unique morphology and vital role of the navicular as a cornerstone of the talonavicular joint require every effort to maintain the congruity and motion of this joint to avoid later fusion. The likelihood for successful reduction decreases with increasing grades of injury. The naviculo-cuneiform joint, alternatively, requires stability for proper foot function and can be fused, if necessary, to improve fixation or enhance vascularity to the navicular. External fixation, bone grafting (often and early), and limited peritarsal fusion also have evolved into useful aids, under certain circumstances, to facilitate the goals of navicular fracture management. Early postoperative range of motion, prolonged protected weight bearing, and aggressive patient counseling as to the severity and long-term implications of these injuries also are paramount to success. Caution also must be exercised in managing navicular dislocations because of the potential long-term complications of redislocation or painful flatfoot deformity if alignment is not maintained. Navicular fracture care remains a challenge to the orthopedic surgeon; successful surgical intervention continues to hinge upon a careful balance between an operative exposure that is limited enough to avoid further devascularization but extensive enough to permit anatomic reduction and rigid internal fixation.

Naviculocuneiform arthrodesis

NC arthrodesis is a useful procedure to alleviate pain secondary to arthritis or collapse of the medial longitudinal arch. Fusion of this joint provides stabilization of the medial column and is often used in conjunction with other flatfoot-correcting procedures to restore normal function to the foot. Because the NC joint is the center of the lever arm of the foot and is therefore subject to bending-moment stress, concomitant gastrocnemius recession or tendo-Achillis lengthening is recommended.

Hallux rigidus: demographics, etiology, and radiographic assessment

PURPOSE

The purpose of the study was to evaluate the demographics, etiology, and radiographic findings associated with hallux rigidus in patients treated surgically over a 19-year period in a single surgeon's practice.

METHODS

Patients treated for hallux rigidus by cheilectomy and metatarsophalangeal joint fusion were identified from 1981 to 1999. Patients who had diabetes, inflammatory arthritis, infectious arthritis, crystalline arthritis, multiple forefoot deformities, neuromuscular disorders, or had died were excluded. A chart review and evaluation of preoperative radiographs were completed on all eligible patients. All identified patients were invited for a follow-up examination that included standard and stress radiographs, range-of-motion testing, Harris mat study, gait analysis, first ray mobility measurement, and standardized questionnaire assessment.

RESULTS

One hundred ten of 114 (96.5%) patients with a diagnosis of hallux rigidus returned for the final evaluation. Eighty cheilectomy patients (93 feet) and 30 arthrodesis patients (34 feet) were evaluated. The mean age at onset in the current study was 43 years (13-70 years) and only six patients developed symptoms at an age of less than 20 years. Hallux rigidus was graded based on a five-grade clinical-radiographic system. The mean follow-up was 8.9 years. Ninety-five percent of patients with a positive family history had bilateral disease at the final follow-up. At the initial examination in the current study, 81% of patients had radiographic and clinical evidence of unilateral disease, but at the final follow-up 79% of patients had radiographic and clinical evidence of bilateral disease. Eleven percent of patients in the present series had pes planus based on either a positive Harris mat study and/or heel valgus. There was no evidence of an Achilles or gastrocnemius tendon contracture. Radiographic analysis found that the concurrent presentation of hallux valgus and hallux rigidus was not common. Ninety-three of 127 feet (73%) had a chevron or flat metatarsophalangeal joint. Thirty-five feet were noted to have mild or moderate metatarsus adductus. A long first metatarsal was no more common in patients with hallux rigidus than in the general population. The mean first ray elevatus was 5.5 mm and was well within acceptable limits of normal. The mean first ray mobility was 5 mm in arthrodesis patients and 5.8 mm in cheilectomy patients.

CONCLUSION

Hallux rigidus was not associated with elevatus, first ray hypermobility, a long first metatarsal, Achilles or gastrocnemius tendon tightness, abnormal foot posture, symptomatic hallux valgus, adolescent onset, shoewear, or occupation. Hallux rigidus was associated with hallux valgus interphalangeus, bilateral involvement in those with a familial history, unilateral involvement in those with a history of trauma, and female gender. Metatarsus adductus was more common in patients with hallux rigidus than in the general population but a clear correlation was not found. Additionally, a flat or chevron-shaped metatarsophalangeal joint was more common in hallux rigidus patients.

Adult acquired flat foot deformity: clinical and radiographic examination

Symptomatic adult acquired flat foot deformity is encountered in the orthopedic office on a frequent basis. Although many causes exist, a careful history and a stepwise approach to the physical examination will clue the examiner into making the correct diagnosis and provide appropriate treatment. Radiographs serve as an adjunct and assist in verifying the examination findings. CT, US, and MRI are helpful modalities for surgical planning or when the diagnosis remains questionable.

Endoscopic gastrocnemius recession: evaluation in a cadaver model

The purpose of this study was to describe a new method of gastrocnemius recession using an endoscopic approach and to determine the accuracy of incision placement during gastrocnemius recession. Fifteen fresh-frozen cadaveric limbs underwent an endoscopic gastrocnemius recession utilizing a two-portal technique. All limbs were anatomically dissected after the procedure and each was examined for injury to the sural nerve. The ability to visualize the sural nerve intraoperatively, improvement in ankle dorsiflexion, time requirement for the procedure, incision size, and appropriateness of placement to facilitate recession were recorded for each specimen. An average of 83% of the gastrocnemius aponeurosis was transected in all 15 cadavers. After modifications of the technique, the final eight cadavers were noted to have had the entire (100%) gastrocnemius aponeurosis transected. Sural nerve injury occurred in one specimen (7%) in which the aponeurosis and the sural nerve were not well visualized. The sural nerve was definitively visualized during the procedure in 5 of 15 specimens (33%). No Achilles tendon injury was noted in any specimen. There was a mean improvement in ankle dorsiflexion of 20 degrees (range, 10 degrees-30 degrees) during full knee extension. The average length of time to perform the procedure was 20 minutes (range, 10-35 minutes). The average medial and lateral incision lengths used in the two-portal technique were 18 mm (range, 14-22 mm) and 17 mm (range, 12-19 mm), respectively, and the average distance from the midpoint of the medial incision to the level of the gastrocnemius-soleus junction was 26 mm (range, 5-60 mm). These results indicate that a complete gastrocnemius aponeurosis transection may be obtained utilizing a modified endoscopic gastrocnemius recession, but visualization of the sural nerve is poor with possible risk of iatrogenic nerve injury.

