Chapter 29: Ankle Conditions

Differential Diagnosis of Chronic Ankle Pain Tarsal

Tunnel Syndrome Sinus Tarsi Syndrome
Peroneal Subluxation
Ankle Arthrodesis
Lateral Ankle Instability
Chronic Lateral Ankle Instability Chronic Medial Ankle
Instability Ankle Equinus
Malunion and Nonunion of the Malleoli
 ANKLE CONDITIONS AND
TREATMENT
Differential Diagnosis of Chronic Ankle Pain
1. Lateral:
a. Peroneal tendon and nerve:
i. Peroneal tendon stenosing tenosynovitis
ii. Peroneal dislocation
iii. Peroneal neuropathy b. Sural nerve injury

2. Dorsolateral
a. Sinus tarsi syndrome
b. Extensor digitorum brevis (myositis, avulsion)
c. Calcaneus anterior process fracture

3. Intracapsular:
a. Talar posterior (lateral) process fracture
b. Talar dome (osteochondral) defects
c. Intra-articular fibrous bands, hypertrophic synovitis, meniscoid bodies

4. Medial:
a. Tarsal tunnel syndrome
b. Posterior tibial tendon tendonitis, rupture
c. Flexor hallucis longus tendonitis
d. Os trigonum fracture

5. Other:
a. Ligamentous injury (instability) b. Traumatic DJD of STJ or ankle

Tarsal Tunnel Syndrome

This is an entrapment or compression neuropathy of the posterior tibial nerve
or one of its three branches, the medial and lateral plantar nerves and/or
medial calcaneal nerve.
1. Anatomy: Nerve entrapment occurs either In the porta pedis or lacinate
ligament
a. The flexor retinaculum (lacinate ligament) extends from the medial
malleolus to the medial process of the calcaneal tuberosity and the plantar
aponeurosis. The deep fibrous septa form four compartments, and converts
bony grooves into canals from anterior-medial to posterior lateral: #1 contains
tibialis posterior tendon (most superficial), #2 FDL tendon, #3 posterior tibial
nerve artery and vein, and #4 FHL tendon. These compartments are unyielding
spaces.
b. The porta pedis is a canal created by the abductor hallucis muscle belly
through which the medial and lateral plantar nerves pass.
c. Division of the posterior tibial nerve into its 3 terminal branches may occur
proximal to the lacinate ligament, which is most common; within the lacinate
ligament, as described in most texts; or distal to the lacinate ligament, which is
rare.
d. The medial calcaneal nerve is entirely sensory, and innervates the medial
and plantar aspect of the heel. It may arise from either the posterior tibial or
lateral plantar nerve.
e. The medial plantar nerve gives sensory innervation to the plantar aspect of
the hallux, second and third toes, medial half of the fourth toe, and the medial
half of the plantar aspect of the foot. It gives motor innervation to the abductor
hallucis, flexor digitorum brevis, flexor hallucis brevis, and the first lumbricalis.
f. The lateral plantar nerve gives sensory innervation to the plantar lateral half
of the fourth toe, plantar aspect of the fifth toe, and plantar lateral aspect of the
foot. Initially it sends motor fibers to the quadratus plantae and abductor digiti
quinti before dividing in a superficial and deep branch. Superficial branch
supplies motor innervation to the flexor digiti quinti brevis and the dorsal and
plantar interossei of the fourth intermetatarsal space. The deep branch
supplies the remaining intrinsic muscles of the foot.

2. Pathology: Compression of the nerve initially causes only sensory

involvement with possibly partial involvement of motor fibers. Continuation of
the irritation, ischemia, and compression may lead to secondary hyperactivity
of the autonomic nervous system, (manifested by coldness and numbness) from
the altered sympathetic activity. Eventual structural changes in the nerve
result in the development of muscle wasting, paresis, and objective sensory
loss.

