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Ankle Equinus in Cerebral Palsy

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Cerebral Palsy

Abstract

Ankle equinus is the most recognized symptom of cerebral palsy (CP). Ankle equinus was the first recognized symptom of CP for which a treatment was reported. It still continues to be one of the most common symptoms to attract the attention of many different specialists. Equinus, which is a primary cause of toe walking, is readily observed by family, friends, and neighbors, as well as all medical practitioners who might watch a child walk. Since it is such a visible aspect of CP, it also attracts the attention of many people who develop the concept that equinus and CP are different names for the same problem. There are multiple causes for equinus in the child with CP, which include poor motor control, spasticity, contractures of muscles, and ankle joint contracture. In some children the equinus is a compensatory position for problems in other parts of their musculoskeletal system. Since there are many causes of equinus there are also many treatment options. The best treatment options can be developed after appropriate diagnostic investigations. For ambulatory children, this often requires a full gait analysis evaluation to ascertain all of the causes of toe walking. When spastic plantar flexors cause equinus, there are many treatment options. These include botulinum toxin injection, therapy, casting, surgery, and various other neurologic interventions. Planning the best treatment options for spastic equinus requires understanding the natural history and considering the age of the child and the child’s overall condition. Treating toe walking and equinus in CP has a long history with many treatments coming into and going out of favor. Understanding this history can give some perspective on current treatment options.

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References

  • Accardo PJ, Barrow W (2015) Toe walking in autism: further observations. J Child Neurol 30:606–609

    Article  Google Scholar 

  • Blackmore AM, Boettcher-Hunt E, Jordan M, Chan MD (2007) A systematic review of the effects of casting on equinus in children with cerebral palsy: an evidence report of the AACPDM. Dev Med Child Neurol 49:781–790

    Article  CAS  Google Scholar 

  • Bleck EE (1984) Forefoot problems in cerebral palsy-diagnosis and management. Foot Ankle 4:188–194

    Article  CAS  Google Scholar 

  • Bleck E (1987) Orthopedic management in cerebral palsy, vol 497. Mac Keith Press, Oxford

    Google Scholar 

  • Borton DC, Walker K, Pirpiris M, Nattrass GR, Graham HK (2001) Isolated calf lengthening in cerebral palsy. Outcome analysis of risk factors. J Bone Joint Surg Br 83:364–370

    Article  CAS  Google Scholar 

  • Carmick J (1995) Managing equinus in children with cerebral palsy: electrical stimulation to strengthen the triceps surae muscle. Dev Med Child Neurol 37:965–975

    Article  CAS  Google Scholar 

  • Chicoine MR, Park TS, Kaufman BA (1997) Selective dorsal rhizotomy and rates of orthopedic surgery in children with spastic cerebral palsy. J Neurosurg 86: 34–39

    Article  CAS  Google Scholar 

  • Chung CY, Sung KH, Lee KM, Lee SY, Choi IH, Cho TJ, Yoo WJ, Park MS (2015) Recurrence of equinus foot deformity after tendo-achilles lengthening in patients with cerebral palsy. J Pediatr Orthop 35:419–425

    Article  Google Scholar 

  • Corry IS, Cosgrove AP, Duffy CM, McNeill S, Taylor TC, Graham HK (1998) Botulinum toxin A compared with stretching casts in the treatment of spastic equinus: a randomized prospective trial. J Pediatr Orthop 18: 304–311

    CAS  PubMed  Google Scholar 

  • Cottalorda J, Gautheron V, Charmet E, Chavrier Y (1997) Muscular lengthening of the triceps by successive casts in children with cerebral palsy. Rev Chir Orthop Reparatrice Appar Mot 83:368–371

    CAS  PubMed  Google Scholar 

  • Craig JJ, van Vuren J (1976) The importance of gastrocnemius recession in the correction of equinus deformity in cerebral palsy. J Bone Joint Surg Br 58:84–87

    Article  CAS  Google Scholar 

  • Davids JR, Foti T, Dabelstein J, Bagley A (1999) Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: a kinematic, kinetic, and electromyographic analysis. J Pediatr Orthop 19:461–469

    Article  CAS  Google Scholar 

  • Deltombe T, Gustin T, Laloux P, De Cloedt P, De Wispelaere JF, Hanson P (2001) Selective fasicular neurotomy for spastic equinovarus foot deformity in cerebral palsy children. Acta Orthop Belg 67:1–5

