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Effects of Gastrocnemius Tightness on Forefoot During Gait
Abstract
The gastrocnemius is the main muscle of the posterior compartment of the leg. As a bi-articular muscle it has very specific biomechanical properties, which are mainly explained by Hill’s model. In this review we present topics on this subject combining the major bio-mechanical topics: anatomy, dynamics, kinetics, and electromyography. This muscle is remarkable in that it has a very low energy consumption and very high mechanical efficacy. In addition to the biomechanical features above, we aim to understand the consequences of its tightness. The dysfunction also appears in all the biomechanical topics and clarifies the reasons of the location of symptoms in the midfoot and on the plantar aspect of the forefoot.
... Although its prevalence varies, Di Giovanni et al. estimated it being present in 88% of patients with symptomatic foot and ankle pathology and in 44% of asymptomatic population [2]. Several studies have showed how GC may have a relevant impact on foot and ankle biomechanics: Achilles tendinopathy [3,4], plantar fasciitis [5], metatarsalgia [6,7], hallux valgus [7] and hallux rigidus [8]. Gait can also be affected, since a dorsiflexion of the ankle greater than 10 • with the knee in extension seems necessary for a normal loading of the foot, especially during the middle stance phase [9]. ...
... Although its prevalence varies, Di Giovanni et al. estimated it being present in 88% of patients with symptomatic foot and ankle pathology and in 44% of asymptomatic population [2]. Several studies have showed how GC may have a relevant impact on foot and ankle biomechanics: Achilles tendinopathy [3,4], plantar fasciitis [5], metatarsalgia [6,7], hallux valgus [7] and hallux rigidus [8]. Gait can also be affected, since a dorsiflexion of the ankle greater than 10 • with the knee in extension seems necessary for a normal loading of the foot, especially during the middle stance phase [9]. ...
... In 1923, Nils Silfverskiold described the proximal gastrocnemius lengthening technique for patients affected by cerebral palsy, consisting of releasing both the medial and lateral gastrocnemius heads at their insertion on the femoral condyles [10]. The rationale behind this surgery was that lengthening the gastrocnemius would increase the passive stretching of the calf during gait, therefore improving the efficiency of muscles and reducing the overloading of the foot [7]. A few years ago, Louis Samuel Barouk proposed a modification of this technique, describing a section limited to the white fibers (aponeurosis) of the medial and lateral gastrocnemius in patients with forefoot overloading [11]. ...
Purpose
Gastrocnemius recession has been described in the treatment of gastrocnemius contracture. The aims of this study were: 1) to assess the change in ankle dorsiflexion after isolated medial gastrocnemius recession performed according to L.S. Barouk’s technique; 2) to compare ankle dorsiflexion after isolated medial head with complete proximal gastrocnemius recession.
Methods
A cadaveric study was performed on 15 lower limb adult specimens. Isolated medial gastrocnemius head recession was initially performed, followed by an additional recession of the lateral gastrocnemius head. Ankle dorsiflexion torque was applied with 2 and 4 kg forces on second metatarsal head. Ankle dorsiflexion was measured with the knee both in extension and at 90° of flexion and values were recorded before surgery (T0), after medial head recession (T1) and after both heads recession (T2). Normality of data was assessed using the Shapiro-Wilk test, then measurements were compared in the three conditions with appropriate statistical tests.
Results
After isolated medial gastrocnemius recession (Δ = T1-T0), ankle dorsiflexion assessed with the knee in extension significantly increased by 5° ± 3 (range, -2 to 10) with a 2-kg torque (p = 0.02) and by 4.5° ± 3 (range, -4 to 10) with a 4-kg torque (p = 0.04). No significant difference was observed with the knee flexed at 90° (p > 0.05 for all measurements). After both gastrocnemius heads recession (Δ = T2-T1), although a further increase in dorsiflexion was noticed, statistical significance was not reached neither with the knee in extension nor at 90° of flexion (p > 0.05 for all measurements).
Conclusion
In this study, isolated medial gastrocnemius head recession performed according to LS Barouk’s technique was effective in improving ankle dorsiflexion, whereas the additional release of the lateral head did not produce any significant change.
Level of evidence
Level V, cadaveric study.
... In the surgical community, the most widespread hypothesis is that restricted ankle dorsiflexion increases plantar pressure during the mid-stance phase. Cazeau et al. [7] found that the time between the 60th and 88th percentiles of the stance phase was the setting for an increase of pressure on the forefoot: at this point the knee is in extension and the ankle in dorsiflexion. Same observations are present in 3D models [8] and cadaver studies [9], where restricted ankle dorsiflexion was found with IGT. ...
... Same observations are present in 3D models [8] and cadaver studies [9], where restricted ankle dorsiflexion was found with IGT. However, these studies [7][8][9] were not carried out in living subjects and are only suppositions. ...
... Our findings are in disagreement with common knowledge and several studies [7][8][9]11]. Aronow et al. [9] found, in patients with IGT, restricted ankle dorsiflexion and foot hyperpressure. These findings are based on fresh cadaver examinations, which could be biased, especially because cadaveric tissue may have different properties and more rigidity than living body tissue. ...
