BACKGROUND:Rehabilitation protocols following medial patellofemoral ligament (MPFL) reconstruction were historically restrictive, with patients often immobilized and/or given weightbearing restrictions. However, more recently published protocols have been more aggressive. We compared patient-reported outcomes and recurrent dislocation risk between patients treated with a restrictive rehabilitation program (early post-operative bracing and weightbearing restrictions) and an accelerated rehabilitation protocol (no post-operative bracing or weightbearing restrictions) following MPFL reconstruction. METHODS:Patients who underwent isolated MPFL reconstruction at an academic center between 2008 and 2016 were identified. Patient demographics, anatomical measurements, surgical details, and outcomes were collected. During this period, the rehabilitation protocol at the center transitioned from a restrictive to an accelerated rehabilitation protocol. Failure risk and patient-reported outcomes were compared based on rehabilitation protocol. RESULTS:Of the163 isolated MPFL reconstructions performed during the study period, 123 (75%) were available for minimum one-year follow up at a mean of 4.0 years post-operative. Overall, 53 knees (43%) underwent the accelerated rehabilitation protocol and the remaining 70 knees (57%) underwent the restrictive protocol. There were 3 recurrent dislocations during the study period (2.4%), all of which occurred in the restrictive rehabilitation group. Multiple linear regression demonstrated that being in the accelerated rehabilitation group was not associated with poorer Knee injury and Osteoarthritis Outcome Score (KOOS) subscales controlling for age, sex, body mass index, Caton-Deschamps Index, tibial tubercle-trochlear groove distance, sulcus angle, MPFL graft choice, and length of follow-up. CONCLUSION:An accelerated rehabilitation protocol without immobilization or weightbearing restrictions does not increase risk of recurrent patellar dislocation or poorer patient-reported outcome following isolated MPFL reconstruction.

Purpose:To evaluate the recurrent dislocation risk and patient-reported outcomes of peroneus longus allograft tissue for medial patellofemoral ligament (MPFL) reconstruction.Methods:Patients who underwent MPFL reconstruction with peroneus longus allograft at an academic center between 2008 and 2016 were identified. Record review and patient contact were used to identify any cases of recurrent patellar dislocation and collect patient-reported outcomes scores (Knee injury and Osteoarthritis Outcome Score [KOOS], Norwich Patellar Instability score, Marx activity scale). Patients with 1-year minimum follow-up were included. Outcomes were quantified and the proportion of patients reaching a previously defined patient acceptable symptom state (PASS) for patellar instability was determined.Results:Sixty-one patients (42 female and 19 male) underwent MPFL reconstruction with peroneus longus allograft during the study period. Forty-six patients (76%) with 1-year minimum follow up were contacted at a mean of 3.5 years postoperative. The mean age at time of surgery was 22 ± 7.2 years. Patient-reported outcomes data were available in 34 patients. Mean KOOS subscale scores were as follows: Symptoms 83.2 ± 19.1, Pain 85.2 ± 17.6, Activities of Daily Living 89.9 ± 14.8, Sports 75 ± 26.2, and Quality of Life 72.6 ± 25.7. The mean Norwich Patellar Instability score was 14.9% ± 17.4%. The mean Marx activity score was 6.0 ± 5.2. No recurrent dislocations were noted during the study period. Sixty-three percent of patients who underwent isolated MPFL reconstruction met PASS thresholds in at least 4 of 5 KOOS subscales.Conclusions:The use of a peroneus longus allograft in MPFL reconstruction in conjunction with other indicated procedures results in a low re-dislocation risk and a high proportion of patients meeting PASS criteria for patient-reported outcome scores 3 to 4 years postoperatively.Level of Evidence:IV, case series.