NOTE* Reflexes are unaffected

3. Etiology: In the many cases no etiology can be found at the time of surgical
decompression.
a. Dilated posterior tibial veins: can also cause severe night discomfort.
b. Trauma: Fracture, dislocation, sprain, post-traumatic edema and fibrosis.
c. Systemic disease: Gouty arthritis with urate deposits, rheumatoid arthritis,
diabetes mellitus, and myxedema.
d. Space occupying lesions: Ganglions, neurofibromas, schwannomas, synovial
cysts, etc.
e. Hypertrophy of abductor hallucis muscle belly.
f. Biomechanical: excessive pronation

4. Clinical Symptoms: Symptoms can be either distal to the metatarsal area,

or the medial and lateral heel depending on the branch involved.
a. Early:
i. Intermittent burning pain, numbness and paresthesias over the medial side
of the heel, the toes, and the plantar aspect of the foot.
b. Late:
i. A paresis that will develop into paralysis of the pedal intrinsic muscles.
ii. Proximal radiations of pain may develop in the posterior calf.
iii. Pain that is proportional to the amount of activity during the day.
iv. May develop some sensory loss

5. Diagnosis: Not always easy, as the signs are not always definitive
a. History of paresthesias
b. History of trauma
c. History of systemic disease
d. Hoffman-Tinel's sign: A tingling in region of the distribution of the involved
nerve with light percussion, results in paresthesias distal to the site of
percussion.
e. Valleix Phenomena: A nerve trunk tenderness above and below the point of
compression, with paresthesias proximal and distal to the point of percussion.
f. Turk's test: Application of a venous tourniquet to the lower extremity will
elicit positive symptoms on the affected side, by producing a venous occlusion.
g. Forced eversion of the foot.
h. Positive radiographic evidence of previous injury i. Positive lab studies for
any specific disease
j. EMG's and nerve conduction studies are only useful for late stage disease.

Note* EMG may show fibrillation potentials which indicate denervation of

muscle. Nerve
Note*
conduction
Placementstudies
of nerve
may
conduction
reveal an
study
increased
surface
distal
electrodes
latency.
are as follows:
1. Proximal stimulation point: distal aspect of popliteal fossa
2. Distal stimulation point: behind the medial malleolus
6. 3. Recording electrode (for conduction of the medial plantar nerve) through the
abductor hallucis ms. belly.
4. Recording electrode (for the lateral plantar nerve) through the abductor digiti
quinti muscle belly.
Treatment: Conservative
a. Local blocks: Posterior tibial nerve blocks with steroids
b. Unna boot: can be combined with nerve blocks
c. Support hose: for varicosities
d. Functional orthoses

7. Treatment: Surgical Decompression (positive EMG's and nerve conduction

studies mandate surgical decompression). Involves the complete exploration of
the tarsal tunnel with release of the flexor retinaculum and its fibrous bands,
and resection and ligation of any dilated veins in the area.
The surgical technique is as follows:
a. A curvilinear incision is made posterior and inferior to the medial malleolus
by 1 cm.
b. The subcutaneous tissue Is Incised and the superficial- vessels are ligated as
necessary.
c. The neurovascular structures superior to the retinaculum are identified,
preserved, and retracted (especially the medial calcaneal branch).
d. The flexor retinaculum is incised and the posterior tibial nerve or its terminal
branches are identified and mobilized.
e. The nerve(s) is retracted with a penrose drain.
f. The nerve(s) is followed proximally, incising the flexor retinaculum as you go.
g. The nerve(s) is followed distally to the point where the medial and lateral
plantar nerves pass through the fibrous canals superior to the abductor
hallucis ms. belly.
h. The abductor hallucis ms. is examined for any abnormality, and any
hypertrophy is excised.
i. If there are any posterior tibial vein varicosities, they should be ligated.
j. The retinaculum is not reapproximated and no deep closure is done.
k. The superficial fascia is reapproximated and the skin reapproximated
i. Sterile compression dressing and a non-weight-bearing BK cast applied for 3
weeks.

8. Complications:
a. Recurrence: due to fibrosis
b. Severing the PT artery : if done then tie off and prepare patient for
microvascular repair later.
c. Severing a nerve
d. Tenosynovitis
e. Hematoma
f. Wound dehiscence

Sinus Tarsi Syndrome

1. Symptoms: A diffuse deep aching pain on the dorso-lateral aspect of the foot
over the sinus tarsi. Relief of the discomfort after an injection of anesthesia
deep into the sinus tarsi while maintaining superficial sensation is a diagnostic
feature.