    CAS  PubMed  Google Scholar 

  • Dillin W, Samilson RL (1983) Calcaneus deformity in cerebral palsy. Foot Ankle 4:167–170

    Article  CAS  Google Scholar 

  • Doute DA, Sponseller PD, Tolo VT, Atkins E, Silberstein CE (1997) Soleus neurectomy for dynamic ankle equinus in children with cerebral palsy. Am J Orthop (Belle Mead NJ) 26:613–616

    CAS  Google Scholar 

  • Dreher T, Buccoliero T, Wolf SI, Heitzmann D, Gantz S, Braatz F, Wenz W (2012) Long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery in spastic diplegic cerebral palsy. J Bone Joint Surg Am 94:627–637

    Article  Google Scholar 

  • Dwyer FC (1975) The present status of the problem of pes cavus. Clin Orthop Relat Res (106):254–275

    Article  Google Scholar 

  • Eilert RE (1984) Cavus foot in cerebral palsy. Foot Ankle 4:185–187

    Article  CAS  Google Scholar 

  • Grant AD, Feldman R, Lehman WB (1985) Equinus deformity in cerebral palsy: a retrospective analysis of treatment and function in 39 cases. J Pediatr Orthop 5:678–681

    Article  CAS  Google Scholar 

  • Hagglund G, Wagner P (2008) Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskelet Disord 9:150

    Article  Google Scholar 

  • Hastings-Ison T, Blackburn C, Rawicki B, Fahey M, Simpson P, Baker R, Graham K (2016) Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial. Dev Med Child Neurol 58:750–757

    Article  Google Scholar 

  • Hicks R, Durinick N, Gage JR (1988) Differentiation of idiopathic toe-walking and cerebral palsy. J Pediatr Orthop 8:160–163

    Article  CAS  Google Scholar 

  • Jahn J, Vasavada AN, McMulkin ML (2009) Calf muscle-tendon lengths before and after Tendo-Achilles lengthenings and gastrocnemius lengthenings for equinus in cerebral palsy and idiopathic toe walking. Gait Posture 29:612–617

    Article  Google Scholar 

  • Joo SY, Knowtharapu DN, Rogers KJ, Holmes L Jr, Miller F (2011) Recurrence after surgery for equinus foot deformity in children with cerebral palsy: assessment of predisposing factors for recurrence in a long-term follow-up study. J Child Orthop 5:289–296

    Article  Google Scholar 

  • Kalen V, Adler N, Bleck EE (1986) Electromyography of idiopathic toe walking. J Pediatr Orthop 6:31–33

    Article  CAS  Google Scholar 

  • Kang BS, Bang MS, Jung SH (2007) Effects of botulinum toxin A therapy with electrical stimulation on spastic calf muscles in children with cerebral palsy. Am J Phys Med Rehabil 86:901–906

    Article  Google Scholar 

  • Kelly IP, Jenkinson A, Stephens M, O’Brien T (1997) The kinematic patterns of toe-walkers. J Pediatr Orthop 17:478–480

    CAS  PubMed  Google Scholar 

  • Koman LA, Mooney JF III, Smith BP, Walker F, Leon JM (2000) Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. Botox Study Group. J Pediatr Orthop 20:108–115

    CAS  PubMed  Google Scholar 

  • Koman LA, Paterson Smith B, Balkrishnan R (2003) Spasticity associated with cerebral palsy in children: guidelines for the use of botulinum A toxin. Paediatr Drugs 5:11–23

    Article  Google Scholar 

  • Lee CL, Bleck EE (1980) Surgical correction of equinus deformity in cerebral palsy. Dev Med Child Neurol 22:287–292

    Article  CAS  Google Scholar 

  • Lespargot A, Robert M, Khouri N (2000) Stretching the triceps surae muscle after 40 degrees C warming in patients with cerebral palsy. Rev Chir Orthop Reparatrice Appar Mot 86:712–717

    CAS  PubMed  Google Scholar 

  • Muir D, Angliss RD, Nattrass GR, Graham HK (2005) Tibiotalocalcaneal arthrodesis for severe calcaneovalgus deformity in cerebral palsy. J Pediatr Orthop 25:651–656

    Article  Google Scholar 

  • Perry J (1992) Gait analysis: normal and pathologic function. Slack, Thorofare, NJ, USA

