SLR - December 2016 - Vincent Mandas

Association Between Achilles Tightness and Lower Extremity Injury in Children

Reference: Liu RW, Xie KK. Association Between Achilles Tightness and Lower Extremity Injury in Children. HSS J. 2016 Oct;12(3):245–249

Scientific Literature Review

Reviewed By: Vincent Mandas, DPM
Residency Program: Grant Medical Center

Podiatric Relevance: Over the past decade, there has been an increased popularity in the podiatric community toward addressing equinus pathology when a patient presents with a foot or ankle injury. The mechanism of a tight gastroc/soleus pathology can further complicate a variety of foot and ankle conditions. Therefore, it is common practice for physicians to address this pathology in patients presenting with foot and ankle injuries. However, the benefits of addressing an isolated tight gastroc/soleus in an asymptomatic patient are less clearly defined. The literature is scarce regarding the consequences of having an isolated tight gastroc/soleus complex in an otherwise healthy child. The authors of the current study suspect that children presenting with foot and ankle injuries have a higher rate of gastroc/soleus tightness. The purpose of this study is to better define this potential relationship to provide a simple target for reducing rates of foot and ankle injuries in children.  

Methods: This cross-sectional study includes 206 children from walking age to 18 years old, who presented to a single-county orthopaedic clinic with new upper and lower extremity complaints. Children were separated into three groups: 1) Upper Extremity group (n=117): Any type of upper extremity complaint; 2) Lower Extremity Atraumatic group (n=40): Lower extremity complaint without evidence of inciting event within the past two weeks; and 3) Lower Extremity traumatic group (n=49): Lower extremity complaint after an inciting event within the past two weeks. Ankle dorsiflexion measurements were recorded and evaluated to identify the potential relationship between gastroc/soleus tightness and increased risk of lower extremity injury. A Chi-squared analysis was performed to compare the rates of gastroc/soleus tightness between the three groups. A multiple regression analysis was performed to determine the relative effects of age, sex and diagnosis group on ankle dorsiflexion. Gastroc/soleus tightness was defined as passive ankle dorsiflexion ≤ 0˚ based on the angle between the lateral border of the foot and a line perpendicular to the anterior border of the lower leg with the knee fully extended and foot inverted.

Results: Of the 206 children included in this study, 44 (21 percent) were diagnosed with gastroc/soleus tightness on the basis of passive ankle dorsiflexion ≤ 0˚. Measurements were performed by a single physician with good reproducibility indicated by an intraclass correlation coefficient of 0.87 by comparing the physician’s visual measurements to digital image measurements. There were significant differences in the prevalence of gastroc/soleus tightness between the three study groups. The average ankle dorsiflexion in the upper extremity group was 15.0° ± 11.6°, in the lower extremity atraumatic group, ankle dorsiflexion was 11.8° ± 14.5°, and in the lower extremity traumatic group, ankle dorsiflexion was 6.5° ± 12.0°. Gastroc/soleus tightness was identified in 12 percent (14/117) of upper extremity patients, in 25 percent (10/40) of lower extremity atraumatic patients and in 41 percent (20/49) of lower extremity traumatic patients. A chi-squared analysis revealed statistically significant differences when comparing the upper extremity group to the lower extremity atraumatic group (P < 0.048) and the lower extremity traumatic group (P < 0.001) respectively. After statistically factoring out the relative effects of age on ankle dorsiflexion, multiple regression analysis revealed high rates of gastroc/soleus tightness in children with lower extremity trauma.

Conclusions: The results of the current study support the authors prediction that children presenting with lower extremity injuries have a higher rate of gastroc/soleus tightness when compared to children presenting with upper or lower extremity complaints. The authors further evaluated data from the lower extremity trauma group, focusing on children with injuries specific to the foot and ankle. Interestingly, there was an even higher prevalence of gastroc/soleus tightness in these children with an average ankle dorsiflexion of 4.2° ± 10.9° and tightness found in 47 percent (15/32). Overall, this study suggests that children with gastroc/soleus tightness are predisposed to an increased risk for foot and ankle injuries, but this study merely documents an associated relationship and does not prove causality. 

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