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Podiatry Today has just published the full text of: Tendo-Achilles Lengthening: Friend Or Foe In The Diabetic Foot?
Paul J. Kim, John S. Steinberg
While various researchers have implicated the equinus deformity as a major deforming force in a host of foot and ankle pathologies, the exact definition of equinus remains unclear.1-4 However, Root states that “the minimal range of ankle joint dorsiflexion that is necessary for normal locomotion is 10 degrees.”5 Subsequent studies report that the ankle joint range of motion for asymptomatic patients ranges from 0 to 13.1 degrees with the knee extended and from 5 to 22.3 degrees with the knee flexed.
The implication from these studies and other papers is that with a decrease in the range of motion at the ankle joint, it is more likely that pathologies will develop. Although other soft tissue and bony constraints may restrict ankle joint range of motion, the Achilles tendon appears to play the dominant role for this limitation.
Multiple factors are involved in the development of pathologies one sees in the diabetic foot. Some of these factors include neuropathy, ischemia and bony deformity. Soft tissue changes in the diabetic foot are particularly important. For example, there is a decrease in the soft tissue density on the plantar aspect of the diabetic foot, which is less tolerant of stress.10-12 We also know that patients with diabetes have less mobility available in their joints.
Background: There are no conclusive data to support the contention that diabetic patients have an increased frequency of ankle equinus compared with their nondiabetic counterparts. Additionally, a presumed contributing cause of foot ulceration is ankle joint equinus. Therefore, we sought to determine whether persons with diabetes have a higher prevalence of ankle joint equinus than do nondiabetic persons.
Methods: A prospective pilot survey of 102 outpatients (43 diabetic and 59 nondiabetic) was conducted. Demographic and historical data were obtained. Each patient underwent a standard lower-extremity examination, including the use of a biplane goniometer to measure ankle joint range of motion.
Results: Equinus, defined as ankle dorsiflexion measured at 0° or less, was found in 24.5% of the overall population. In the diabetes cohort, 16 of 43 patients (37.2%) were affected compared with 9 of 59 nondiabetic participants (15.3%) (P = .011). There was a threefold risk of equinus in the diabetic population (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.28–8.44; P < .013). The equinus group had a history of ulceration in 52.0% compared with 20.8% of the nonequinus group (P = .003). Equinus, therefore, imparted a fourfold risk of ulceration (OR, 4.13; 95% CI, 1.58–10.77; P < .004). We also found a 2.8 times risk of equinus in patients with peripheral neuropathy (OR, 2.8; 95% CI, 1.11–7.09; P < .029).
Conclusions: Equinus may be more prevalent in diabetic patients than previously reported. Although we cannot prove causality, we found a significant association between equinus and ulceration