    Google Scholar 

  • Perry J, Hoffer MM, Giovan P, Antonelli D, Greenberg R (1974) Gait analysis of the triceps surae in cerebral palsy. A preoperative and postoperative clinical and electromyographic study. J Bone Joint Surg Am 56:511–520

    Article  CAS  Google Scholar 

  • Pierrot AH, Murphy OB (1974) Albert E. Klinkicht Award, 1972. Heel cord advancement. A new approach to the spastic equinus deformity. Orthop Clin North Am 5:117–126

    CAS  PubMed  Google Scholar 

  • Rutz E, Baker R, Tirosh O, Romkes J, Haase C, Brunner R (2011) Tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy. Gait Posture 33:152–157

    Article  Google Scholar 

  • Saraph V, Zwick EB, Uitz C, Linhart W, Steinwender G (2000) The Baumann procedure for fixed contracture of the gastrosoleus in cerebral palsy. Evaluation of function of the ankle after multilevel surgery. J Bone Joint Surg Br 82:535–540

    Article  CAS  Google Scholar 

  • Segal LS, Thomas SE, Mazur JM, Mauterer M (1989) Calcaneal gait in spastic diplegia after heel cord lengthening: a study with gait analysis. J Pediatr Orthop 9:697–701

    Article  CAS  Google Scholar 

  • Sharrard WJ, Bernstein S (1972) Equinus deformity in cerebral palsy. A comparison between elongation of the tendo calcaneus and gastrocnemius recession. J Bone Joint Surg Br 54:272–276

    Article  CAS  Google Scholar 

  • Shore BJ, White N, Kerr Graham H (2010) Surgical correction of equinus deformity in children with cerebral palsy: a systematic review. J Child Orthop 4:277–290

    Article  Google Scholar 

  • Siegel IM (1988) Historical vignette #9. Little big man: the life and genius of William John Little (1810–1894). Orthop Rev 17:1156, 1161–1166

    Google Scholar 

  • Silfverskiold N (1923) Reduction of the uncrossed two joint muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand 56:315–330

    Google Scholar 

  • Strecker WB, Via MW, Oliver SK, Schoenecker PL (1990) Heel cord advancement for treatment of equinus deformity in cerebral palsy. J Pediatr Orthop 10:105–108

    Article  CAS  Google Scholar 

  • Tsang ST, McMorran D, Robinson L, Herman J, Robb JE, Gaston MS (2016) A cohort study of tibialis anterior tendon shortening in combination with calf muscle lengthening in spastic equinus in cerebral palsy. Gait Posture 50:23–27

    Article  CAS  Google Scholar 

  • Tustin K, Patel A (2015) A critical evaluation of the updated evidence for casting for equinus deformity in children with cerebral palsy. Physiother Res Int 22:e1646

    Article  Google Scholar 

  • Waugh TR, Wagner J, Stinchfield FE (1965) An evaluation of pantalar arthrodesis. A followup study of one hundred and sixteen operations. J Bone Joint Surg Am 47:1315–1322

    Article  CAS  Google Scholar 

  • Winters TF Jr, Gage JR, Hicks R (1987) Gait patterns in spastic hemiplegia in children and young adults. J Bone Joint Surg Am 69:437–441

    Article  Google Scholar 

  • Yngve DA, Chambers C (1996) Vulpius and Z-lengthening. J Pediatr Orthop 16:759–764

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

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  1. Freeman Miller
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Correspondence to Freeman Miller .

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Editors and Affiliations

  1. Alfred I. duPont Institute, Wilmington, DE, USA

    Freeman Miller

  2. Cerebral Palsy Program, AI DuPont Hospital for Children , Wilmington, DE, USA

    Steven Bachrach

  3. AI DuPont Hospital for Children , Wilmington, DE, USA

    Nancy Lennon

  4. Drexel University, PHILADELPHIA, PA, USA

    Margaret O'Neil

Section Editor information

  1. Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

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Miller, F. (2019). Ankle Equinus in Cerebral Palsy. In: Miller, F., Bachrach, S., Lennon, N., O'Neil, M. (eds) Cerebral Palsy. Springer, Cham. https://doi.org/10.1007/978-3-319-50592-3_199-1

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  • DOI: https://doi.org/10.1007/978-3-319-50592-3_199-1

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-50592-3

  • Online ISBN: 978-3-319-50592-3

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