Acute Achilles tendon rupture: Do cast boots produce adequate equinus when used for functional rehabilitation?

Acute Achilles tendon rupture is frequently treated conservatively using functional rehabilitation protocols in which the ankle is held in equinus. Equinus is achieved using a variety of means including equinus casts and rigid boots with heel wedges. Concerns have been raised that rigid boots with heel wedges do not achieve adequate equinus. Patients presenting to our institutions with an acute Achilles tendon rupture were randomised to treatment with an equinus cast or rigid boot with heel wedges. After application of these lateral radiographs of the hindfoot and ankle were taken, and these used to measure tibiotalar angle (TTA), tibio-1st metatarsal angle (TMA) and posterior malleolar to calcaneal tip height (PCH). 15 patients were randomised to a rigid boot and 14 to an equinus cast. The mean TTA was 124° in the rigid boot group and 136° in the equinus cast group (p<0.001). The mean TMA was 134° in the rigid boot group and 147° in the equinus cast group (p<0.001). The mean PCH was 25mm in the rigid boot group and 15mm in the equinus cast group (p<0.05). Our results demonstrate that the rigid boots with heel wedges used in our institutions produce significantly less equinus than an equinus cast. Whilst the clinical relevance of this remains uncertain, clinicians should be aware that rigid boots with wedges and equinus casts may not achieve the same degree of Achilles tendon shortening.

Long-Term Outcome of Open Plantar Fascia Release.

BACKGROUND: Plantar fasciitis is thought to be a self-limiting condition best treated by conservative measures, but despite this many patients have a prolonged duration of symptoms and surgery may be indicated. Partial plantar fascial release is reported to have a short-term success rate of up to 80%, but anecdotally this was not thought to represent our local experience. METHODS: An audit of long-term patient-reported outcomes following open partial plantar fascia release was performed. A total of 30 patients (33 feet) were identified over a 10-year period and case notes were reviewed. Patients were contacted by letter and invited to complete 2 validated patient-reported outcome score questionnaires (Visual Analog Scale-Foot and Ankle [VAS-FA] and Manchester Oxford Foot Questionnaire [MOXFQ]). Responses were received from 24 patients (26 feet). The average ages were 42.4 (range 24-61) for male and 46.2 (range 33-60) for female patients, with a female/male ratio of 2.7:1. The average duration of treatment prior to operative intervention was 3.1 years (range 1-5). Preoperatively, our cohort underwent a range of conservative measures. All patients were reviewed postoperatively, and average time from surgery to completion of questionnaires was 80 months (range 14-130). RESULTS: The outcomes were worse in patients who had received preoperative steroid injections and this was found to be statistically significant. The mean MOXFQ score was 33.6 ± 3.9 (0-64). Mean VAS-FA score was 57.8 ± 4.9 (24-100). CONCLUSION: This study found a negative correlation between duration of follow-up and outcome, in both MOXFQ and VAS-FA, showing that patients continued to improve many years postoperatively. The authors also found worse outcomes with preoperative steroid injections, better outcomes in older patients, and a weak gender bias, suggesting results in men were better than those in women. A prolonged recovery period and generally poor outcomes leads the authors to suggest that open plantar fascia release is of questionable clinical value and that patients may improve in the natural course of the disease, in spite of surgery. LEVEL OF EVIDENCE: Level III, comparative study.