Background
Isolated gastrocnemius tightness (IGT) has been suggested as an etiologic factor in mechanical disorders of the foot and ankle without a clear pathophysiological mechanism in the literature. We hypothesized that restricted ankle dorsiflexion inducing increased forefoot pressure in IGT patients could be this pathophysiological mechanism.
Methods
Case/control experimental observational investigation. Forty lower limbs in 20 asymptomatic IGT patients were included and compared to controls. Quantitative gait analyses coupled with dynamic baropodometry were used for comparison between groups. The primary outcome was maximum ankle dorsiflexion during stance phase. Secondary outcomes were knee flexion and forefoot pressure.
Results
Maximum ankle dorsiflexion and maximum forefoot pressure were similar between groups. Increased knee flexion was found in the asymptomatic IGT group.
Conclusions
IGT induced compensatory knee flexion during stance phase, which probably prevents increased pressure on the forefoot by allowing ankle dorsiflexion.
Level of evidence
Level IV, Case/control experimental observational investigation.
... Thus, the muscle is tensioned when the knee is extended and the ankle joint in slight dorsiflexion. 15 Forefoot pressures are highest when, in this position, the tight gastrocnemius is maximally stretched. 15,16 During gait this occurs between the 60th and the 90th percentile of the stance phase. ...
... 15 Forefoot pressures are highest when, in this position, the tight gastrocnemius is maximally stretched. 15,16 During gait this occurs between the 60th and the 90th percentile of the stance phase. 15,17 Restricted ankle dorsiflexion alters gait to early heel-off, subtalar overpronation, and dorsal-extension stress on the midtarsal joints and consecutive midfoot hypermobility. ...
... 15,16 During gait this occurs between the 60th and the 90th percentile of the stance phase. 15,17 Restricted ankle dorsiflexion alters gait to early heel-off, subtalar overpronation, and dorsal-extension stress on the midtarsal joints and consecutive midfoot hypermobility. 18 In patients with hallux valgus, a tight gastrocnemius can often be found, 19,20 and more than 60% of these patients also present symptoms of metatarsalgia. ...
Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.
... Huerta summarized that MGT increases Achilles tndon tension during weight bearing, leading to an increase in forefoot pressure with an anterior displacement of the center of pressure [9]. Cazeau concludes that MGT has a biomechanical effect on the lower limb joints and the forefoot, with the risk of forefoot pain when the associated muscles are maximally stretched [10]. Nakale et al., in a study of 223 patients, found a strong association between plantar fasciitis, osteoarthritis, and hallux valgus, among others, with isolated MGT [11]. ...
... It is a cost-effective approach and can be performed by patients on their own. Bernand and Cazeu believe that stretching exercises should be the first line of treatment [7,10]. If this fails, there is a Grade B recommendation for gastrocnemius recession surgery for overload symptoms (isolated pain) [13]. ...
Aim Musculus Gastrocnemius Tightness (MGT) has been linked with common foot and ankle pathologies. These symptoms sometimes are not severe enough for the patient to seek treatment. This study aims to determine the incidence rate of MGT among our clinical personnel and if there is any association between foot and ankle symptoms with MGT. Materials and methods This observational cross-sectional study involves clinical personnel from our Specialist Clinics at Hospital Kulim, Malaysia. We interviewed and assessed 85 volunteers of which, we measured the passive ankle dorsiflexion of the volunteers (the Silfverskiöld) test, to diagnose MGT. We then used the Manchester Oxford Foot Questionnaire (MOxFQ) is used to determine the functional outcome of our volunteers. Results Out of a total of 85 volunteers assessed, 12 (14%) volunteers were found to have gastrocnemius tightness. Among this cohort, 11 were symptomatic. Out of the 73 who did not have MGT, there were three symptomatic volunteers. There was a significant association between volunteers with foot and ankle symptoms with gastrocnemius tightness, compared to those without. There was a significant difference in the relationship between the MOxFQ scores in all components (walking, pain, and social) when comparing those with and those without MGT. Conclusion We conclude that there is a significant association between foot and ankle symptoms and MGT in our clinic sample population. However, these symptoms were not severe enough for these symptomatic volunteers to seek treatment. We should consider screening symptomatic staff and implementing stretching protocols.
... HR Mat™ pressures were evaluated using a mask similar to that used in previous studies with the only change being consolidation of three metatarsophalangeal joint regions into one forefoot region [25]. Only the forefoot pressure variables are included in this statistical analysis as an ankle equinus is proposed to contribute to gait alterations that elevate forefoot plantar pressures and increase foot ulcer risk in at risk diabetes populations [26]. ...
... A WB equinus value of 30 degrees was used in these calculations because, as described above, we believe this value to be representative of an ankle dorsiflexion restriction when measured at the anterior tibia. An ankle equinus is proposed to restrict the forward progression of the tibia over the foot during stance phase, resulting in gait alterations that elevate forefoot plantar pressures thereby increasing foot ulcer risk in at risk diabetes populations [26]. In support of this theory we have demonstrated that a WB equinus has significant effects on barefoot forefoot plantar pressure variables in older adults with diabetes. ...
Background
Accurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion < 30°) in unimpaired cohorts, and secondly to investigate any clinical effects this degree of ankle dorsiflexion restriction has on forefoot plantar pressure variables in older adults with diabetes.