2. Etiology:
a. Post traumatic:
i. Inversion ankle sprain
ii. Fibular fracture
iii. Calcaneal fracture
iv. Talar neck fracture

NOTE* Arthroscopic studies of the posterior facet showed an absence of the

normal synovial recesses in front of the talocalcaneal interosseous ligament.
This may indicate synovial hyperplasia, scarring, and/or synovitis

b. Biomechanical fault:
i. Pes piano valgus (stretching of the cervical ligament)
ii. Pes cavus
c. Systemic arthritic/metabolic:
i. RA
ii. Gout
iii. Seronegative arthropathies

3. Findings:
a. Subjective:
i. Diffuse pain on the lateral side of the foot
ii. Feeling of rearfoot instability especially on uneven terrain
iii. Dramatic relief of symptoms with an anesthetic block b. Objective:
i. Pain reproduced with direct pressure over the sinus tarsi
ii. Discomfort with forced inversion and plantarflexion
iii. X-rays normal
iv. Ankle joint is WNL
v. STJ motion painful but not limited
vi. MTJ motion mostly pain free
vii. Palpation of the intermediate dorsal cutaneous nerve and sural nerve
uneventful
viii. Palpation of the anterior talofibular and calcaneofibular ligaments is
uneventful
ix. Elicit pain by digital pressure on both sides of the sinus tarsi
simultaneously
c. Diagnostic:
i. X-rays
ii. Diagnostic anesthetic block
iii. Arthrography of the posterior facet of the STJ
iv. Ankle stress films (to RIO ankle instability)
v. 3 phase bone scan to R/O fracture
vi. MRI to evaluate the soft tissues, fracture, and infectious disease or arthritic
process
vii. CT scan to R/O coalitions

4. Differential diagnosis:
a. Entrapment neuropathy of the intermediate dorsal cutaneous nerve
b. Entrapment neuropathy of the sural nerve
c. Damage to the anterior talofibular ligament d. Damage to the calcaneofibular
ligament
e. Peroneal tenosynovitis
f. DJD of the STJ (posterior or middle facet)
g. Coalition
h. Talar neck fracture
i. RA, gout, seronegative arthritides
j. Talar dome fractures
k. Space-occupying lesion

5. Treatment:
a. Conservative:
i. Injection of series of local anesthetic/steroid, once every 2 weeks x 3 times
ii. NSAID's
iii. Tape immobilization
iv. BK cast
v. Foot orthoses (if biomechanical)
vi. Physical therapy
b. Surgery: Sinus Tarsi evacuation as follows:
1. Transverse incision over the sinus tarsi 4 cm.
ii. Resection of portions of the extensor retinaculum, a fatty plug, the
cervical ligament, and a synovectomy of the adjacent middle and
posterior articulations of the STJ for a total distance of 2 cm.
iii. Evaluation of the STJ articulations (ATFL, CFL, and peroneals)
iv. Postop: Orthopedic shoe for 2 weeks, followed by physical therapy

NOTE* if the pain persists despite appropriate care then a STJ fusion or triple
arthrodesis is indicated

6. Complications:
a. Entrapment neuropathies
b. Avascular necrosis
c. Subtalar instability

Peroneal Subluxation
1. Clinical presentation:
a. Post-traumatic state: Evident after acute injury or later with a history of
recent antecedent trauma. The post-traumatic state represents:
i. Either a subperiosteal dissection of the superior peroneal retinaculum or
ii. An avulsion fracture of the fibula with the adherent superior peroneal
retinaculum and deep fascia
b. Chronic subluxing state with an insidious progression of pain about the
peroneals (not necessarily associated with trauma). This state represents:
i. A stretching, redundancy, or pouching of the superior peroneal retinaculum
and deep fascia permitting displacement of the peroneal tendons within an
intact compartment

NOTE* The key difference between the two forms of tendon dislocation is based
upon the relationship of the deep fascia and superior peroneal retinaculum to
the peroneal tendons and the distal fibula

