Why It Is Crucial To Treat Equinus In The Diabetic Foot

It's getting to the point of absurdity. Despite the overwhelming literature regarding equinus, too few practitioners routinely evaluate and document it, and a shockingly low number treat equinus. Lack of a consistent definition and less than perfect methods of clinical measurement potentially explain the lackadaisical attitude toward equinus.

Frankly, these excuses do not resonate as authentic. Gatt and coworkers brought clarity to the proper evaluation technique (supinate the entire foot to eliminate midtarsal motion, isolating the dorsiflexion force to the hindfoot).¹ The authors also defined the relationship between clinical examination and dynamic function (less than 5 degrees of ankle joint dorsiflexion with the knee extended and the foot fully supinated resulted in substantially less ankle joint dorsiflexion at midstance than required for normal gait).

The podiatric profession continues to lead the way in prevention and treatment of diabetic foot ulcerations, saving both limbs and lives. This statement is not hyperbole. Diabetic foot examination with risk categorization, diabetic foot care, diabetic shoes and orthoses are the staples of preventative care in the patient with diabetes.

However, clinicians continue to ignore the prophylactic treatment of equinus deformity in the patient with diabetes despite the evidence-based research on the topic. It is baffling considering the universal acceptance of other preventative measures.

Searle and colleagues shone a light on this subject recently.² The authors stated, "If ankle equinus is found to contribute to high plantar pressures, then it could present an opportunity for earlier clinical detection of patients at risk of pressure-related foot ulcer and may also provide additional preventative treatment options for these patients." In this meta-analysis of 15 articles meeting the inclusion criteria, Searle and coworkers found that "Limited ankle joint dorsiflexion may be an important factor in elevating plantar pressures, independent of neuropathy."²

In their conclusion, Searle and colleagues leave little doubt about the importance of this topic.

"Routine screening for limited ankle dorsiflexion range of motion in the diabetic population would allow for early provision of conservative treatment options to reduce plantar pressures and lessen ulcer risk."²

It is time for the profession to take action on behalf of our patients with diabetes. Treatment of a diagnosed equinus as part of a diabetic foot examination must become the default action. Those who lecture on the diabetic foot must embrace this as part of their message while educating lower extremity healthcare providers. In the instance of a healed diabetic forefoot ulcer with an underlying equinus deformity, treatment of the equinus must become mandatory on the part of both the clinician and patient.

The time is now for diabetic lower extremity healthcare providers to elevate preventative care in this at-risk group of patients to the next level by providing simple and effective treatment of equinus deformity.

References

1. Gatt A, DeGiorgio S, Chockalingam N, Formosa C. A pilot investigation into the relationship between static diagnosis of ankle equinus and dynamic ankle and foot dorsiflexion during stance phase of gait: Time to revisit theory? Foot. 2017; 30:47-52.
2. Searle A, Spink MJ, Ho A, Chuter VH. Association between ankle equinus and plantar pressures in people with diabetes. A systematic review and meta-analysis. Clin Biomech. 2017; 43:8-14.