Background: Patella alta and elevated tibial tubercle–trochlear groove (TT-TG) distance can predispose patients to lateral patellar dislocations and recurrent instability. Their influence on patient-reported outcomes (PROs) after medial patellofemoral ligament (MPFL) reconstruction is less clear. Hypothesis: We hypothesized that neither moderately increased TT-TG distance nor patella alta would negatively affect PROs after isolated MPFL reconstruction in patients with relatively normal patellar tracking (no large J-sign). Study Design: Cohort study; Level of evidence, 3. Methods: We identified patients who underwent isolated MPFL reconstruction at a single institution between 2008 and 2016. The decision to perform an isolated MPFL reconstruction was at the discretion of the operating surgeon but was not performed in the setting of a large J-sign. Patient characteristics and surgical details were collected, and patients completed the Norwich Patellar Instability Score, Knee injury and Osteoarthritis Outcome Score, and Marx activity score. Patellar height (Caton-Deschamps Index [CDI]) was assessed on preoperative lateral radiographs, and TT-TG distance was measured on preoperative axial magnetic resonance imaging (MRI) scans. Patients were grouped based on CDI and TT-TG distance, and outcomes were compared. Linear regression modeling was performed to determine whether patella alta or elevated TT-TG distance was associated with poorer PRO scores. Results: Of 165 knees in 152 patients who underwent isolated MPFL reconstruction, 115 patients (125 knees; 76%) with minimum 1-year follow-up were contacted at a mean of 5.2 years after surgery. Recurrent dislocation occurred in 5 of 125 knees (4%). Preoperative radiographs were available in 111 knees (89%), and preoperative MRI scans were available in 89 knees (71%). Mean CDI was 1.13, and 35% had a CDI ≥1.20. Mean TT-TG distance was 17.5 mm, and 26% had a TT-TG distance >20 mm. After adjusting for patient age, sex, body mass index, and graft choice, we observed that neither patella alta nor elevated TT-TG distance were associated with poorer PROs. Conclusion: Isolated MPFL reconstruction in the setting of moderately elevated TT-TG distance or patella alta was not associated with worse PROs in this cohort with relatively normal patellar tracking (no large J-sign).

Plantar fasciitis is a common cause of heel pain that is seen by both orthopedic surgeons and primary care providers. It is a condition that was previously thought to be because of inflammation of the plantar fascia but has more recently been linked an equinus contracture of the gastrocnemius muscle. The condition can be handled both conservatively and surgically, with the primary management being nonoperative. For operative interventions, the treatment of choice was classically a plantar fasciotomy. Over the past several years, the gastrocnemius recession has become an operative treatment of choice. The gastrocnemius recession has shown better symptom relief with less morbidity. The technique to perform a gastrocnemius recession is described within the chapter, as well as the postoperative management. In the future, the duration of nonoperative management for recalcitrant disease may be reduced. However, more randomized control trials showing positive results of the gastrocnemius recession may allow for shorter nonoperative management period creating a new standard treatment algorithm. Level of Evidence: Diagnostic level I, systematic review of studies.

Background The Lapidus procedure has become a popular procedure in correcting hallux valgus deformities and has undergone several modifications in an effort to improve the efficacy of the procedure. The senior author modifies this procedure with the addition of an intermetatarsal and intercuneiform fusion. Our hypothesis is that this will improve the procedure outcomes and decrease deformity recurrence. Methods We reviewed patient charts who underwent the procedure between 2014 and 2017 performed by the senior author. This yielded 47 reviewable cases, with 34 meeting study criteria. The cases were analyzed for standard hallux valgus measurements (intermetatarsal angle [IMA], hallux valgus angle [HVA]) and fusion on X-ray. Results The results of the study showed partial intermetatarsal and intercuneiform fusion failure in seven (20%) cases, and one case where the great toe fell into varus. These cases were excluded. In the remaining cases, there was a statistically significant improvement in the HVA and IMA between the preoperative X-ray and first postoperative X-ray. Additionally, there was no significant difference between HVA and IMA between first and final postoperative radiographs. There was a significant increase in IMA for the fusion failure cases (p=0.001). Conclusion Clinically, our findings demonstrate that successful union is possible with low recurrence and complication rates when using this modification of the Lapidus procedure in patients with hallux valgus deformity.