2. Classification of peroneal injuries (Eckert and Davis):

3. Surgical technique (one type): A reduction of the deep fascial
redundancy with insertion Into the fibula
a. 8 cm incision placed posterior to the palpable posterior division of the
anterior border of the fibula overlying the peroneal compartment
b. Incision into the superficial and deep fascia
c. Periosteal incision just superior to the posterior division of the anterior
border of the fibula
d. 5 drill holes into the fibula from the lateral surface to the posterior surface,
with the most distal drill hole just overlying the peroneal groove area
e. Redundant deep fascia containing the peroneals is plicated
f. Sutures inserted (twice around) with the knots below the deep fascia
g. BK weight-bearing cast applied for 6 weeks

NOTE* A Jones procedure for peroneal stabilization involves detaching a small

strip of Achilles tendon proximally, and rerouting it from posterior to anterior
through a drill hole in the fibula, then sutured onto itself
Arthrodesis of the Ankle
1. Indications: This procedure is indicated primarily in patients with severe
pain and deformity, Including: DJD, RA, talar collapse, failed ankle joint
prostheses, infection of the ankle joint, drop foot, invasive tumors, and
congenital deformities

2. Preoperative evaluation:
a. Patients selected for ankle fusion should be those for whom it will be
reasonable to expect a significant reduction in pain and deformity, and an
increase in activity
b. Evaluate integrity of adjacent joints (STJ and forefoot): To R/O the necessity
for a secondary STJ fusion or triple arthrodesis
c. Ankle joint is fused at right angle to the leg, and compensation for heel
height must then come from plantarflexion at the midtarsal and
tarsometatarsal joints
d. Stability at the knee joint is important in those patients undergoing a
pantalar fusion
e. Good bone stock a necessity

3. Surgical approaches: Dictated by the exposure necessary to perform the

desired technique
a. Transverse anterior approach (Charnley): Severs the extensor tendons and
anterior neurovascular bundle
b. Midline longitudinal anterior approach: Inadequate visualization of the
posterior ankle joint
c. Lateral approach via hockey-stick incision: When combined with a fibular
osteotomy this approach gives good exposure of the posterior, lateral, and
anterior aspects of the ankle
d. Medial malleolar approach: When combined with medial malleolar osteotomy
gives good exposure of the anteromedial, medial, and posteromedial aspects of
the ankle joint

NOTE* Procedure of choice for good visualization is the lateral hockeystick

incision plus medial incision
4. Surgical technique categories:
a. Articular wedging with or without grafting
b. Anterior arthrodesis with inlay grafting
c. Articular wedging combined with malleolar osteotomy
d. Dowel or other subtotal fusions
e. Compression arthrodesis

5. The requirements for a successful fusion:

a. Complete removal of all the cartilage, fibrous tissue, and any other material
that may prevent contact of raw bone to raw bone
b. Accurate and close fitting of the fusion surfaces
c. Optimal position of the ankle joint
d. Maintenance of the bone apposition in an undisturbed fashion until fusion is
completed
 Chrenshaw AH (ed): Campbell's Operative Orthopedics, Volume 2, CV. Mosby, St.Louis, 1971, p. 1126, with permission

Lateral Ankle Instability

1. Plantar flexion inversion injury classification (Leach):
a. 1st degree: ATFL
b. 2nd degree: ATFL, CFL, and capsule
c. 3rd degree: ATFL, CFL, PTFL, and capsule

2. Factors which predispose to recurrent ankle sprains:

a. Tibial varum
b. Ankle varum
c. Calcaneal varum
d. STJ varus
e. Plantarflexed 1st ray
f. Rigid forefoot valgus
g. Uncompensated equinus
h. Muscle imbalance
i. Weak peroneals
ii. Overactive tibialis anterior and tibialis posterior
i. Previous ankle sprains
j. Torsional abnormality
k. Short leg syndrome
Chronic Lateral Ankle Instability
Many surgical procedures have been devised to reconstruct the lateral
ligaments, but because of their unique configuration, accurate anatomic
reconstruction is nearly impossible.