Methods
Ankle dorsiflexion was measured using a Lunge test with the knee extended in young adults without diabetes (YA) and older adults with diabetes (DA). In‐shoe and barefoot plantar pressure was recorded for the DA group. Spearman's correlation was calculated to determine any association between the presence of ankle equinus and plantar pressure variables in the DA group. DA group differences in people with and without an equinus were examined.
Results
A weight bearing equinus of < 30°, assessed in a lunge using an inclinometer placed on the anterior tibia, falls within the restricted range in young unimpaired cohorts. In the DA group this degree of ankle restriction had a fair and significant association with elevated barefoot forefoot peak pressure ( r = 0.274, p = 0.005) and pressure‐time integrals ( r = 0.321, p = .001). The DA equinus group had significantly higher barefoot peak pressure (mean kPa (SD): 787.1 (246.7) vs 652.0 (304.5), p = 0.025) and pressure‐time integrals (mean kPa (SD): 97.8 (41.6) vs 80.4 (30.5), p = 0.017) than the DA non equinus group.
Conclusions
We support a preliminary weight bearing ankle equinus value of < 30°. This value represents a restricted range in young adults and is correlated with increased forefoot plantar pressure variables in older adults with diabetes. Mean population weight bearing ankle dorsiflexion data presented here for older adults with diabetes, will allow use of the more functional Lunge test with knee extended in research and clinical practice.
... [1] Bu yürüyüş bozukluğunda da öncelikli tedavi hedefi birincil ve ikincil nedenler olmalı üçüncül nedenlerin ise kendiliğinden düzeleceği ön görülmelidir. [11,12] Parmak ucu yürüyüş gösteren bir hastada gerçek ekin basışına dizde ve/veya kalçada fleksiyonda basış eşlik ediyorsa, bu yürüyüş "sıçrayarak yürüyüş" olarak tanımlanmalıdır (Şekil 5). Bu bozuklukta birincil ve ikincil nedenler ayak bileğinin yanı sıra dizde veya kalçada da mevcuttur (Şekil 6). ...
... Bu amaçla, gastroknemius kası gerginliğinin Aşil tendonu kısalığından ayırt edilmesinde Silverskiöld testi, ayak arkasının varusa alınmasına dikkat edildiğinde ve aşırı kuvvet uygulanmadığında, etkili bir şekilde kullanılmaktadır. [11,12] Gerçek ekin basışına diz ve/veya kalçada hiperekstansiyonun eşlik ettiği yürüme için ise yine parmak ucu yürüme tanımı kullanılabilir. Yani, yürüme bozukluğundaki birincil ve ikincil nedenler ayak bileği kaynaklıdır. ...
... Porém, apenas alguns rotineiramente procuram por essa alteração (3,4) . O teste clínico para avaliar a contratura isolada do gastrocnêmico foi descrito por Silverskiold (5,6) . ...
... Não conhecemos nenhum documento abordando especificamente a prevalência da contratura gastrocnêmica isolada ou seus efeitos em longo prazo em pessoas normais e saudáveis (1) . Sabe-se apenas que é mais prevalente em pacientes com dor no antepé e no mediopé do que a população em geral (6) . ...
Objective: To determine the prevalence of short gastrocnemius in orthopaedic patients treated in the emergency room and the foot and ankle outpatient clinic of a public hospital and to evaluate the relationship between prevalence and certain specific symptoms. Methods: This was an observational cross-sectional study conducted using a questionnaire completed by patients treated in February 2018. Results: Of the 160 patients studied, 21 (13.1%) had a diagnosis of shortening of the gastrocnemius. The condition was more prevalent in females than in males, with no differences in race, age, laterality or occupation. The most commonly associated symptoms were calf pain, back pain, equinism and metatarsalgia, which were all present in more than 2/3 of cases. Conclusion: Shortening of the gastrocnemius is a fairly common pathology that deserves greater attention in orthopaedic practice. Additional studies are needed to better correlate epidemiological findings with this pathology. Level of Evidence II; Diagnostics Studies.
... In 1913, Nutt (57) shed considerable light on this subject only to be lost until now. In 2014, Cazeau and Stiglitz (14) described causality to some extent as equinus relates to increased forefoot pressures describing the critical area of the gait cycle as the C-zone when the ankle dorsiflexion is less than 5° and the maximal point of forefoot pressure as the X point and just after. ...
... The incidence of non-neuromuscular equinus in otherwise normal, healthy people (5,11,13,14,18,23,25,(57)(58)(59) is not known; however, it is likely far more common than currently perceived. While most would consider a calf that is too tight to be trivial, this could not be further from the truth. ...
We are currently in the process of discovering that many, if not the majority, of the non-traumatic acquired adult foot and ankle problems are caused by a singular etiology: non-neuromuscular equinus or the isolated gastrocnemius contracture. There is no question that this biomechanical association exists and in time much more will be uncovered. There are three basic questions that must be answered: why would our calves tighten as we normally age, how does a tight calf, or equinus, actually cause problems remotely in the foot and ankle, and how do the forces produced by equinus cause so many seemingly unrelated pathologies in the foot and ankle? The purpose of this paper is to address the second question: how does a tight calf mechanically cause problems remotely in the foot and ankle? There has been little evidence in the literature addressing the biomechanical mechanisms by which equinus creates damaging forces upon the foot and ankle, and as a result, a precise, convincing mechanism is still lacking. Thus, the mere concept that equinus has anything to do with foot pathology is generally unknown or disregarded. The split second effect, described here, defines exactly how the silent equinus contracture creates incremental and significant damage and injury to the human foot and ankle resulting in a wide variety of pathological conditions. The split second effect is a dissenting theory based on 30 years of clinical and academic orthopedic foot and ankle experience, keen clinical observation along the way, and review of the developing literature, culminating in examination of many hours of slow motion video of normal and abnormal human gait. To my knowledge, no one has ever described the mechanism in detail this precise.
