A couple of years ago in our clinic a rotating 29 year old female orthopaedic resident started to present a new patient to me out in the hall and before she could get much out I interrupted her and said “let me guess, a 56 year old female?”. She reacted a bit like I was patient profiling, which I was, making such a bold statement with little, if any information. She responded as politely as possible in her heavy Tennessee accent “now Dr. AO, how can you say something like that?”. “Because I am probably right”, I responded. She then had to reluctantly admit that the patient on the other side of that door was indeed a 55 year old female.
“…in her heavy Tennessee accent ‘now Dr. AO, how can you say something like that?'”
Fast forward, after this same resident has been around for a couple of weeks in my world and back in the same hallway with another new patient. I ask “what do you have?” referring to the patient on the other side of the door. She responded with a resigning attitude “Another 56 year old female!”.
BOOM, told ya!
The scientific evidence has existed for years and is mounting by the day that the isolated gastrocnemius contracture (AKA, equinus) is here and it is real and it is causing the majority of non-traumatic acquired foot and ankle pathology we see. This is the very thing I have promoted for all 30 years of my practice and on this site. But I digress. Back to the 56 year old.
Not to sound creepy, but I could make and sustain a busy orthopaedic practice by seeing only women in their fifties and sixties. Why? Around 45 and increasingly thereafter is when the cumulative effects of long standing and increasing isolated gastrocnemius contractures start to become noticeable and symptomatic in many forms, more in women more than men, in general. And 56 seems to be the perfect age.
The two most common problems I see in the 56 year old female, without question, are second MTP synovitis and midfoot arthritis. Other problems in all ages resulting from an isolated gastrocnemius contracture, and in general, are start up pain and stiffness, plantar fasciitis, Sever’s disease, shin splints, posterior tibialis tendon rupture (PTTR) acquired flatfoot deformity, second MTP synovitis which leads to plantar plate rupture and ultimately a hammer toe, Morton’s neuroma, insertional Achilles tendinosis/Haglund’s deformity, Achilles tendinitis, musculotendinous Achilles ruptures, calf cramps at night/Charley horse, anterior ankle spurs, Jones/Fifth MT stress fracture, diabetic Charcot arthropathy, diabetic malperforans ulcer formation, and lesser metatarsal stress fractures.
Here is the problem. People, including the majority of my doctor colleagues, either don’t know or don’t believe, even though the evidence is there and is solid. It is too bad because the secondary foot or ankle problem naturally becomes the focus of treatment, which might make a person feel somewhat better, but it will not fix the primary problem, the isolated gastrocnemius contracture. Ever wonder why plantar fasciitis seems to just linger on or mysteriously returns when you have “tried everything”?
Let me be clear on the next point: WE ARE TREATING THE WRONG THING. And it is wasting loads of money and time for all you out there suffering.
“WE ARE TREATING THE WRONG THING”
On a final note, of my few colleagues who get that the isolated gastrocnemius contracture is the problem, want to guess what their solution is? Surgery to lengthen the Achilles or the gastrocnemius, of course. Don’t get me wrong, I surgically lengthen the gastrocnemius as well, but only after clear cut failure of dedicated daily gastrocnemius stretching, which works just fine most of the time.
Why would somebody take on the expense and obvious risk of any surgery when it can be avoided in most cases. All it takes is ONE simple exercise, daily calf stretching and some patience.
This is for all you lovely 56 year olds. I love ya. Now stretch!
Be a believer,
AO
I came across this blog and I am a 58 year old female who in the past four months has developed feet problems! First diagnosis was Metatarsalgia with no imaging. Then Morton’s neuroma after an ultrasound. Still limping so after an MRI dx with bone edema and microstress fracture of Fifth Metatarsal. I was given a CAM boot yesterday and am miserable. Already have back and hip issues. Anyway, I don’t want to waste your time but didn’t find a search function for your site. It looks like you’re still answering comments so if you could direct me to anything you’ve already written on stress fractures I’d appreciate it! I have been in PT through this ordeal and calf stretches have been the one thing I thought was helping. My PT person is on vacation and I’m not sure what if anything I can do regarding stretching. I have arthritis in my ankles and I’m afraid of it getting stiff if I don’t move it. Thanks in advance!
Found search function! But would still love input on 5th metatarsal stress fractures!
Hi Barb,
You are a late bloomer two years over 56. But it is never too late for equinus to jump up and bite you in the butt. I also know you found my new and improved search function. Pretty cool, huh?