The above diagram shows the relationship of the anterior talo-fibular ligament to the calcaneo-
flbular ligament. This relationship is hard to recreate with any surgical procedure. This is why
there is limitation of STJ range of motion following stabilization surgery

1. Etiology:
a. Post-traumatic ligamentous disruption
b. Osteochondral dome fractures
c. Degenerative joint disease
d. Peroneal subluxation
e. Muscular weakness or paralysis
f. Talofibular meniscoid
g. Generalized ligamentous laxity
h. Tibio-fibular diastasis
i. Non-union of previous fracture
j. Poorly reduced/healed fracture
k. Fixed calcaneal varus
l. Tibial varum
m. Rigid plantarflexed 1st ray
2. Anatomy of the lateral ankle:
a. The peroneal muscles terminate in tendons proximal to the ankle joint and a
common synovial sheath surrounds the peroneals at this point above the ankle
and contains them in a fibro-osseous tunnel
b. Posterolaterally, they are contained by the superior peroneal retinaculum
and medially by the lateral ankle joint ligaments
c. At the level of the ankle joint the peroneus brevis lies anterior and deep
against the fibular groove, with the peroneus longus posterior
d. As the peroneus brevis tendon passes distally, below the tip of the fibula, it
turns anterior, plantar, and lateral, crossing the CFL superficially
e. As the peroneus longus passes distally it runs plantar and anteriorly, then
passes in an inferior tunnel formed by the inferior peroneal retinaculum at the
level of the peroneal tubercle of the calcaneus. The peroneus brevis tendon lies
in a similar tunnel superior to the tubercle on the calcaneus
f. The ATFL is intracapsular
g. The CFL, PTFL, and fibulotalocalcaneal (not always present) are
extracapsular

NOTE* Due to the angular relationships of the ATFL and the ankle, inversion of
the ankle is primarily resisted by the ATFL when the ankle is plantarflexed,
and by the CFL when the ankle is dorsiflexed

3. Clinical and radiographic evaluation:

a. Common complaints: persistent instability, pain, edema, weakness, and
associated insecurity on uneven surfaces
b. Radiology: Talar tilt and anterior draw test (need comparison views of the
contralateral ankle), arthrography, tenography, and MRI

NOTE* Controversy exists over the interpretation of inversion stress views. The
anterior draw test is most useful in assessing the ATFL integrity (0-5 mm of
anterior displacement is normal, 8-10 mm consistent with a single ligament
rupture, 10-1.5 mm consistent with a double ligament rupture, and greater
than 15 mm anterior displacement is consistent with a triple ligamentous
rupture).
These two tests are complementary.
They should be done under common peroneal and sural nerve block. A Telos®
stress device is used for more of a constant/gradually applied
force.

4. Surgical Procedures: Stabilization procedures depend upon the patient's

needs
a. Delayed primary repair: Suturing of the ATFL/CFL with a non-absorbable
suture (0 or 2-0), with NWB BK casting for 6 weeks b. Delayed secondary
repairs (utilizing fascial grafts): Are categorized according to the number of
ligaments ruptured
i. Single ligament rupture:
 Watson-Jones*: This uses the peroneus brevis, which passes through
the fibula from posterior to anterior, through the neck of the talus from plantar
to dorsal, back through the fibula, from anterior to posterior, and sutured back
onto itself.
 Lee Procedure (modified Watson-Jones)*: This uses the peroneus
brevis tendon, which is then passed through the fibula, from posterior to
anterior, and then sutured back onto itself.
 Evans*: This utilizes the peroneus brevis through an oblique hole
through the fibula sutured back onto. the belly of the peroneus brevis.
 Storren
 Nilsonne
 Pouzet
 Haig
 Castaing and Meunier
 Dockery and Suppan

ii. Double ligament rupture:

 Elmslie*: Originally described as using the fascia lata and passed
through a drill hole in the lower aspect of the fibula, through the calcaneus,
back through the same drill hole, and tied onto itself, after passing through the
neck of the talus.
 Chrisman and Snook*: This uses the split peroneus brevis, which is
passed through the fibula from anterior to posterior through a flap in the
calcaneus, and is then sutured back to the peroneus brevis tendon.
 Stroren
 Hambly
 Winfield
 Gschwend-Francillon

iii. Triple ligament rupture:

 Spotoff
 Rosendahl and Jansen
 NOTE* A Split Peroneus Brevis Lateral Ankle Stabilization Procedure was
developed at Doctor's Hospital, which has proven to have minimal morbidity
and to be dependable, especially for the athletic individual The surgical
procedure is as follows:
a. Patient lying in the lateral position with thigh tourniquet
b. Single incision beginning approx. 10-12 cm proximal to the lateral malleolus,
extending distally just posterior to the fibular malleolus
c. A subperiosteal channel is created from the neck of the talus to the base of
the 5th metatarsal, and a wire loop is placed within the channel to facilitate
passage of the tendon later
d. The peroneal retinaculum is incised just posterior to the fibula, peroneals
retracted posteriorly, CFL exposed, and a 4 mm hole is made from the anterior
edge of the fibula, angled slightly inferiorly (bone plug is saved)

e. A 6 mm hole is made in the body of the calcaneus adjacent to the insertion of

the CFL
f. A final subperiosteal channel is made from the posterior fibula to the hole
created in the calcaneus, and a wire loop is inserted for later passage of the
tendon
g. The peroneus brevis tendon is then split (at the start of the muscle belly),
tagged with a suture and pulled distally within its tendon sheath to the base of
the 5th metatarsal
h. The tendon is brought through the 1st subperiosteal channel to the neck of
the fibula and passed through from anterior to posterior, sutured to the
anterior fibula
i. The tendon is brought through its 2nd subperiosteal channel and buried into
the hole created in the calcaneus

NOTE* Either dacron mesh (Dacron Cooley graft) or Marlex surgical mesh (porous
film) can be used as an adjunct in the repair of the lateral ligaments

5. Complications after reconstruction:

a. Questions that should be asked to determine problems:
i. Is there still a sense of ankle instability and repeated inversion injuries?
ii. Is the primary problem chronic pain? If the problem is the former, then
reconstruction is the problem.. If the problem is the latter then there might be a
secondary lesion
b. A varus rearfoot can contribute to reinjuring the ligament and causing a
failed reconstruction over time. Also subtalar instability can cause failure (if
this is the reason, the patient might. require additional surgery involving the
calcaneofibular ligament)
c. If pain is the patient's main complaint you must rule out a coexistent lesion
such as an osteochondral fracture, tarsal coalition, ankle arthrosis, chronic
tear in the peroneal tendon, or postoperative neuroma of the sural nerve
Chronic Medial Ankle Instability
Deltoid injuries are rare and occur when the foot is forcibly everted on the leg
(see chapter 25: Deltoid Injuries). If an external rotary component is also
present, a concomitant fibular fracture with disruption of the T-F syndesmosis
will occur. Therefore, when confronted with an unstable medial ankle check for
a displaced fibular fracture or T-F diastasis
1. Anatomy:
a. Superficial deltoid: Tibiocalcaneal
b. Deep deltoid: Anterior tibiotalar, tibionavicular, and posterior tibiotalar

2. Surgical repair:
a. Delayed primary repair

Ankle Equinus
Primary neuromuscular spasticity of the posterior muscle group needs to be
approached differently than a secondary acquired contracture of the
gastrocnemius. The goal of the surgery will also depend on the etiology.
The resulting gains in ankle joint dorsiflexion must be weighed against the loss
of a grade of muscle strength
1. Patient complaints:
a. Low back pain
b. Calcaneal apophysitis in children
c. Heel spur syndrome in adults
d. Arch pain
e. Inability to stand for long periods without pain/fatigue
f. Juvenile HAV
g. Digital contractures

2. Anatomy:
a. The gastrocnemius is a muscle spanning two joints, and forming the belly of
the calf attached by two heads to the femoral condyles, the medial head being
larger
b. The gastrocnemius and soleus are innervated by the tibial nerve from S1 and
S2
c. The soleus is a broad flat muscle deep to the gastrocnemius, arising from the
back of the head and the upper fourth of the posterior surface of the fibula.
d. The soleus joins with the gastrocnemius to form the tendo Achilles. At the
insertion, the gastrocnemius component usually comprises the lateral side of
the superficial surface and a small portion of the lateral aspect of the deep or
anterior surface of the tendon
e. Superficial to soleus are gastrocnemius and plantaris; deep are flexor
digitorum longus, flexor hallucis longus, tibialis posterior, and the posterior
tibial vessels and tibial nerve, all separated from soleus by the deep transverse
fascia
f. The plantaris arises in close association with the lateral head of the
gastrocnemius, has a small fusiform belly, that ends in a long slender tendon,
which crosses obliquely between gastrocnemius and soleus and runs along the
medial border of the tendo Achilles,-to be inserted with it. The plantaris limits
dorsiflexion of the ankle
g. The tendo Achilles is the thickest and strongest human tendon, surrounded
by a paratenon (highly vascular areolar tissue which bathes the tendon in
synovial fluid). The tendo Achilles attaches to the posteriorsuperior surface of
the calcaneus
h. The anatomy of the ankle joint is a modified ginglymus joint because in full
plantarflexion, the narrow posterior aspect of the trochlear surface of the talus
allows the frontal plane motion of inversion and eversion to occur in the mortise
(normal dorsiflexion should be 10-200, normal plantarflexion 30-500)

