Dr. DeHeer's thoughts on "The gastrocnemius: a new paradigm for the human foot and ankle"

Article: The gastrocnemius: a new paradigm for the human foot and ankle

Amis, James. Foot and ankle clinics 19.4 (2014): 637-647

Abstract Link: http://www.foot.theclinics.com/article/S1083-7515(14)00090-4/fulltext

 

Key Points:

  1. There is significant literature to support the role of equinus on numerous lower extremity pathologies
  2. Often physicians are treating the symptoms and not the underlying cause, which is often equinus
  3. The literature supports stretching of the Gastrocsoleal complex as an effective method to treat equinus and associated pathologies
  4. The role of equinus in lower extremity pathologies has been described in literature for over 100 years
  5. The origins of calf contracture fall into one of four categories: activity changes, physiological changes, genetics and reverse evolution.
  6. Activity changes consist of three subcategories:
    1. Decreased activity with age – the GSC muscle-tendon unit (MTU) fails to reach maximum length with any regularity and thereby contracts to the shortest position possible (Law of Davis)
    2. Recent changes in activity (bed rest due to illness or recovery from surgery/injury/pregnancy) – abrupt reduction in normal mobility resulting in little or no tension being placed on the GSC resulting in tightening (Law of Davis)
    3. Athletes (especially distance runners) – during running the GSC and hamstrings are never fully extended while the ankle is being dorsiflexed resulting in adaptation to this shortened position
  7. Physiologic changes to muscle and tendon – normal changes with aging to collagen (cross-linking) and connective tissue (less compliant and decrease in elastin) locking the MTU in a shortened position
  8. Genetics – some people have tighter muscles than others
  9. Reverse evolution –
    1. Humans evolved from quadrupeds to bipeds approximately 2.2 to 3 million years ago, prior to that bipedal gait was used only occasionally
    2. The ankle had to dorsiflex approximately 70° for bipedal gait to get the heel down to the ground and the foot plantigrade – puts the foot in a biomechanically disadvantaged position shifting from a vertical compressive load to a vector leveraged/bending load (compression on the dorsal aspect of the foot and anterior ankle, and tension on the plantar aspect of the foot and posterior ankle)
    3. The knee and hip had to extend
    4. Certain muscles lengthened (hip flexors, GSC and hamstrings) while opposing muscles shortened (quadriceps and anterior tibial tendon)
    5. This whole process took place later during evolution, therefore with aging these later lengthening muscles (hip flexors, hamstrings, GSC) are the first to tighten up with aging
    6. This process is termed the Predilection Pattern
  10. A negative Silfverskiöld test may not exclude the gastrocnemius as the cause for an underlying lower extremity pathology
  11. Contracture of the gastrocnemius for several reasons tightens with age, which leads to incremental damage to the foot and ankle

 

DeHeer’s Opinion: I think these quotes from the discussion section in this landmark article that sums things up best, “It seems that merely being human places a risk for developing acquired foot and ankle problems. This damage is mediated through the gastrocnemius that tightens for several reasons with age and these same contracted calves do incremental harm to the human foot and ankle.” “Considering this knowledge, I assert, if not challenge, that the calf is a common source of a majority of acquired, nontraumatic adult foot and ankle problems, such as plantar fasciitis, nontraumatic midfoot osteoarthritis, insertional Achilles tendinosis, posterior tibialis tendon dysfunction, and Achilles tendinitis, to name a few.” These are bold statements that with each passing article on equinus provides backing for Amis’ statements. I have put together a list of pathologies associated with equinus that now numbers over 140 references (http://www.fixequinus.com/pages/related-pathologies). The take home message is walking upright combined with factors such as aging and reverse evolution makes equinus a very common pathological condition that most of the population develops.



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