Equinus: causes, diagnosis and treatment

Anatomy: Why the heel needs the ground

A healthy gait cycle requires sufficient dorsiflexion (elevation) of the foot in the upper ankle joint. This movement is made possible primarily by the stretchability of the calf muscles (gastrocnemius and soleus) and the Achilles tendon. When the heel lands, the load is distributed over the entire sole of the foot. If the heel phase is missing, the load moves to the forefoot - calluses, pain under the metatarsal heads and changed statics can result.

• Calf muscles (gastrocnemius/soleus) → Achilles tendon → heel bone
• Upper ankle joint: crucial for dorsiflexion
• Forefoot structures: tend to become overloaded and calloused under constant strain

What is equinus foot? Shapes and division

In equinus foot, the foot is fixed or preferred in plantar flexion and the heel remains elevated when walking. A distinction is made between flexible (still passively correctable) and fixed (structurally anchored) equinus feet. There are also dynamic forms, for example due to increased muscle tension (spasticity), and structural forms when muscle-tendon units are shortened.

• Flexible vs. fixed: passively correctable or not
• Dynamic (e.g. spastic) vs. structural (e.g. tendon shortening)
• Isolated equinus vs. combinations (e.g. equinovarus in clubfoot)

Causes and risk factors

The causes are diverse. There is often functional or structural shortening of the calf muscles and Achilles tendon. Children can have idiopathic tiptoe walking, which often becomes fused, but should be monitored and treated if necessary. Neurological diseases with increased muscle tension (e.g. cerebral palsy) often lead to spastic equinus.

• Muscular shortening: gastrocnemius/soleus contracture, shortened Achilles tendon
• Neurological: cerebral palsy, consequences of stroke, traumatic brain injury
• Orthopedic: Consequence of clubfoot, hollow foot (pes cavus), tarsal coalition
• After immobilization: longer immobilization in a cast/walker
• Everyday factors: long-term wearing of high heels, lack of stretch
• Metabolic/tissue: scarring, post-traumatic soft tissue changes

Symptoms and possible consequences

Walking on tiptoe is typical. Those affected can hardly put their heel down and their calves are often hard or painful. The forefoot load promotes calluses, corns and discomfort under the metatarsal heads (metatarsalgia). In the long term, this can lead to unsteady gait, frequent twisting and problems in the knees, hips or back.

• Toe walking, missing heel phase
• Forefoot pain, calluses and pressure points
• Calf tension, night cramps
• Unsteady gait, stumbling, ankle instability
• Accompanying deformities: hammertoes, hallux valgus (due to forefoot overload)

Warning signs – when to investigate?

• Heel cannot be brought to the ground even passively
• Rapidly increasing tiptoe walking in children
• Neurological abnormalities: spasticity, muscle weakness, numbness
• Recurrent falls or significant twisting of an ankle
• Painful pressure points, cracks, open areas on the forefoot

Diagnostics in our practice

At the beginning there is the exact anamnesis: how long has the toe walk been there, is it bilateral, have there been any injuries, neurological events or prolonged immobilization? During the clinical examination, we assess the gait, the mobility of the ankle joint and the soft tissue tension.

• Functional examination: degree of dorsiflexion, strength, coordination
• Silfverskiöld test: Difference between knee extended vs. flexed to differentiate gastrocnemius/soleus involvement
• Inspection of calluses and pressure zones, footprint analysis
• Imaging depending on the findings: X-ray for fixed deformities; Sonography of the Achilles tendon for tendon problems
• If a neurological cause is suspected: collaboration with neurology/neuropediatrics

Conservative therapy: treat gently at first

Most equinus symptoms can be addressed conservatively. The goal is to gain mobility, improve muscle balance and reduce forefoot overload. The therapy is planned individually and should be implemented consistently over a period of weeks.

