EquinusEquinus, , PesPes CavusCavus and and DropfootDropfoot

-- Video Gait Analysis Video Gait Analysis --

Craig A. Camasta, DPM, FACFASCraig A. Camasta, DPM, FACFASAtlanta, Georgia, USAAtlanta, Georgia, USA

EquinusEquinus = “Toe Walker”= “Toe Walker”

Soft TissueSoft TissueStatic Static –– fixed contracturefixed contractureDynamic Dynamic –– spastic, hypertonicspastic, hypertonic

BoneBoneProcurvatumProcurvatum, Post, Post--TraumaticTraumaticRemodeled / Arthritic PostRemodeled / Arthritic Post--ContractureContracture

LocationLocationLeg, Ankle, FootLeg, Ankle, Foot

Bone v. Soft Tissue v. CombinationBone v. Soft Tissue v. Combination

CavusCavus = High Arch= High Arch

Forefoot Forefoot PlantarflexedPlantarflexed on on RearfootRearfootNormal Ankle ROMNormal Ankle ROMFamilial TendencyFamilial TendencyInherited Neuromuscular Inherited Neuromuscular DxDx((CharcotCharcot--MarieMarie--Tooth)Tooth)

DropfootDropfoot

Weak Weak DorsiflexionDorsiflexion

Nerve InjuryNerve InjuryCVACVACrush/LacerationCrush/Laceration

Neuromuscular Neuromuscular DxDxCMTCMT

EquinusEquinus vs. vs. CavusCavus

EquinusEquinus = Ankle or Above = Ankle or Above CavusCavus = Below Ankle= Below Ankle

PesPes CavusCavus = Forefoot = Forefoot EquinusEquinus“Pseudo “Pseudo EquinusEquinus””

DropfootDropfoot (spinal injury)(spinal injury)

DropfootDropfoot + + EquinusEquinus (CMT)(CMT)

DropfootDropfoot -- CP Nerve InjuryCP Nerve InjuryPrePre TPTT/STJ FusionTPTT/STJ Fusion

EquinusEquinus ContractureContracture

GastrocnemiusGastrocnemiusCrosses KneeCrosses KneeTight With Knee ExtensionTight With Knee Extension

GastroGastro--SolealSolealTight With Knee FlexionTight With Knee Flexion

Static vs. Hypertonic/SpasticStatic vs. Hypertonic/SpasticClonusClonusHyperHyper--reflexiareflexia

EquinusEquinus AssessmentAssessment

Testing For Testing For EquinusEquinus……Observation Stance & GaitObservation Stance & GaitManual AssessmentManual AssessmentTEST WITH FOOT “NEUTRALIZED…”TEST WITH FOOT “NEUTRALIZED…”

1. Reduce Deformity & Maintain Position1. Reduce Deformity & Maintain Position2. 2. DorsiflexDorsiflex Forefoot While Pulling Down HeelForefoot While Pulling Down Heel

HubshireHubshire ManeuverManeuverPatient may need to step forward…Patient may need to step forward…

Toe Raise Toe Raise Heel Inversion?Heel Inversion?Arch Reduction?Arch Reduction?

Neutralized Neutralized DorsiflexionDorsiflexion

Neutralized Neutralized DorsiflexionDorsiflexion

HubshireHubshire & Toe Raise& Toe Raise

HypertoniaHypertonia & & EquinusEquinus

Heel Cord LengtheningHeel Cord Lengthening

When is it INDICATED?When is it INDICATED?Heel Pitch InclinedHeel Pitch Inclined

Never IndicatedNever Indicated

Heel Pitch Flat or Heel Pitch Flat or DeclinatedDeclinatedAlways IndicatedAlways Indicated

TAL vs. TAL vs. GastrocGastroc RecessionRecession

TALTALGastroSolealGastroSoleal EquinusEquinusLongLong--standing Deformitystanding DeformitySevere ContractureSevere ContractureOlder PatientsOlder Patients

GastrocnemiusGastrocnemius RecessionRecessionGastrocnemiusGastrocnemius EquinusEquinusLesser Degree of Lesser Degree of EquinusEquinusYoung PatientsYoung PatientsEasier RecoveryEasier Recovery