... The patients with gastrocnemius contracture mainly show limitations of ankle dorsiflexion. The severe cases even present with the equinus deformity, which seriously affects activities of daily life [1,2]. The Silfverskiöld test is often used to diagnose gastrocnemius contracture and distinguish it from Achilles tendon contracture. ...
Background and Objectives: This study aimed to evaluate the effectiveness and safety of endoscopic gastrocnemius recession using the self-developed Modified Soft Tissue Release Kit. Materials and Methods: This retrospective review followed up 22 patients (34 feet) who underwent endoscopic surgery and 20 patients (30 feet) who received open surgery between January 2020 and January 2022. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the maximum ankle dorsiflexion angle were evaluated preoperatively and at the last follow-up. Postoperative complications were recorded. Patient satisfaction was surveyed at the last follow-up. The comparison between quantitative data was analyzed with the Wilcoxon signed-rank test. The comparison between qualitative data was analyzed with the chi-square test. Results: There was no significant difference in the baseline characteristics between the two groups. The AOFAS score in the endoscopic group increased from 50 (18) points preoperatively to 90 (13) points at the last follow-up; the maximum ankle dorsiflexion angle increased from −7.7 (2.8) degrees to 10.6 (3.6) degrees. The AOFAS score in the open group improved from 47 (15) points preoperatively to 90 (18) points at the last follow-up; the maximum ankle dorsiflexion angle increased from −7.6 (4.0) degrees to 10.7 (3.3) degrees. The change values of the AOFAS scores in the endoscopic and open groups were 39 (15) and 40.5 (11) points, respectively, and there was no significant difference between them. The change values of the maximum ankle dorsiflexion angles in the endoscopic and open groups were 19.5 (4.3) and 19.1 (4.9) degrees, respectively, and there was no significant difference between them. There were no complications, such as sural nerve injury, in both groups. There was no significant difference between the two groups in satisfaction with the surgical outcome. Conclusions: Endoscopic gastrocnemius recession using the Modified Soft Tissue Release Kit can significantly improve the foot function with significant mid-term efficacy and high safety.
... So, it is very meaningful to study WD with extremities dystonia. Previous studies have reported that the abnormal tension of the biceps brachii and medialis and lateralis gastrocnemius muscle is one of the commonly involved parts of extremities dystonia and can also reveal the degree of dystonia in upper and lower limbs, which can be indirectly reflected by measuring the muscle tension levels of biceps brachii and gastrocnemius muscle [22][23][24][25]. Furthermore, previous dystonia-related studies and our recent dystonia study of WD have shown that the digital muscle function assessment system (MyotonPRO) can reliably assess the degree of extremities dystonia by measuring the muscle tension levels of the biceps brachii and gastrocnemius [26][27][28][29][30]. Therefore, we selected the extremities to measure the biomechanical level of WD patients, and the muscle biomechanical level was assessed using the MyotonPRO by measuring the biceps brachii and medialis and lateralis gastrocnemius muscle on both sides to reflect the degree of dystonia. ...
Dysfunction of the lenticular nucleus is thought to contribute to neurological symptoms in Wilson’s disease (WD). However, very little is known about whether and how the lenticular nucleus influences dystonia by interacting with the cerebral cortex and cerebellum. To solve this problem, we recruited 37 WD patients (20 men; age, 23.95 ± 6.95 years; age range, 12–37 years) and 37 age- and sex-matched healthy controls (HCs) (25 men; age, 25.19 ± 1.88 years; age range, 20–30 years), and each subject underwent resting-state functional magnetic resonance imaging (RS-fMRI) scans. The muscle biomechanical parameters and Unified Wilson Disease Rating Scale (UWDRS) were used to evaluate the level of dystonia and clinical representations, respectively. The lenticular nucleus, including the putamen and globus pallidus, was divided into 12 subregions according to dorsal, ventral, anterior and posterior localization and seed-based functional connectivity (FC) was calculated for each subregion. The relationships between FC changes in the lenticular nucleus with muscle tension levels and clinical representations were further investigated by correlation analysis. Dystonia was diagnosed by comparing all WD muscle biomechanical parameters with healthy controls (HCs). Compared with HCs, FC decreased from all subregions in the putamen except the right ventral posterior part to the middle cingulate cortex (MCC) and decreased FC of all subregions in the putamen except the left ventral anterior part to the cerebellum was observed in patients with WD. Patients with WD also showed decreased FC of the left globus pallidus primarily distributed in the MCC and cerebellum and illustrated decreased FC from the right globus pallidus to the cerebellum. FC from the putamen to the MCC was significantly correlated with psychiatric symptoms. FC from the putamen to the cerebellum was significantly correlated with muscle tension and neurological symptoms. Additionally, the FC from the globus pallidus to the cerebellum was also associated with muscle tension. Together, these findings highlight that lenticular nucleus–cerebellum circuits may serve as neural biomarkers of dystonia and provide implications for the neural mechanisms underlying dystonia in WD.
