Equinus | Intelligent Management | EQ/IQ Brace No. 4 in a Series

In an attempt to get stability in the treatment of equinus, I have been trying to establish a definition. Previous posts have discussed research regarding the definition numbers. The definition standards would be helpful both in diagnostic evaluation and treatment of equinus.

When it comes to the treatment of equinus, the current non-surgical modalities have been effectual at best. I have invented equipment that I believe is a superior non-surgical treatment for equinus. The design process is based entirely on evidence based medicine and the references are readily available — please contact me if you want to see them.

First, I would like to discuss night splints and why they are ineffective. I have had personal experience using night splints during which I realized their flaws first hand.

I developed Posterial Tibial tendonitis in my right ankle from running; the condition was not improving with orthosis. I did not want to stop running because the activity had helped me lose 40 pounds. I had equinus like many of the population, which was worsening with the running. I started using night splints to help. One night, I woke up at 3:00 am to take the splints off and looked down at my legs. I sleep on my side with my knees bent, like most adults; especially when wearing night splints. I realized the night splints were doing nothing. It is well documented that the Gastrocnemius muscle is the muscle that is tight as it crosses the knee, ankles and subtaler joints. My Gastrocnemius muscles were not being stretched at all; a complete waste of time. Additionally, I was not sleeping well due to the night splints. I was ready to burn them.

The proverbial light bulb went off — I would have to have an above the knee extension to lock the knee in extension. The solution I came up with is the EQ/IQ brace.

The EQ/IQ brace, intelligent management for equinus, does not need to be slept in. I recommend using it 30 minutes in the morning and 30 minutes in the evening with 15 minutes spent stretching the Gastroc-Soleus complex and 15 minutes spent stretching the Soleus.

I will discuss features of the EQ/IQ brace from proximal to distal.

There is an above-the-knee extension with a hinge at the knee. The extension allows the knee to be locked into extension to stretch the Glastrocnemius muscle. The hinge can be released to allow for ease of application and isolated stretching of the Soleus. There is also a hinge at the ankle joint which allows the treating physician to set exactly the amount of dorsiflexion desired based on the patient’s biomechanical exam. I estimate 5 degrees the first month increasing to 10 degrees the second month, then if needed, 15 degrees the third month. The hinge goes from -30 degrees to +30 degrees, in 5 degree increments.

We, as treating podiatrists, will measure everything from X-ray angles to forefoot varus position. Yet, we slap on a night splint and tell our patients, “Pull as tight as you can.” This makes not sense to me. We should have more control and precision over the treatment of equinus.

More about the EQ/IQ

Rocker Soles:

I designed the EQ/IQ brace to be ambulatory with a negative heel rocker sole, which allows ambulation with a fixed dorsiflexed position.

The rocker soles can be removed. Three different sizes (5, 10, and 15 degrees) are included with the brace to match the amount of ankle joint dorsiflexion.

Adjustable Wedges:

There is an adjustable wedge that goes under the hallux to engage the Windlass Mechanism. These wedges come in 35, 50, and 65 degree sizes and Velcro to the foot bed.

I designed varying degrees for the wedges to allow for patients with hallux limitus or rigidus.

Adjustable Uprights:

The femoral and tibial uprights are adjustable for leg and should be set by the physician

Foot Bed Sizes:

The standard foot beds will fit a small/medium size. However, the foot bed can be replaced by an extended version that will fit a large/extra large size.

Using the EQ/IQ Brace:

I am recommending time periods for wearing the EQ/IQ based upon recommendations for manual stretching, but doubled. Most manual stretching recommendations have the stretches done about 30 minutes per day. I think an hour a day is reasonable from a compliance stand point compared to 6-8 hours at night while disturbing the patient’s sleep.

The ambulatory component of the brace is an important factor. Patients can wear the brace during ther preparations for the day – after dressing the brace is working while they perform typical morning rituals. A similar scenario would play out for the evening stretching.

How to Get the EQ/IQ Brace:

The EQ/IQ brace is being prepared for production in the next few weeks. Treating professionals such as podiatrists, orthopedic surgeons, chiropractors, physical therapists, athletic trainers may pre-order the brace at an introductory discount of $170.00 per brace plus free shipping. Later the price will increase to $200.00 per brace.

To pre-order or get additional information, contact me at 317-660-2115 or you may use the contact/comment form at the Hoosier Foot and Ankle website, available 24/7 for your convenience.

Equinus | Intelligent Management| No. 3 in a Series

I’ve been discussing the need for a standard definition to apply to equinus conditions. I believe the condition is under diagnosed because of the vast variety of opinions about just what qualifies as equinus.

Last week, I covered research that I felt was based on low numbers which can lead to the opposite situation — over diagnosis. (Equinus | Intelligent Management No. 2 in a Series)

Referring to an article by J.F. Grady and A. Saxena; Effects of stretching the gastrocnemius muscle, in J. Foot Surg 30: 465, 1991 — a uniblind examination of ankle joint dorsiflexion with various times of stretching exercises performed once a day for six months:

• 30 seconds
• 2 minutes
• 5 minutes

The study used found the average pre-stretching measurements of the 25 participants to be 2.86+/-2.99 degrees of dorsiflexion with the knee extended and 9.02+/-2.35 degrees of ankle joint dorsiflexion with the knee flexed. Their study showed no statistical significance to the improved ankle joint dorsiflexion to recommend manual stretching.

The key point for this discussion is the pre-treatment numbers. The patients were measured with a goniometer in subtaler neutral with the midtarsal joint locked. This number is similar to Hill’s definition of 3-degrees as mentioned in the last post entitled Equinus | Intelligent Management No. 2 in a Series. Again, I think this is slightly off toward the low end.

