SLR - September 2022 - Douglas Holder, DPM
Reference: Liyanarachi S, Hulleberg G, Foss OA. Is Gastrocnemius Tightness a Normal Finding in Children?: A Cross-Sectional Study of 204 Norwegian Schoolchildren. J Bone Joint Surg Am. 2021 Oct 20;103(20):1872-1879.Level of Evidence: II
Scientific Literature Review
Reviewed By: Douglas Holder, DPM
Residency Program: The Jewish Hospital - Mercy Health, Cincinnati, OH
Podiatric Relevance: Isolated gastrocnemius tightness has been associated with a variety of chronic foot conditions and symptoms. There are a limited number of prior studies inspecting gastrocnemius tightness in healthy children and a normal range of ankle dorsiflexion has not been sufficiently explored. This study was designed to measure gastrocnemius tightness in healthy school age children and to investigate any association between ankle dorsiflexion and footprint.
Methods: Children from three Norwegian public schools were examined for this diagnostic study. Four different age groups were invited to participate: 5 to 6 years (group I), 8 to 9 years (group II), 11 to 12 years (group III), and 14 to 15 years (group IV). Gastrocnemius tightness was assessed via the Silfverskiold test. Ankle dorsiflexion was performed with and without the knee extended by an experienced orthopedic surgeon while another experienced orthopedic surgeon recorded the measurements by use of a digital goniometer. Footprints were obtained via an ink pad with bilateral weightbearing. The ink prints were used to calculate the Chippaux-Smirak Index (CSI). All calculations were performed via SPSS and the p value was set at ≤0.05. For each child, a measurement from one randomly selected leg was used for analysis.
Results: Two hundred four (204) children participated in the study. Mean ankle dorsiflexion with the knee flexed was 23.4 degrees on the left and 22.9 degrees on the right. Mean ankle dorsiflexion for girls was 22.4 degrees and 23.9 degrees for boys with the knee flexed. Mean ankle dorsiflexion with the knee extended was 5.0 degrees on the left and 4.9 degrees on the right. Mean ankle dorsiflexion for girls was 4.6 degrees and 5.2 degrees for boys with the knee extended. Between the four groups, ankle dorsiflexion with knee flexed and extended decreased as the age of the children increased. With equinus contracture defined as ankle dorsiflexion of ≤5 degrees compared to the knee extended, 238 feet were contracted. With equinus contracture defined as ankle dorsiflexion of ≤0 degrees compared to the knee extended, 15 feet were contracted. Four hundred eight (408) feet were examined using the footprint CSI analysis. Fifteen had a flat footprint, 340 had a normal footprint, and 53 had a cavus footprint. There were no clear associations between CSI and ankle dorsiflexion.
Conclusions: The study demonstrated the range of passive ankle dorsiflexion with the knee flexed and extended for four different age groups of children. The study showed that there was an association between the degree of dorsiflexion and age, with ankle dorsiflexion decreasing with increasing age. Limitations of this study include inaccuracies in performing the Silfverskiold test and intra-observer measurement errors. The authors propose that using age-matched norms for equinus is of high importance. Overall, the authors conclude that utilizing a stricter value of ≤0 degrees as the threshold for the Silfverskiold test will likely signify pathology in the clinical setting, when then should be addressed in a pathologic pediatric foot.