... Structural causes include insufficiency or relative shortness of the first ray 2,3 . Gastrocnemius tightness also produces forefoot overload during the third rocker and causes metatarsalgia 4,5 . Haglund deformity commonly presents with swelling at the posterolateral aspect of the heel that interferes with shoewear. ...
Cases:
Two women presented with newly growing callosities beneath the first and second metatarsal heads, initially believed to reflect gastrocnemius tightness and plantar plate pathology. In another man, swelling at the posterolateral aspect of the heel was mistaken for a Haglund deformity. Subsequent imaging of each patient led to delayed diagnosis of extraskeletal osteochondroma (ESO). Surgical excision resolved symptoms in all 3 with no recurrence over 12 months later.
Conclusions:
Whenever bony prominences newly develop in soft tissues of the foot, ESO should be suspected and appropriate imaging obtained. We describe physical features to help differentiate ESO from other common causes of foot overload.
... Y. Stiglitz, C. Cazeau, C. Piat Introduction L'instabilité CM1, responsable d'une hypermobilité pathologique du premier rayon, est une étiologie débattue dans la genèse de l'HV [71][72][73]. Elle est pourtant considérée comme une entité réelle dans les études biomécaniques, et de nombreuses publications l'identifient comme une cause avérée de récidive après chirurgie [74][75][76]. Sa recherche doit être systématique par un examen clinique précis et minutieux Le recours aux examens complémentaires est rarement contributif. ...
... Barouk [9] l'associe aux hallux valgus juvéniles (avec une brièveté présente dans 78 % des cas), Solan [10] aux aponévropathies plantaires et aux tendinopathies achilléennes, DiGiovanni [11] aux pieds plats, Lun [12] aux syndromes fémoro-patellaires, Wilder [13] [14], l'impact de ce raccourcissement sur la marche se retrouve principalement dans une zone allant du 60 e au 88 e percentile de la phase d'appui. Dans cette zone, le genou est en position d'extension et la cheville entre -5°et +10°de dorsiflexion. ...
Introduction: Isolated gastrocnemius tightness is common and often associated with ankle and foot pathologies. The pathophysiology of this association is not clearly established. A review was performed to assess repercussion of gastrocnemius tightness on gait, and to evaluate scientific knowledge on this field. Materials and methods: The review was conducted using the Pubmed, SpringerLink and Science Direct databases. Results: Studies based on clinical findings and biomechanical basis, seem to show, that ankle dorsiflexion limitation during swing phase of gait, due to gastrocnemius tightening, lead to forefoot hyperpressure. These findings are not observed in dynamic optoelectronic studies involving patients with gastrocnemius tightness; in which knee flessum during swing phase seems to be a compensatory mechanism. Conclusions: There is a difference between the common belief and laboratory analysis results on this subject. Current scientific knowledge cannot explain the increased prevalence of foot and ankle pathologies in patients with gastrocnemius tightness.
... Il se subdivise en cinq rayons ayant chacun des propriétés anatomiques, mécaniques et fonctionnelles propres. Mécaniquement, le premier rayon est le plus sollicité, aussi bien en conditions statiques que dynamiques (en particulier en fin de phase d'oscillation, juste avant le toe off) [1]. De ce fait, il peut être sujet à une atteinte arthrosique plus fréquemment que les quatre autres rayons, et l'arthrose peut concerner chaque étage articulaire : articulation cunéométatarsienne (C1M1), articulation métatarsophalangienne (MTP1) et articulation interphalangienne (IP). ...
Le premier rayon de l’avant-pied se situe dans un environnement mécanique spécifique qui explique les fréquentes atteintes arthrosiques dont il peut être atteint. Les trois étages (articulations C1M1, MTP1, et IP) sont concernés et présentent cliniquement à des degrés divers les signes habituels d’arthrose : douleur, raideur et déformation. Les solutions chirurgicales peuvent être conservatrices (exérèse des ostéophytes, ostéotomies de réorientation…) ou radicales (arthrodèses). Les techniques mises en œuvre sont choisies pour permettre un appui postopératoire total et immédiat. Le recours aux procédures mini-invasives et percutanées est très souvent possible, à condition qu’elles soient compatibles avec une remise en charge immédiate.
... 15 Other authors showed that gastrocnemius lengthening would have therapeutic effects on plantar heel pain and metatarsalgia, supporting use of this procedure by many foot and ankle surgeons. 23,24 There are some limitations in our study. We tested a limited number of six matched pairs of cadaveric feet; the study was likely not adequately powered and no clinically meaningful effect size was stated. ...