TendoAchillesTendoAchilles LengtheningLengthening

Many Approaches…Many Approaches…

TenotomyTenotomyOpen or Open or PercutaneousPercutaneous

PercutaneousPercutaneousSeries of StabsSeries of Stabs18 Ga. Needle18 Ga. Needle

Open Frontal “Z”Open Frontal “Z”ControledControled LengthLength

GastrocGastroc RecessionRecession

Many Approaches…Many Approaches…

Limited Open Limited Open TenotomyTenotomyContained SystemContained System

Open Open TenotomyTenotomyTongue / GrooveTongue / Groove

CompensationCompensation

Ability of Limb to Accommodate DeformityAbility of Limb to Accommodate DeformityAvailable ROMAvailable ROMPlane of DeformityPlane of Deformity

SagittalSagittal primaryprimaryTransverse & Frontal secondaryTransverse & Frontal secondary

Beyond Available ROM Beyond Available ROM

RESIDUAL DEFORMITYRESIDUAL DEFORMITY

EquinusEquinus CompensationCompensation

FullyFully--Compensated Compensated Heel Contacts GroundHeel Contacts Ground

UnCompensatedUnCompensatedHeel FloatingHeel Floating

Compensated Compensated EquinusEquinus

PesPes ValgusValgusHammertoes / HAVHammertoes / HAVGenuGenu RecurvatumRecurvatum

Increased Pressure ForefootIncreased Pressure ForefootDiabetic Diabetic TrophicTrophic UlcersUlcers

Foot CompensationFoot Compensation

PesPes PlanovalgusPlanovalgus -- Hammertoes / HAVHammertoes / HAV

Foot CompensationFoot Compensation

Diabetic Ulcers …Diabetic Ulcers …

Foot CompensationFoot Compensation

NeuropathicNeuropathic -- CharcotCharcot ArthropathyArthropathy

Manual ReducibilityManual ReducibilityEliminate Eliminate EquinusEquinus

17 F Clubfoot 17 F Clubfoot SxSx Age 1Age 1

17 F Clubfoot17 F Clubfoot

17 F Clubfoot17 F Clubfoot

EquinusEquinus: Stance & Gait: Stance & GaitCompensated Compensated EquinusEquinus

PesPes PlanovalgusPlanovalgus / Abducted Gait/ Abducted GaitEarly HeelEarly Heel--Off Off Forward Leaning Posture / Forward Leaning Posture / GenuGenu RecurvatumRecurvatumProlonged Limb Support in Gait Prolonged Limb Support in Gait Lack of Full Knee Extension in GaitLack of Full Knee Extension in Gait

Compensated Compensated EquinusEquinus

Stance / PostureStance / Posture

Gait AnalysisGait Analysis

Compensated Compensated EquinusEquinus ::GenuGenu RecurvatumRecurvatum

Gait Gait -- Compensated Compensated EquinusEquinus

Compensated (?) Compensated (?) EquinusEquinusComfortComfort Forced StanceForced Stance POY 3 TALPOY 3 TAL

POY 6

EquinusEquinus--Compensated FlatfootCompensated Flatfoot7 / F Severe 7 / F Severe PesPes planovalgusplanovalgus / Vertical Talus/ Vertical Talus

Compensated Compensated EquinusEquinus Gait Gait -- CVACVA

EquinusEquinus--Compensated FlatfootCompensated Flatfoot

Gait Gait -- Compensated Compensated EquinusEquinus

EquinusEquinus FlatfootFlatfootPO Y2 TN Fusion / TALPO Y2 TN Fusion / TAL

EquinusEquinus Flatfoot GaitFlatfoot Gait

GastrocGastroc / Evans / Medial Arch/ Evans / Medial Arch

9 9 yoyo F F EquinusEquinus / Vertical Talus/ Vertical Talus

TAL & Spring Ligament TAL & Spring Ligament PlicationPlication

Young’s Young’s TenosuspensionTenosuspension

TAL Repair + ResultTAL Repair + Result

Pre and Post Reduction of Pre and Post Reduction of EquinusEquinus

Spastic Spastic EquinusEquinus & Gait& Gait

Spastic Spastic EquinusEquinus –– M GravisM Gravis

Spastic GaitSpastic Gait

PrePre--OpOp PostPost--Op TA, TP, AchillesOp TA, TP, Achilles

Compensated Compensated EquinusEquinus -- MVAMVA

EquinusEquinus: Stance & Gait: Stance & Gait

UnCompensatedUnCompensated EquinusEquinusPesPes EquinusEquinus or or EquinoVarusEquinoVarus