Let’s say you do have a 5th metatarsal stress fracture? Interesting for 58, but entirely possible. You have touched on a subject I have not commented on much in the past. My experience over the past 20 years, supported by a smidge of evidence, is that the 5th metatarsal stress fracture (often mislabeled as a Jones fracture) is entirely secondary to equinus. This thought is completely dissenting and everyone would say this is crazy. However, I have soccer moms, NFL, MLB, collegiate players and just regular people who would argue this point for me. And hey, this is my site and I get to talk about it.
Many 5th metatarsal stress fractures still need surgery, usually an intramedullary screw. Surgery depends on where you are in the process. In your case, if they needed an MRI to detect it you are likely a prime candidate for calf stretching as your primary treatment. Regardless of your diagnosis, I say the odds are that your problem is stemming from equinus and calf stretching your treatment. Of note, I designed the Jones screw for an orthopaedic device company and in all good faith, I still root against its use because there is often better treatment available.
It sounds like you’re feeling it already. Calf stretching is really magical and I am quite certain it is your answer. However, even though I doubt you have a stress fracture (dorsal pain, swelling), you need to stretch making sure to contact under the arch of your foot to go easy on the metatarsals. Go easy, take your time and be patient and you will be amazed.
Please let us know how things go, although I already know how this story plays out.
Stay healthy my friends,
AO
I am so excited you saw my comment and responded! Thank you! My podiatrist only spent 20 seconds with me and sent me home with a boot. I’m thinking I may need to get a second opinion on what kind of stress fracture/if it truly is one or see if I can get her to spend a bit more time with me. I do have a physical therapist who is very much into calf stretching and looking above the foot for issues. That is good. She was very reassuring to me yesterday and thought the boot might be overkill, although she said she can’t say because she’s not a doctor. If I get another opinion do you think it matters if I try another podiatrist or go with an orthopedic doc?
Hi Barb,
You are excited and I am angry! What is that all about? I love your PT and they know these things. Here is some useful information regarding the use of the boot. First, your doc believes you have a “Jones” or a 5th metatarsal stress fracture, and you may. The question is how symptomatic are you? If little and you are wearing because you were told and you can easily get by without, then do without. This is just common sense, which lots of us docs lack. Possibly, in this case, the MRI is being treated, not the patient. It is remarkable how often this occurs. Of course, if you are symptomatic enough to require the boot, then, by all means, wear it.
Fifth MT (proximal middle third region) stress fractures can symptomatically range from acutely painful requiring a boot because it is just a bit sore and one can get around quite well without a boot. Based on the evidence, the status quo treatment algorithm is to boot these and they heal in time (8-12 weeks) or they fail and they go to surgery. Frankly, I have nothing against that treatment except it never addresses the underlying cause.
However, about twenty years ago, once I determined the causal relationship between these fractures and equinus, I took a different path. I started to bucket patients into three groups: (1) those who were less symptomatic and could manage without immobilization in a boot or cast (~40%), (2) those who needed help now to keep active (~30%) who went into the boot, and (3) those who needed surgery (~30%). The latter group were acute on chronic “injuries”* meaning they were mysteriously sore for a few weeks and then a minor twist or turn and the stressed area of the 5th MT finally completed itself and broke through. No amount of calf stretching was going to solve their problem and they usually required surgery. These tend to be the more athletic group.
The first two groups got the same treatment whether they were in a boot or not. They were put on my calf stretching protocol. My results are purely anecdotal (but true none the less) and would be frowned upon as such, but this is my website and I get to post this stuff. About 95% of these patients, those who actually did the calf stretching (some can’t be convinced), ultimately became pain-free and returned to all their “pre-injury” activities. This took anywhere from a couple weeks to as much as 3 months (ave. 4-6 weeks) for the more symptomatic cases. What can I say, the rest of the orthopedic and podiatric community has this one wrong, in my not so humble opinion.
Stay healthy my friends,
AO
* “Injuries” is in quotes because these are not injuries or overuse syndromes. An injury is a car accident or twisting your ankle. The problems I discuss here are erroneously called injuries and/or overuse syndromes. They are what I have described in the literature as overuse syndromes of muscular imbalance. Simply put the balance is off and in time there is incremental damage and eventually, there are symptoms. Please read my blogs The Bad Rap On Inflammation, Part 1 and Part 2.