Destruction of the normal metatarsal arch by a long metatarsal is often a cause for metatarsalgia. When surgery is warranted, distal oblique or proximal dorsiflexion osteotomies of the long metatarsal bones are commonly used. The plantar fascia has anatomical connection to all metatarsal heads. There is controversial scientific evidence on the effect of plantar fascia release on forefoot biomechanics. In this cadaveric biomechanical study, we hypothesized that plantar fascia release would augment the plantar metatarsal pressure decreasing effects of two common second metatarsal osteotomy techniques. Six matched pairs of foot and ankle specimens were mounted on a pressure mat loading platform. Two randomly assigned surgery groups, which had received either distal oblique or proximal dorsiflexion osteotomy of the second metatarsal, were evaluated before and after plantar fasciectomy. Specimens were loaded up to a ground reaction force of 400 N at varying Achilles tendon forces. Average pressures, peak pressures, and contact areas were analyzed. Supporting our hypothesis, average pressures under the second metatarsal during 600 N Achilles load were decreased by plantar fascia release following proximal osteotomy (p <.05). However contrary to our hypothesis, peak pressures under the second metatarsal were significantly increased by plantar fascia release following modified distal osteotomy, under multiple Achilles loading conditions (p <.05). This article is protected by copyright. All rights reserved.
Citation: Hamza, A.; Martinez, L.; Sacco, R.; Amouyel, T.; Held, E.; Beldame, J.; Billuart, F.; Lalevée, M. Stretching and Eccentric Exercises Normalize Gait Parameters in Gastrocnemius Tightness Subjects. Abstract: Background: Isolated gastrocnemius tightness (IGT) is a prevalent condition linked to various foot pathologies. In a previous quantitative gait analysis study, we identified an increase in knee flexion during the midstance phase in IGT patients compared with controls. Although stretching and eccentric exercises (the Stanish protocol) are commonly used for IGT management, their impact on gait parameters remains poorly understood. This study aimed to assess the influence of a Stanish protocol on gait parameters in bilateral IGT subjects. Methods: We enrolled 10 asymptomatic bilateral IGT subjects and 10 controls. Quantitative gait analysis and dynamic baropodometry were carried out on each subject. A Stanish protocol was applied for 4 weeks (five sessions/week) by the IGT group, followed by a similar gait analysis. The ankle and knee range of motion and foot pressure distribution were assessed during the midstance phase of the gait. Results: An increase in knee flexion was initially present in the IGT group compared with controls (8.9 +/− 4.6 vs. 3.4 +/− 2.3 degrees, p < 0.001). There was no difference in the ankle range of motion and foot pressures between the groups at that time. Significant reductions in knee flexion during gait were observed in the IGT subjects after the Stanish protocol (8.9 +/− 4.6 to 3.7 +/− 2.3 degrees, p < 0.001) with a normalization of this parameter (3.4 +/− 2.3 in controls vs. 3.7 +/− 2.3 degrees in IGT, p = 0.72). There was no change in ankle range of motion and foot pressure after the Stanish protocol. Conclusions: Our findings support the effectiveness of the Stanish protocol in reducing knee flexion and normalizing gait in IGT subjects. This protocol not only offers a noninvasive approach for IGT-related issues management but could also enable prophylactic care in asymptomatic cases.
Proximal gastrocnemius lengthening was initially developed in the case of gastrocnemius contraction with positive Silfverskiold’s sign, concerning both medial and lateral procedures. Nowadays only a medial release is performed, which suits with minimally invasive trends and provides the same results with less risks ok complications (cheloid scar and loss of strength). This procedure improves ankle dorsiflexion but has other benefits such as reducing forefoot pain (metatarsalgia, hallux rigidus) or ankle instability. This is the reason why the indications were progressively widened.KeywordsGastrocnemius muscleSilfverskiold’s signAnkle dorsiflexionMetatarsalgia
Gastrocnemius tightness is often associated to subjective or objective instability of the ankle. It is important to research it systematically by an appropriate clinical examination represented by the Silfverskiold test. Several reasons explain the importance of the equinus in the instability of the talus between the malleolas.
Background:
Muscle tightness is a complex ailment that affects quality of life in people who experience it. Muscle tightness is not clearly defined by National Library of Medicine, which creates confusion in clinical practice.
Objectives:
The purpose of this study was to identify the attributes of muscle tightness from expert clinicians' perception and develop a consensus definition from multidisciplinary perspectives.
Methods:
This non-intervention study employed semi-structured interviews using qualitative design. Twelve multidisciplinary expert clinicians participated in the study.
Results:
The results indicate that limited range of motion is a key feature of muscle tightness; however, there are six other attributes: loss of function, changes in muscle texture, change in sensation, asymmetry, pain, and contracted muscle state. These attributes are largely subjective and are inter-related.
Discussion:
The new definition captures the multiple domains of muscle tightness. Lack of a standardized tool is a challenge, particularly when subjective assessments require patients' input. Development of such a tool to measure muscle tightness is advocated.
A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics.
The term tendinopathy includes a series of pathologies, all of which have a combination of pain, swelling, and impaired performance. The terms tendinosis, tendinitis and peritendinitis are all within the main heading of tendinopathy; this terminology provides a more accurate understanding of the condition and highlights the uniformity of clinical findings while distinguishing the individual histopathological findings of each condition. Understanding the clinical features and the underlying histopathology leads to a more accurate clinical diagnosis and subsequent treatment selection. Misuse of the term tendinitis can lead to the underestimation of chronic degenerative nature of many tendinopathies, affecting the treatment selection.
The Achilles tendon is the strongest and thickest tendon in the body and is subjected to unique forces during the activities of living. A variety of pathologic processes have been identified causing clinical symptoms in patients of all ages. A detailed understanding of Achilles anatomy is necessary to understand the pathologic process that are seen in the tendon. As with all medical topics and conditions, our understanding is evolving as new research sheds light on pathologic processes involved with the Achilles tendon. This article reviews the anatomic, histologic, hemodynamic, and mechanical properties of the Achilles tendon and associated muscle structures.