3. Muscular activity:
a. The muscles of the calf are the major plantarflexors, the gastrocnemius
also extends the knee, and the soleus steadies the leg on the foot in standing
b. Phasic activity of the triceps is from shortly after heel contact until just
before toe-off, all functioning to extend the knee during a normal gait
cycle (it does this through the soleus, by slowing the forward progression of the
tibia, thus allowing the femur to rotate over it, extending the knee joint)
c. The soleus fires at about 15%-20% of the stance phase of gait, slightly ahead
of the gastrocnemius

4. Pathomechanics:
a. In normal function, with the knee fully extended and the STJ in neutral
position, at least 100 of dorsiflexion of the foot to the leg are needed
b. When there is pronation past perpendicular, this shortens the origin to
insertion distance of the gastrocnemius (the distal aspect of the calcaneus
lowers, the midtarsal joint lowers to the ground, the calcaneal inclination angle
decreases) and over a period of time there is secondary adaptation, and the
amount of dorsiflexion is limited
c. With a primary equinus deformity at 50%-60% of midstance, with the hip
and knee extended, you cannot get 100 of dorsiflexion and, therefore, the
subtalar joint and midtarsal joints pronate to give more dorsiflexion (the oblique
axis of the MTJ gives more dorsiflexion than any other joint in the foot as it
compensates for the equinus
d. This midtarsal joint pronation will also induce the forefoot into a supinatus
deformity

NOTE* Tendon lengthening should not be done unless the etiology of the
equinus is absolutely certain because there will be an automatic loss of 5.
10% of its strength
Classification:
a. Uncompensated: The STJ remains supinated, therefore, the lack of
dorsiflexion at the ankle joint cannot be compensated by abnormal STJ and
MTJ pronation (the CP patient)
b. Fully compensated: Presents with STJ and MTJ pronation, seen as the
hypermobile flatfoot, with the rearfoot maximally everted to the floor and the
forefoot everted on the rearfoot (the most severe symptom complex). Creates a
spinal lordosis, excessive transverse plane motion about the knee, low back
pain, chondromalacia, exaggerated genu valgum, juvenile bunions, and digital
contractures
c. Partially compensated: The patient has sufficient combination of ankle joint
dorsiflexion and dorsiflexion about the oblique axis of the MTJ to permit heel
contact during the early portion of the stance phase of gait. However, there is
insufficient dorsiflexory motion to permit the leg to angulate 100 to the floor
later in stance. Early heel-off is seen during gait. Generally, with a partially
compensated equinus, the calcaneus will strike the floor but will evert only
minimally, and then will rapidly achieve an early heel-off

6. Etiologies:
a. Muscular (gastrocnemius equinus, gastrosoleus equinus)
ii. Congenital shortness: Toe walker for 1 st 6 months
iii. Acquired shortness: From casts, high-heeled shoes, excessive pronation
b. Osseous
i. Osseous equinus: Dorsal exostosis of the talar neck from a flat top talus (can
be from treatment of a clubfoot)
ii. Pseudoequinus (cavus foot type)

7. Clinical findings:
a. With the patient supine and the knee extended and the STJ in neutral
position, the foot is dorsiflexed. If dorsiflexion is less than 100 an ankle equinus
to exists
b. Silverskiold test is then used to differentiate gastrocnemius equinus from the
remaining types of posterior equinus: by flexing the patient's knee to a right
angle and again dorsiflexing the patient's foot. If more than 100 of dorsiflexion
is found a gastrocnemius equinus still exists. Thus after performing the
Silverskiold test there is still limitation of ankle joint dorsiflexion, other sources
of ankle joint dorsiflexion remain to be evaluated (either gastrosoleal equinus or
osseous equinus).