or or EquinoAdductoVarusEquinoAdductoVarusIncreased Angle & BaseIncreased Angle & BaseResidual Knee FlexionResidual Knee FlexionLateral Ankle InstabilityLateral Ankle InstabilityCircumductoryCircumductory GaitGaitShortened Limb Support in GaitShortened Limb Support in GaitLLD LLD –– longer leglonger leg

Combination DeformitiesCombination DeformitiesTalipesTalipes equinovarusequinovarus = clubfoot= clubfoot

Bony Bony EquinusEquinus –– Residual DeformityResidual Deformity

Uncompensated Uncompensated EquinusEquinus –– PesPesValgusValgus

Gait Gait -- Uncompensated Uncompensated EquinusEquinus

Spastic Spastic EquinusEquinus -- CVACVA

23 Year Post MVA, CP Nerve 23 Year Post MVA, CP Nerve Paralysis, Paralysis, DropfootDropfoot EquinovarusEquinovarus

PostPost--Op TAL / AJC Op TAL / AJC

Pre and Post GaitPre and Post Gait

Pre and Post With ShoePre and Post With Shoe

Uncompensated Uncompensated EquinusEquinus –– Brain TumorBrain TumorPrePre--OpOp XX--RayRay Post TAL/AJCPost TAL/AJC

Pre and Post Pan Pre and Post Pan TalarTalar ArthrodesisArthrodesis

Before & After Before & After

Uncompensated Uncompensated EquinusEquinus GaitGait

BeforeBefore AfterAfter

Uncompensated Uncompensated EquinusEquinus –– 1.5 Year 1.5 Year Post MVA, Talus AVN, Flap/GraftPost MVA, Talus AVN, Flap/Graft

Pre and Post Pre and Post -- TAL/AJC, TAL/AJC, PanTalarPanTalar ArthrodesisArthrodesis

Pre and Post Y 1 & GaitPre and Post Y 1 & Gait

EquinusEquinus -- Surgical Principles Surgical Principles

Assess Bone & Soft TissueAssess Bone & Soft TissueStaged ApproachStaged Approach

TAL, AJCTAL, AJCBone ResectionBone Resection

One StageOne StageMore Bone ResectionMore Bone ResectionLoss Limb Length…Loss Limb Length…

52 M 52 M EquinusEquinus + + CavusCavus

Gait AnalysisGait Analysis

EquinusEquinus ??

PesPes CavusCavus ??

DropfootDropfoot ??????

Combination Deformity …Combination Deformity …

EquinusEquinus

GastrocnemiusGastrocnemius or or GastroSolealGastroSolealAssess With Foot NEUTRALIZEDAssess With Foot NEUTRALIZED

TAL vs. TAL vs. GastrocGastroc RecessionRecession

CompensatedCompensatedHeel on GroundHeel on Ground

UncompensatedUncompensatedToe WalkerToe Walker

DropfootDropfoot & & EquinusEquinus & & CavusCavus

All Limited All Limited DorsiflexionDorsiflexion……DropfootDropfoot

Weakness of Weakness of DorsiflexionDorsiflexionEquinusEquinus

Primary Deformity At / Above AnklePrimary Deformity At / Above AnkleCompensation Above (Compensation Above (genugenu recurvatumrecurvatum) & Below ) & Below Ankle (Ankle (pespes valgusvalgus, HAV, HT), HAV, HT)

CavusCavusPrimary Deformity Below Ankle (foot)Primary Deformity Below Ankle (foot)Compensation Distal (toes) & Proximal (ankle)Compensation Distal (toes) & Proximal (ankle)