Foot & Ankle International - July 2016 - (Page 790)

654966 FAIXXX10.1177/1071100716654966Foot & Ankle InternationalLetter to the Editor letter2016 Letter to the Editor Letter Regarding: Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia Dear Editor: With great interest we read the article by Morales-Muñoz and colleagues.10 The authors reported a prospective case series of 78 patients suffering mechanical metatarsalgia due to isolated M. gastrocnemius tightness (MGT). All patients were treated by a proximal release of the medial gastrocnemius.3 At 6 months' follow-up, the mean AOFAS score was 84 points (preoperative: 47 points), with nearly 70% of patients being completely satisfied. No major complications were reported. Morales-Muñoz et al10 defined impaired ankle dorsiflexion (ADF) as ADF values d0° with the knee extended. Preoperative mean ADF values were −17.5° (range −30° to −5°). Previous studies defined impaired ADF between 0° and 12° with the knee extended.4,6,12 In their keystone paper, DiGiovanni et al4 conducted a prospective case-control study and reported average ADF values of 4.5° in their patient group (metatarsalgia or related midfoot/forefoot symptoms) and 13.1° in their healthy control group. Despite similar patient cohorts, the mean ADF values reported by Morales-Muñoz et al10 and DiGiovanni et al4 differ by more than 20°. Although surprising at first glance, these pronounced differences are most likely due to the different testing protocols conducted to assess ADF. Although both authors applied nonweightbearing testing, Morales-Muñoz et al10 conducted their measurements with the "subtalar joint supinated," the anatomic landmarks applied were the "shaft of the fibula and lateral border of the foot," and a goniometer was used. One investigator conducted the measurement, as indicated in Morales-Muñoz et al's Figure 1. DiGiovanni et al,4 on the contrary, used an equinometer, locked the midfoot, and ensured neutral hindfood position, applied a constant torque of 10 Nm and used the fibula and plantar aspect of the foot as measurement landmarks. These are just 2 of numerous measurement techniques reported in literature. Testing protocols vary in almost every aspect, the general setup (nonweightbearing,2 weightbearing,11 and instrumented5), the measurement landmarks used (y-axis: fibula, tibia, or Achilles tendon,1,13,14 x-axis: shaft of the fifth metatarsal bone, plantar aspect of the foot, or the floor8,9,13), and the measurement devices used (mobile apps, inclinometers, or goniometers1,7,14). Clearly, each single aspect has a pronounced influence on the ADF values measured. Moreover, some protocols appear more applicable than others. Morales-Muñoz et al,10 for example, had one investigator controlling foot position, applying maximum ankle dorsiflexion and conducting the Foot & Ankle International® 2016, Vol. 37(7) 790-791 © The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100716654966 fai.sagepub.com measurements. From our own clinical experience, we find it hard to conduct all of these maneuvers at once. Despite the promising treatment approach to MGT reported by Morales-Muñoz et al,10 the examination technique and equinus ADF values reported highlight the major shortcoming in current research on MGT. In order to identify patients suitable for gastrocnemius release and to interpret the results of different procedures in various pathologies, standard techniques to assess ADF should be applied. Currently, various tests are being used to assess ADF. Therefore, the informative value of the studies as well as the comparability between studies suffers considerably. We are convinced that it is essential to first agree on a standardized technique to quantify ADF. Further, using this standardized technique's physiological and pathological norm values should then be defined. These values build the prerequisite for any treatment study. Therefore, we would like to emphasize the need to agree on a standardized, evidence-based examination technique to assess ADF and MGT. Sebastian F. Baumbach, MD Mareen Braunstein, MD Hans Polzer, MD Munich University Hospital Department of Trauma Surgery Nussbaumstr. 20 80336 Munich, Germany Email: hans.polzer@med.uni-muenchen.de References 1. Baumbach SF, Brumann M, Binder J, et al. The influence of knee position on ankle dorsiflexion-a biometric study. BMC Musculoskelet Disord. 2014;15(1):246. doi:10.1186/14712474-15-246. 2. Bolívar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot Ankle Int. 2013;34(1):42-48. doi:10.1177/1071100712459173. 3. De Los Santos-Real R, Morales-Muñoz P, Payo J, Escalera-Alonso J. Gastrocnemius proximal release with minimal incision: a modified technique. Foot Ankle Int. 2012;33(9):750-754. doi:DOI: 10.3113/FAI.2012.0750. 4. DiGiovanni CW, Kuo R, Tejwani N, et al. Isolated gastrocnemius tightness. J Bone Joint Surg Am. 2002;84-A(6):962-970. 5. Gatt A, Chockalingam N. Validity and reliability of a new ankle dorsiflexion measurement device. Prosthet Orthot Int. 2013;37(4):289-297. doi:10.1177/0309364612465886. http://www.sagepub.com/journalsPermissions.nav http://fai.sagepub.com

Table of Contents for the Digital Edition of Foot & Ankle International - July 2016

TOC/TOC/Verso
Editorial Board
Advertiser Index
Long Term Follow-up of a Randomized Controlled Trial Comparing Scarf to Chevron Osteotomy in Hallux Valgus Correction
Clinical Outcome and Fusion Rate following Simultaneous Subtalar Fusion and Total Ankle Arthoplasty
Anterior Heterotopic Ossification at the Talar Neck After Total Ankle Arthroplasty
Secondary Arthrodesis After Total Ankle Arthroplasty
Functional Outcomes Following First Metatarsophalangeal Arthrodesis
Increased Reduction Clamp Force Associated With Syndesmotic Overcompression
Pain Threshold Tests in Patients With Heel Pain Syndrome
Long-term Results of Chronic Achilles Tendon Ruptures With V-Y Tendon Plasty and Fascia Turndown
Peroneal Tendon Abnormalities on Routine Magnetic Resonance Imaging of the Foot and Ankle
Incisura Morphology as a Risk Factor for Syndesmotic Malreduction
Total Arthroplasty of the Metatarsophalangeal Joint of the Hallux
Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy
Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act
Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia
Gastrocnemius Proximal Release in the Treatment of Mechanical Metatarsalgia: A Prospective Study of 78 Cases.
Response to "Letter Regarding: Gastrocnemius Proximal Release in the Treatment of Mechanical Metatarsalgia"
The Internal Brace for Midsubstance Achilles Ruptures
The Evolution of Patient Safety
Education Calendar
Foot & Ankle International - July 2016

Foot & Ankle International - July 2016