C.W. Digiovanni, R. Kuo, N. Tejwani, et al wrote Isolated gastrocnemius tightness, in J Bone Joint Surg Am 84; 962, 2002, which examined the frequency of equinus in a symptomatic patient group and control group; and the reliability of clinical evaluation of equinus compared to an equinometer (this would be a computer measurement of ankle joint dorsiflexion). They used two definitions of equinus — 5-degrees and 10-degrees ankle joint dorsiflexion with the knee extended.

In the symptomatic group, the average ankle joint dorsiflexion with the knee extended was 4.5-degrees. In the control group, it was 13.1-degrees. The 5-degree group contained 65% symptomatic patients and 24% control group patients. In the 10-degree group, there were 88% symptomatic patients and 44% were of the control group.

The reliability of clinical exam compared to the equinometer for the 5-degree group was 76% for the symptomatic group of patients and 94% for the patients in the control group. For the 10-degree group, the reliability was 88% for the symptomatic group and 79% for the control group. The following quote from their article summarizes their findings.

“We have selected <5° of maximal ankle dorsiflexion with the knee in full extension as our definition because it allowed us to diagnose the problem in those who were at risk (symptomatic patients) with fairly good reproducibility (76%) and, more importantly, we were able to reliably avoid (in 94% of the cases) unnecessary treatment of those who were not at risk (asymptomatic people).”

When examining this literature, it is clear to me that the standard definition of equinus should be 5-degrees of ankle-foot dorsiflexion with the knee extended. It is important to have the subtaler joint in neutral postion and the midtarsal joint locked.

Readers who are experienced with foot conditions will be more familiar with some of the terms than patients or people who have foot pain but who haven’t found someone who can offer relief. If you have questions about your condition, I recommend that you contact a professional with your questions and seek a professional evaluation. As this post reports, standard definition and professional evaluation can both deliver adequate treatment and/or avoid over-treatment.

Equinus | Intelligent Management| No. 2 in a Series

The concerns and issues of Equinus treatment are faced by patients first, then their podiatrists and other professional contacts. I am suggesting some standard definitions for diagnosis and treatment so that we can help patients ‘get back in step’

Informational literature has Equinus definition ranges between -10 and +22 degrees of ankle joint dorsiflexion for normal ambutlation. I found a consensus of 13 different studies for10-degrees. Having a firm definition range should make communication between specialties and among practitioners much easier when discussing equinus.

For example, I am the team podiatrist for both the Indiana Pacers team and the Indiana Fever team. Within my determination of the measurement degrees, I think every player has equinus. The trainers use different measurements which lead them to think none of the players have equinus. It is a matter of definition and evaluation.

An article written by R.S. Hill; “Ankle equinus: prevalence and linkage to common foot pathology.” in JAPMA 85: 295, 1995, discusses the evaluation of 206 new patients from Kaiser Permanente clinics over a six-week period of time. This article helps establish a definition of equinus that we need.

Additionally, the information shows how frequently equinus is associated with the pathologies we see every day in our podiatry practices. Twenty-six patients were excluded because they didn’t meet criteria – ingrown toenails, onychomycosis, verrucae plantaris were involved among other similar conditions. Six patients of the remaining 174 had normal ankle joit dorsiflexion. Of the 168 patients left in the study, three had gastrocnemius equinus and 165 had gastrocsoleus equinus. Hill used a definition of 3-degrees of ankle joint dorsiflexion and normal ankle joint dorsiflexion. In the study, 96.5% of the patients with foot or ankle symptoms had equinus using these definitions. I think Hill’s definition was a little low and will use the remaining two articles to further discuss a definite definition.

Readers who are experienced with foot conditions will be more familiar with some of the terms than patients or people who have foot pain but haven’t found someone who can offer relief. If you have questions about your condition — perhaps your pain is connected to equinus — I recommend that you contact a professional with your questions and seek a professional evaluation.

Equinus | Intelligent Management | A Series

“Equinus deformity is the most profound causal agent in foot pathomechanics and is frequently linked to common foot pathology.” from Biomechanics of the First Ray Part V: The Effect of Equinus Deformity | CH Johnson and JC Christensen in J. Foot Ankle Surg. 44: 114-120, 2005

It is my opinion that this ‘profound causal agent’ receives too little attention from us – the practitioners. I’m further convinced that the lack of attention is connected to no absolute definition of equinus.

Through this series, I propose to provide an absolute definition of equinus based on three very profound articles and other research. I will also elaborate on a treatment protocol using an ‘intelligent brace’ that I have invented.

My interest in equinus was piqued beyond my patient roster when healthy exercise began to result in equinus symptoms in my own right ankle. Running was giving me trouble, yet that very exercise was connected to a significant weight loss. When we are counseling patients toward a healthier life-style, we owe to them to be prepared to guide them through the process. The perfect situation would be wise exercise with no injury. When injury occurs podiatrists have the opportunity to help patients through to healthier feet.

In the next posts, I will discuss research in the articles mentioned earlier, share my opinions and my justification for the equinus definition that I believe is applicable and describe the breakthrough of the EQ/IQ brace.

As you read you may have questions. As doctors, trainers, therapists, you wonder where and how to obtain the EQ/IQ brace. As equinus sufferers, you will be seeking information that you can share with your doctor. You can contact me at Hoosier Foot and Ankle. You can call 317-660-2115 with questions or you can leave your message/question on the Contact Form available in the sidebar of the Hoosier Foot and Ankle website.