Ankle dorsiflexion in adolescent athletes

Ankle equinus has been proposed to be associated with lower-extremity pathology. Physiologically normal measurements have been quantified in various populations. Forty high-school athletes (16 girls and 24 boys) without a history of ankle injury had ankle dorsiflexion measured with the knee extended and flexed by an experienced evaluator using a goniometer with the subjects supine. The group mean +/- SD dorsiflexion for the right ankle was 0.35 degrees +/- 2.2 degrees with the knee extended and 4.88 degrees +/- 3.23 degrees with the knee flexed. The values for the left ankle were -0.6 degrees +/- 2.09 degrees and 4.68 degrees +/- 3.33 degrees, respectively. There were no statistically significant differences between limbs using the Student t-test. In girls, values for right and left ankle dorsiflexion were 0.19 degrees +/- 2.1 degrees and -0.7 degrees +/- 2.3 degrees, respectively, with the knee extended and 4.88 degrees +/- 3.59 degrees and 4.88 degrees +/- 3.07 degrees, respectively, with the knee flexed. In boys, these values were 0.46 degrees +/- 2.3 degrees and -0.5 degrees +/- 1.98 degrees with the knee extended and 4.88 degrees +/- 3.04 degrees and 4.54 degrees +/- 3.55 degrees with the knee flexed. There were no statistically significant differences between boys and girls. Ankle dorsiflexion in asymptomatic adolescent athletes is approximately 0 degrees with the knee extended and just less than 5 degrees with the knee flexed.

Anatomic study of the gastrocnemius-soleus junction and its relationship to the sural nerve

BACKGROUND

Gastrocnemius recession is performed for equinus contracture of the ankle and as an adjunct treatment for various foot pathologies. Successful release relies on many factors, including a thorough knowledge of the anatomy of the gastrocnemius-soleus junction and its relationship to the sural nerve which may be vulnerable to iatrogenic injury. Neither the average width of the tendon at the gastrocnemius-soleus junction, the anatomy of the sural nerve with respect to the gastrocnemius-soleus junction, nor appropriate landmarks for accurate incision placement at this level to avoid undesirable vertical extension, however, have yet to be acceptably defined.

METHODS

Fourteen fresh-frozen cadavers were dissected and the width of the tendon at the gastrocnemius-soleus junction, the distance of the sural nerve from the lateral border of the tendon at this level, the length of the fibula, and the distance from the distal tip of the fibula to the gastrocnemius-soleus junction were measured.

RESULTS

The average width of the gastrocnemius-soleus complex at the junction was 58 mm (range, 44-69 mm), the average distance of the sural nerve from the lateral border of the gastrocnemius-soleus complex at the level of the gastrocnemius-soleus junction was 12 mm (range, 7-17 mm), the average percentage of this distance as compared to the entire width of gastrocnemius-soleus junction was 20% (range, 13%-27%), and the ratio of the distance of the gastrocnemius-soleus junction from the distal tip of the fibula divided by the length of the fibula was 0.5 (range, 0.5-0.6).

CONCLUSION

These results provide some guidelines as to the approximate size of the gastrocnemius-soleus complex at the site of gastrocnemius recession along with the location of the sural nerve at the musculotendinous junction. Also, the results indicate that the fibula can serve as a reproducible anatomic landmark to enable localization of the gastrocnemius-soleus junction at the time of gastrocnemius recession.

Hallux valgus in men. Part II: First ray mobility after bunionectomy and factors associated with hallux valgus deformity

PURPOSE

To determine the 1st ray mobility following a distal soft-tissue procedure with proximal osteotomy (DSTP-PMO) and any associated factors.

METHODS

A retrospective study of 30 men (35 feet) was performed. First ray mobility, ankle dorsiflexion, pes planus, and metatarsus adductus were evaluated at the final follow-up. All internal fixation was routinely removed at six to eight weeks postoperatively. Standard radiographs were evaluated and angular measurements were calculated on all feet.

RESULTS

The mean follow-up was 78 months. No cases of degenerative arthritis of the 1st MTC joint were noted on follow-up radiographs. DSTP-PMO resulted in a mean postoperative 1st ray mobility of 4.9 mm (range, 2.5 to 8). In those feet evaluated following bunion correction, there was no correlation with pes planus, limited ankle dorsiflexion or metatarsus adductus. The preoperative hallux valgus angle and 1-2 intermetatarsal angle correlated with toe pronation and a positive family history. Twenty-two patients had an AOFAS score of 90-100, seven of 80-89 and one less than 69.

CONCLUSION

Hallux valgus in this group of male patients was not associated with limited ankle dorsiflexion or pes planus. Men with toe pronation and a positive family history had a greater hallux valgus deformity than those without after a distal soft tissue repair with proximal first metatarsal osteotomy. There was no evidence of first ray hypermobility after a DSTP-PMO.