What Do We Know About The Prevalence Of Ankle Equinus?

Despite its impact on a multitude of lower extremity pathologies, there is relatively little data regarding the true prevalence and laterality of ankle equinus in the literature. A recent study in the Journal of the American Podiatric Medical Association aimed to assess these metrics in a prospective cohort study of 249 patients in a single practice. Included patients underwent ankle range of motion measurement by a single rater, and did not have histories of Achilles tendon rupture, posterior muscle group lengthening or previous non-surgical or surgical treatment of equinus. Researchers in this study defined equinus as ankle joint dorsiflexory range of motion of less than or equal to zero degrees and severe equinus as less than or equal to negative five degrees.

Ankle equinus was present in 183 out of 249 patients (73 percent) and nearly all experienced this bilaterally (180 out of 183). They also found equinus to be more common among those with diabetes, higher body mass index (BMI) or symptoms of overuse. The authors conclude that many people presenting to foot and ankle practices will likely have ankle equinus, and certain groups of patients are especially likely to experience this condition.

Patrick DeHeer, DPM, FACFAS, FASPS, lead author on the study, says the findings do align with what he sees clinically.

“I treat both limbs when I am treating equinus on a patient as part of their overall treatment plan, even if the pathology is a unilateral condition,” he notes.

“If you only treat one side and not both, you create a functional limb length inequality and the ramifications of that can be significant,” he relates. “I like to always put this way, ‘Do you make one orthotic or two?’ You of course make two, and treating equinus is the same thing. If it is bilateral, and most of the time it is, treat both limbs.”

Dr. DeHeer notes the study based its definitions of equinus on the literature at the time of data collection. Since the study concluded, he shares an article by Gatt and colleagues that correlated static measurement with dynamic function.¹

“They clarified the proper technique to measure statically is to supinate the entire foot then dorsiflex the ankle,” he explains. “This method locks the midtarsal joint to 2.5 degrees of motion, which is clinically insignificant and isolates all the dorsiflexion to the hindfoot. Additionally, as the foot supinates it externally rotates the tibia, allowing for full knee extension critical to evaluate the gastrocnemius muscle.”¹

He adds that a study by Dayton and team also confirmed this as a more reliable method.²

“Gatt and colleagues’ study concluded that the definition of equinus should actually be negative five degrees with the knee extended and the foot fully supinated,¹” relates Dr. DeHeer. “That is the methodology I teach and use clinically now.”

He hopes that those reading the study will evaluate for equinus and treat it on both sides when it is present.

“It is almost always present, and article after article relates equinus and numerous lower extremity pathologies to each other, so a comprehensive treatment plan must include equinus management,” adds Dr. DeHeer, Director of the St. Vincent Hospital Podiatric Residency Program in Indianapolis.

Does Discharge Destination Have An Impact On Limb Salvage Surgeries?

By Jennifer Spector, DPM, FACFAS, Managing Editor

Do patients fare better when discharged to home or a skilled nursing facility (SNF) after surgery for limb salvage? A recent study in the International Wound Journal evaluated 175 subjects over a 12-month period from a single center to investigate this question. Patients discharged to SNF (n = 40) exhibited longer healing times, more rehospitalizations that required podiatric consultation, increased future major lower extremity amputation and higher mortality than the home discharge cohort. Researchers found no significant differences between the groups in surgically cleared osteomyelitis and the Charlson Comorbidity Index values. The authors concluded that discharge destination is indeed an important factor in outcomes for patients after limb salvage surgery.

Rebecca A. Burmeister, DPM, MPH, lead author on the study, points out that discharge to a SNF is typically a very strategic decision.

“Prior to our study we intuitively felt a discharge to a SNF would have been protective since the patient receives 24-hour medical care,” she says. “I do not think any members of our podiatry team at the University of Michigan recognized these poorer outcomes in patients discharged to a SNF were so significant.”

When considering why patients discharged to home experienced better outcomes compared to SNF, Dr. Burmeister shares that the role of social and physical support at home are perhaps underappreciated factors. Additionally, she notes nearly daily conversations with patients and family expressing the desire to return home after discharge to reduce risk of COVID-19 exposure.

As far as take away messages, Dr. Burmeister hopes that podiatrists note that SNF discharge is not a protective factor, and is in fact a risk for poorer outcomes after diabetic limb salvage surgery. Diving deeper into the research, Dr. Burmeister relates that they did not examine specific characteristics of each discharge environment that could influence outcomes in each destination.

“This does not mean that we feel SNF stays are unsafe, but we think it demonstrates that there are other patient factors or SNF-related factors which could explain such a difference in outcomes,” explains Dr. Burmeister, a Podiatry Fellow at the University of Michigan Medicine in Ann Arbor, Michigan.

APMA Task Force Addressing Diversity, Equity And Inclusion

By Jennifer Spector, DPM, FACFAS, Managing Editor 

The American Podiatric Medical Association (APMA) Diversity, Equity and Inclusion (DEI) Task Force is exploring and identifying related issues and potential gaps in internal policies and procedures in order to work towards more diverse and inclusive points of view among membership and staff.¹ In 2020, APMA undertook concerted efforts to take positive action on DEI issues including those in recruitment, educational efforts, research, meeting faculty selection and inter-organizational collaboration.¹ Additional goals include review of and measurable progress on internal APMA documents, manuals and procedures.¹

The task force members are comprised of current and past APMA leadership, leaders of related organizations, educational representatives, staff liaisons and young members. APMA also held a DEI Town Hall during the 2021 Virtual House of Delegates meeting with speakers including Janet Simon, DPM, Jondelle Jenkins, DPM, Karen Langone, DPM and William Long, DPM. These speakers shared moving personal and organizational experiences and data on DEI issues relevant to podiatry.

“The purpose of the DEI task force is to make sure that everybody has a voice,” said Dr. Long, Chair of the Task Force, at the 2021 APMA House of Delegates Virtual Town Hall.

He went on to say that it is up to the leaders in the profession to make things better for those that follow them.

“We have to be more understanding of everyone’s differences,” he continued. “I’m glad that APMA is stepping forward and taking this on, head-on.”

According to the task force website¹, the work of this group is ongoing and membership continues to evolve to exemplify their goal of inclusivity.

Equinus

1. Gatt A, De Giorgio S, Chockalingam N, Formoas C. A pilot investigation into the relationship between static diagnosis of ankle equinus and dynamic ankle and foot dorsiflexion during stance phase of gait: Time to revisit theory? Foot. 2017; 30:47-52.

2. Dayton P, Feilmeier M, Parker K, et al. Experimental comparison of the clinical measurement of ankle joint dorsiflexion and radiographic tibiotalar position. J Foot Ankle Surg. 2017; 56(5):1036-1040.

APMA

1. Diversity, Equity and Inclusion Task Force. American Podiatric Medical Association. Available at: www.apma.org/dei . Accessed May 6, 2021.