NOTE* To help evaluate osseous equinus a stress dorsiflexion lateral x-ray is

used. Comparison is made with the regular lateral view and checked for 2
items:
a. The excursion of the tibia over the talus
b. How much motion of the tibia and talus is occurring as a unit

8. Surgical procedures: See Chapter 27, Tendon pathology: Tendon

Lengthening and Tenotomy
a. Distal recession (Volpius and Stoffel)
b. Slide lengthening (White)
c. Distal recession (Strayer)
d. Lengthening the apneurotic tendon of. the gastrocnemius (Baker)
e. "Z" plasty (Sgarlato)
f. Frontal plane "Z" plasty (McGlamry)
g. Modified Baker tongue and groove (Fulp and McGlamry): For nonspastic
gastrocnemius equines

Malunion and Nonunion of the Malleoli

According to Ramsey and Hamilton, 1 mm of ankle asymmetry causes a 42%
decrease in contact area between the talus and the tibia. Therefore, because
stress per unit area increases as the total contact area decreases, even mild
malunion of the fibula and the ensuing talar instability can result in significant
disability
1. Malunion of the fibula:
a. Might not become symptomatic for several years, with the patient
complaining of a dull ache over the anterior aspect of the ankle which worsens
with use, swelling, onset of arthritis, and a limp
b. Radiographic criteria used to diagnose a malunion of the lateral malleolus
are similar to those used in evaluating acute ankle fracture
i. Evaluation of the tibiofibular articulation
ii. Fibular length and rotation
iii. Ankle mortise symmetry
iv. Talar tilt
v. Bimalleolar angle: measures the exact amount of fibular shortening
(comparison of both ankles is necessary, and a 10 change in the angle
 NOTE* Three views should be used (AP), (LAT), and 15° internally rotated mortise
view
corresponds to a 1 mm change in fibula length).
c. Conservative treatment:
i. AFO
ii. NSAIDs
iii. Injections
d. Surgical treatment: When conservative measures fail, reconstruction can be
attempted. If that fails. then a fusion can always be done.
i. The concurrent presence of a medial malleolar malunion makes
reconstruction more difficult. A malleolar malunion has no substantial effect on
stability of the ankle and only needs to be corrected if symptomatic or - with a
step-off in the weight-bearing joint surface of more than 2 mm.
ii. A concomitant malunion of a large posterior malleolar fragment (more than
30% of the joint) usually precludes reconstruction (posterior displacement of
the talus, soft tissue scarring, and osteoporosis of the displaced piece make
reduction difficult)
iii. The fundamentals are that there is a shortened and externally rotated
lateral malleolus, with lateral subluxation. The procedure to accomplish
correction is as follows:
 The fibula must be freed leaving only the collateral ligaments intact
 An oblique or transverse osteotomy is made at the level of the malunion
and an AO compression device set in the distraction mode (to increase fibular
length)
 A plate is fixed to the fibula
 The syndesmosis is held in reduction with a 4.5 mm cortical screw

2. Nonunion of the medial malleoli:

a. Occurs more frequently in fractures that are treated with closed reduction
b. Surgery for a nonunion should only be considered if the clinical examination,
including pain, tenderness at the fracture site, correlates with the radiographic
findings
c. Nonunion of the medial malleolus can occur anywhere but proximal lesions
nearer the weight-bearing aspect of the tibial plafond are more likely to be
symptomatic
d. If a malunion is present it should be taken down and anatomically reduced
with compression screws and a local cancellous bone graft from the metaphysis
of the distal tibia
e. If the nonunion is in anatomic alignment, it can be left in place with a trough
trough created across the nonunion site and packed by a cancellous bone

3. Nonunion of the lateral malleoli:

a. Similar approach should be taken as with medial malleolar nonunions,
although these are more prone to produce a malunion and instability
b. A small, distal, non-united fragment (smaller than 1 cm) should be excised
rather than trying to obtain osseous union. The collateral ligaments should be
carefully reattached