Gait dysfunction is a strong issue in elderly women with a history of falls. The purpose of this study was to compare the temporal activity of the ankle muscles during gait in elderly women with and without a history of recurrent falls. Eighty-nine (89) elderly women - one group with a history of falls (45) and another group without (44) - participated in the study. The mean range of temporal activation of the gastrocnemius, tibialis anterior and soleus muscles during gait was obtained using electromyography. The muscles were considered active when the signal magnitude surpassed two standard deviations of the minimal magnitude of the average signal per individual. The results showed that the mean range of gastrocnemius muscle activation of the group of recurrent fallers was significantly shorter, 2.9% (16.9±5.7%) compared to the group without recurrent falls (19.8±6.6%) (p=0.004). The shorter duration in the gastrocnemius muscle activation during stance could possibly affect stability in the support phase, since the gastrocnemius is the main decelerator of the trunk. Clinically, this finding shows the importance of rehabilitation programs for elderly women that focus on strengthening the plantar flexor musculature aiming to reestablish the function and stability of gait and possibly avoiding falls.
Stretching exercises are commonly prescribed for patients and healthy individuals with limited extensibility of the gastrocnemius muscle.
To determine effects of gastrocnemius stretching on ankle dorsiflexion, knee extension, and gastrocnemius muscle activity during gait.
Randomized-control trial.
Biomechanical laboratory.
Sixteen volunteers (9 men and 7 women, mean age = 27 y) with less than 5 degrees of passive ankle-dorsiflexion range of motion randomly assigned to an experimental or control group.
The experimental group performed gastrocnemius stretching for 3 wk.
Maximum ankle dorsiflexion, maximum knee extension, and EMG amplitude of the gastrocnemius muscles were measured between heel strike and heel-off before and after intervention.
No significant effect of group or time was found on maximum ankle dorsiflexion, maximum knee extension, or EMG activity of the medial or lateral gastrocnemius muscles between heel strike and heel-off. The experimental group had significantly greater passive ankle-dorsiflexion range of motion bilaterally at posttest than the control group.
Stretching did not alter joint angles or gastrocnemius muscle activity in the early to midstance phase of gait.
Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed.
This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed).
With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group.
On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present. Clinical Relevance: These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.
Muscles are required to perform or absorb mechanical work under different conditions. However the ability of a muscle to do this depends on the interaction between its contractile components and its elastic components. In the present study we have used ultrasound to examine the length changes of the gastrocnemius medialis muscle fascicle along with those of the elastic Achilles tendon during locomotion under different incline conditions. Six male participants walked (at 5 km h(-1)) on a treadmill at grades of -10%, 0% and 10% and ran (at 10 km h(-1)) at grades of 0% and 10%, whilst simultaneous ultrasound, electromyography and kinematics were recorded. In both walking and running, force was developed isometrically; however, increases in incline increased the muscle fascicle length at which force was developed. Force was developed at shorter muscle lengths for running when compared to walking. Substantial levels of Achilles tendon strain were recorded in both walking and running conditions, which allowed the muscle fascicles to act at speeds more favourable for power production. In all conditions, positive work was performed by the muscle. The measurements suggest that there is very little change in the function of the muscle fascicles at different slopes or speeds, despite changes in the required external work. This may be a consequence of the role of this biarticular muscle or of the load sharing between the other muscles of the triceps surae.
The gastrocnemius medialis (GM) muscle plays an important role in stair negotiation. The aim of the study was to investigate the influence of cadence on GM muscle fascicle behaviour during stair ascent and descent. Ten male subjects (young adults) walked up and down a four-step staircase (with forceplates embedded in the steps) at three velocities (63, 88 and 116 steps/min). GM muscle fascicle length was measured using ultrasonography. In addition, kinematic and kinetic data of the lower legs, and GM electromyography (EMG) were measured. For both ascent and descent, the amount of fascicular shortening, shortening velocity, knee moment, ground reaction force and EMG activity increased monotonically with gait velocity. The ankle moment increased up to 88 steps/min where it reached a plateau. The lack of increase in ankle moment coinciding with further shortening of the fascicles can be explained by an increased shortening of the GM musculotendon complex (MTC), as calculated from the knee and ankle angle changes, between 88 and 116 steps/min only. For descent, the relative instant of maximum shortening, which occurred during touch down, was delayed at higher gait velocities, even to the extent that this event shifted from the double support to the single support phase.
This is a study of a method for obtaining a mathematical description of the most significant variables concerning kinematics and dynamics of human locomotion.The method is characterized by a typical approach of system theory. It consists of an analytical procedure for the processing of data obtained by the most common experimental techniques in this area. i.e. photography for recording the movement, and the force platform for measuring the ground reactions.The proposed mathematical algorithms have been designed to obtain the time functions of the variables cited above in an analytical form, and a measurement of the relative indefiniteness induced by experimental errors.The results of the latter allows a critical evaluation of the experimental procedure. In particular, a maximum limit of the number of experimental data to be taken, can be evaluated.The subsystem of the locomotor apparatus which the present work deals with, is the lower limb.The method presented can be applied successfully to all of the gaits having a constant mean direction of progression and periodic time patterns.