• Physiotherapy: targeted stretching of the gastrocnemius/soleus, mobilization of the ankle joint, gait training
• Eccentric strength training of the calves and strengthening of the foot muscles
• Self-exercises: Calf and Achilles tendon stretches on the wall/stairs, 2–3 times daily
• Orthotic care: dynamic night splints/AFO if necessary, roll-off soles to relieve the forefoot
• Shoe advice: stable heel cap, sufficient drop, rocker sole if necessary; Avoid long-term high heels
• Serial casting (serial plastering), especially in children or spastic forms, to gradually gain length
• Pain and stimulus modulation: manual techniques, heat/cold according to instructions

Heel wedges can relieve Achilles tendon discomfort in the short term, but tend to increase plantar flexion. They should – if at all – only be used temporarily and specifically. Carrying out the exercises regularly and adapting your everyday routine (e.g. walking breaks, stretching routines) are crucial for success.

Injections and complementary procedures

In the case of spastic equinus foot, a temporary reduction in tone with botulinum toxin in the calf muscles can be considered - ideally combined with physiotherapy and serial casting to stabilize the mobility achieved. The effect is temporary and may need to be repeated if there is benefit.

• Botulinum toxin for spastic equinus: individual dose planning, time-limited effect
• No evidence for injections such as PRP to treat structural contracture
• The goal always remains to improve function through exercise therapy

Special situations: children, teenagers, adults

Children occasionally exhibit idiopathic toe walking without structural shortening. The focus here is on observation, playful gait training, stretching programs and, if necessary, occasional splints or plaster casts. For neurological causes, we work in an interdisciplinary manner and combine physiotherapy, orthoses and – if appropriate – botulinum toxin.

• Infancy: often flexible form; Follow-up and home exercises
• Neurological causes (e.g. cerebral palsy): combination therapy, individual aids
• Adolescents/adults: often structural after immobilization or years of high heels; consistent stretching and training therapy

Surgical options – rare, but sometimes useful

An operation can be considered if there is a relevant, everyday limitation due to a fixed equinus foot and conservative measures have been exhausted over a sufficient period of time. The choice of procedure depends on the structure affected (gastrocnemius vs. Achilles tendon) and the accompanying deformity.

• Gastrocnemius recession (e.g. Strayer): with isolated calf muscle shortening
• Achilles tendon lengthening (open or percutaneous multiple hemisection/Z-plasty): for combined contracture
• Combined soft tissue corrections in the context of complex deformities (e.g. club foot)
• In selected cases, bony corrections for accompanying axis errors

Risks and limitations are discussed in detail in advance. Possible complications include impaired wound healing, nerve irritation, over- or under-correction, persistent weakness or recurrence. The decision is always individual and evidence-based.

Follow-up treatment, rehabilitation and course

Depending on the technique, short-term immobilization, a functional splint/walker and a gradual increase in load are common after surgical procedures. Physiotherapy focuses on stretching, scar management, gait training and strengthening. The return to sporting activities takes place gradually and individually.

• Typical time frame: several weeks for everyday functions, months until full resilience is achieved
• Consistent stretching programs prevent recurrences
• Accompanying insoles/roll-off soles can reduce forefoot stress

Without surgery, endurance is required: an 8-12 week structured program with stretching, eccentric training and orthoses can noticeably improve mobility and gait. What is crucial is the continuous implementation and regular adjustment of the measures as the process progresses.

Everyday life, sport and prevention

Well-fitting, stable shoes with sufficient drop and a firm heel cap help in everyday life. Wearing very high heels for long periods of time should be avoided. Stretch your calves regularly - short, frequent sessions are effective. Activities with a controlled rolling movement and moderate stretching requirements are suitable for sports and leisure activities.

• Suitable sports: cycling, walking, swimming, moderate running training with technique training
• Home exercises: Calf wall stretch, stair stretch, towel/belt stretch – 2-3 times daily
• Stress control: Use pain as a guiding signal, avoid stabbing pain
• Workplace: alternating between sitting and standing, short breaks for movement and stretching

Have equinus foot treated – our approach in Hamburg

We combine careful diagnostics with a conservative, function-oriented therapy plan. This includes physical therapy, home exercises, shoe inserts/orthotics and, if necessary, serial casting or botulinum toxin. Surgical procedures are only considered if there is a clear indication and after joint decision-making.

• Individual assessment with gait and functional analysis
• Conservative measures first, clear treatment path
• Interdisciplinary collaboration on neurological causes
• Transparent information about the opportunities and limitations of each method