Wow! Hi AO – maybe I have stumbled across the solution after countless hours searching the internet for answers! I am a 55yo female and my feel got horribly sore about six months ago and then got worse. I can barely hobble in the mornings and eat painkillers to get about my busy life. I’ve been to a podiatrist, two doctors, a surgeon (told him there would be nothing being cut) and a orthotic person who sold me expensive titanium plates that are too hard and painful to walk on. Oh and now a physio guy. I have had xrays and ultrasounds, they don’t think it’s arthritis but nobody seems to knows what it is. I shall start the stretches!
Thank-you!
Tracy
Hi Tracy,
Yep, you are experiencing the standard foot and ankle vortex, and you are so wise to question (everyone, except for me, ha). Definitely get with the calf stretching and soon you will be 39 again. Be patient and you will not be disappointed. Then reach out to the world and tell them how incredibly stupid, simple this stuff is. My vision is a world in the future where you know this, because it is common knowledge, and you just start stretching with no medical visits. Equinus is that common and stretching works that well, but you will not hear any of that from the mainstream. Pity.
Stay healthy, my friends,
AO
Hi AO,
I have a question about equinus. Is it still possible to have it if you have normal ankle dorsiflexion? I’m not a 56-year old female, I’m a 43-year old female with an 8-year history of debilitating foot pain. It seems to help a lot to release my calves with a lacrosse ball (“calf smash”), but I’m not having as much luck with stretching. I tried your calf stretch on a stair, very carefully following the instructions (e.g. putting the arch on the edge of the step), and couldn’t even feel a stretch in one of my legs, and in the other leg there was barely anything. Plus I have good ankle dorsiflexion. I just wonder if I have this contracture you talk about or not.
Thanks,
Sara
Hi Sara,
First off, I do not have a clue what you have, but I hear ya. I do know that no matter what you feel (or don’t feel) when you stretch, or what your problem is, calf stretching can’t hurt you and given time, calf stretching will still likely solve your problem even though you sense it is not accomplishing much. Indeed, your yield may go down if you don’t feel you have equinus as you claim, but I have seen too many patients succeed with your story.
I get that you can’t feel a stretch and you note that you have good, if not excessive ankle dorsiflexion (DF). However, in my opinion subtle equinus is basically not quantifiable by testing as normal and abnormal. My colleagues continue to be obsessed with testing attempting to quantify whether a patient has equinus or not. This is just unnecessary as you will see.
I take a completely different approach as my colleagues regarding equinus. First and foremost, I do not test for equinus, I just treat. This whole subject makes me angry, so I will be blunt. If a patient has one of the 20 non-traumatic acquired foot and ankle pathologies (all are easy enough to diagnose) caused by equinus then THEY HAVE EQUINUS by default and they stretch their calves. Of course, if the issue is more advanced then I treat more aggressively as needed, for sure. When I see smoke I know there is a fire and I don’t need some test to guide me on that one.
So, why would I not test when everyone else is testing? While following the herd is boring, I am quite certain that each of us has our own ankle DF that is acceptable or normal for us while the next person has ankle DF requirement that is completely different. I am also quite certain that this lack insight is exactly why there are so many published articles looking at measuring ankle DF attempting to defining equinus, yet there is still no consensus. Could it be they are barking up the wrong tree? When it comes to equinus, different strokes for different folks and one number for “normal” cannot be applied. Yes, I just said that and want to go on record as such. In fact, I am on record having peer review published on this very subject.
So, as an example, you Sara sound like you are on the upper end of the DF spectrum where, say 20 degrees of ankle DF is present, which would, by testing, indicate that there is no equinus present, right? So, in the current prevailing, wrong paradigm you would not address or be told to address equinus because it is not present. NO wonder so many people fail so many treatments. Yet, you may have an 8-year history of debilitating foot pain that by my definition, by your diagnosis whatever it is, you likely have equinus. Then there is the person with only 2 degrees of ankle DF who goes thru life never having one of the 20 non-traumatic acquired foot and ankle pathologies that are caused by equinus. Thus, there is no equinus.
Finally, you might ask, “would it not be advantageous to know before one has one of these problems?” Well, yes, but would you really know with testing? NO! So, my answer if you are the kind of person that would like to know, is forget knowing and stretch proactively. If you choose to not know, then if and when you have an equinus related issue start stretching immediately.
Whew, that was round the world. Please let me know if this does not make sense.
Stay healthy, my friends,
AO