The EMG patterns for 16 muscles involved in human walking are reported along with stride-to-stride and inter-subject variability measures. These profiles and measures were developed for basic researchers and clinical investigators as a baseline reference of motor patterns and for use in the diagnosis of gait pathologies. Evident from a comparison of these patterns were some fundamental aspects of the neuromuscular control and the mechanical demands of walking. These comparisons can be summarized as follows: (1) The distal support muscles (soleus, tibialis anterior, gastrocnemii) are the most active muscles, the more proximal muscles are least active. (2) The least variable EMG patterns, as quantified by the normalized inter-subject variability measures, are seen in the most distal single joint muscles, the most variable are the more proximal muscles. The EMGs of the biarticulate muscles, both proximal and distal, exhibit higher variability than the EMGs of the single joint muscles. (3) The detailed patterns and levels of EMG activity demonstrate the different mechanical tasks of each muscle over the gait cycle.
Plantar foot pain can be caused by a wide variety of diseases. To facilitate diagnosis and treatment differentiation of two entities is useful. The first group contains those painful disturbances that are due to mechanical overload, the second group has no relation to biomechanical problems. Tightness of the gastrocnemius muscles and hamstrings are the main factors leading to mechanical overload. Therefore, thorough evaluation of these muscles and treatment of shortening by stretching exercises is of paramount importance.
The aim of the present study was to establish the behavior of human medial gastrocnemius (GM) muscle fascicles during stair negotiation. Ten healthy male subjects performed normal stair ascent and descent at their own comfortable speed on a standard-dimension four-step staircase with embedded force platforms in each step. Kinematic, kinetic, and electromyographic data of the lower limbs were collected. Real-time ultrasound scanning was used to determine GM muscle fascicle length changes. Musculotendon complex (MTC) length changes were estimated from ankle and knee joint kinematics. The GM muscle was mainly active during the push-off phase in stair ascent, and the muscle fascicles contracted nearly isometrically. The GM muscle was mainly active during the touch-down phase of stair descent where the MTC was lengthened; however, the GM muscle fascicles shortened by approximately 7 mm. These findings show that the behavior and function of GM muscle fascicles in stair negotiation is different from that expected on the basis of length changes of the MTC as derived from joint kinematics.
In the absence of bony deformity, ankle equinus is generally the result of shortening within the gastrocnemius-soleus complex. Restriction of ankle dorsiflexion as a proxy for equinus contracture has been linked to increased mechanical strains and resultant foot and ankle pathology for a long time. This entity has many known causes, and data suggest it can manifest as either an isolated gastrocnemius or combined (Achilles) contracture. Numerous disorders of the foot and ankle have been linked with such "equinus disease", and although some of these relationships remain controversial, a reasonably convincing relationship between equinus contracture and the development of flatfoot exists. What is still perhaps most misunderstood is the temporal association between these two pathologies, and hence higher levels of evidence are needed in the future to define more precisely the interplay between flatfoot deformity and gastrocnemius-soleus tightness.
Contracture of the gastrocnemius musculature is a prevalent finding in the setting of foot and ankle pathology. Tightness of the posterior musculotendinous structures in the leg limits ankle range of motion and affects an equinus posture of the foot. Increased contact pressures are generated in the plantar foot with weightbearing. The resultant overload of the ligaments and the intrinsic muscles of the midfoot and forefoot is manifest in a variety of pathologic processes. The altered mechanics contributes to, among other conditions, ankle impingement, plantar fasciitis, midfoot arthritis, posterior tibial tendon dysfunction, forefoot overload, diabetic ulceration, and Charcot arthropathy. Effective management of these conditions includes addressing the underlying gastrocnemius contracture as well as the related foot and ankle pathology. Here we describe the underlying biomechanical abnormalities and radiographic findings in these pathological conditions of the foot and ankle associated with gastroequinus contracture. An awareness and understanding of the pathomechanics should enable the radiologist to better appreciate the form and function associated with the image.
Analyse des consé quences biomé caniques de la briè veté du gastrocné mien sur l'avant-pied Montpellier (France): Sauramps Medical; 2012
- Cazeau C Stiglitz
Cazeau C, Stiglitz Y. Analyse des consé quences biomé caniques de la briè veté du gastrocné mien sur l'avant-pied. In: Barouk LS, Barouk P, editors. Briè veté des Gastrocné miens. Montpellier (France): Sauramps Medical; 2012. p. 79–91.
The principal elements in human locomotion
- Eberhart Hd
- Inman Vt
- Bresler
Eberhart HD, Inman VT, Bresler B. The principal elements in human locomotion.
Analyse des consé quences biomé caniques de la briè veté du gastrocné mien sur l'avant-pied
- C Cazeau
- Y Stiglitz
Cazeau C, Stiglitz Y. Analyse des consé quences biomé caniques de la briè veté
du gastrocné mien sur l'avant-pied. In: Barouk LS, Barouk P, editors. Briè veté
des Gastrocné miens. Montpellier (France): Sauramps Medical; 2012. p. 79-91.
The principal elements in human locomotion
- H D Eberhart
- V T Inman
- B Bresler
Eberhart HD, Inman VT, Bresler B. The principal elements in human locomotion.
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