Introduction Isolated gastrocnemius equinus contracture has been associated with several foot and ankle pathologies within the literature. The Silfverskiöld test is commonly used to identify isolated gastrocnemius contracture, however, the proper technique for performing the test has been scrutinized. The purpose of this study was to determine if there is a clinical significance in the ankle dorsiflexion that is obtained when the examination is performed incorrectly with a single hand versus the correct two-hand technique. Methods Thirty consecutive new patients with conditions associated with gastrocnemius equinus were included in the study. The Silfverskiöld test was performed with a two-hand technique and a single-hand technique. The amount of dorsiflexion obtained with the knee in full extension was measured and recorded using an extendable goniometer for each technique, with the arms aligned with the fifth metatarsal and fibular head. Results The average amount of dorsiflexion that was obtained with the two-hand technique with the knee in full extension was 76.3°±4.2°. When the one-hand technique was utilized the average amount of dorsiflexion obtained with the knee in full extension was 88.4°±4.2°. This was found to be statistically significant (p<0.01). Conclusion This study demonstrates that if the Silfverskiöld test is not performed correctly, the diagnosis of an isolated gastrocnemius contracture could be underappreciated. Accordingly, it may be important to perform the test with two hands in order to neutralize the hindfoot, midfoot, and forefoot, so that the dorsiflexion motion is through the tibiotalar joint alone.

To determine the rate of recurrent dislocation and patellar instability following medial patellofemoral ligament (MPFL) reconstruction with allograft or autograft tissue and compare patient-reported outcomes for patients undergoing allograft and autograft MPFL reconstruction. One hundred and fifteen MPFL reconstructions (78 allograft, 37 autograft) without concurrent bony procedures performed between 2008 and 2014 by four sports medicine fellowship-trained orthopedic surgeons at our center were identified. Patient demographics and surgical data were identified by chart review. Chart review and patient interviews were undertaken to identify recurrent patellar dislocations and as recurrent subjective patellofemoral instability. Recurrent dislocation and subjective instability risk were compared between the allograft and autograft groups. Eighty-seven patients (76%) with complete baseline data and minimum 1-year follow-up were contacted at a mean of 4.1 years following isolated MPFL reconstruction, including 57 patient with allograft reconstructions and 30 with autograft reconstructions. No significant differences in patient sex, age at reconstruction, body mass index, or time to follow-up were noted between groups. Recurrent dislocation occurred in 2 patients in the allograft group (3.5%) and 1 patient in the autograft group (3.3%), (n.s.). Recurrent subjective instability occurred in 17 patients in the allograft group (28.9%) and 11 patients in the autograft group (36.7%), (n.s.). No significant differences in patient-reported outcomes were noted between groups. The use of either allograft or autograft tissue for MPFL reconstruction results in low (< 3%) risk of recurrent patellar dislocation. Risk of recurrent subjective instability is higher but is similar for both graft types. Surgeons can utilize either graft choice at their discretion without anticipating a significant impact of graft choice on patient outcomes. III.

Background: Anterior cruciate ligament reconstruction (ACLR) is a common orthopaedic sports medicine procedure, but graft failure is not uncommon and often leads to revision ACLR. Revision surgery can be performed in a 1- or 2-stage fashion. Hypothesis: Graft failure risk, patient-reported outcomes, and anterior knee laxity are similar after 1- and 2-stage revision ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed to evaluate patient outcomes after 1- versus 2-stage revision ACLR. A search was performed with the phrase "revision anterior cruciate ligament reconstruction" across Embase, PubMed, Scopus, and SportDiscus from the beginning of their archives through July 12, 2019. Results: Thirteen studies met inclusion criteria and included 524 patients: 319 patients who underwent 1-stage revision ACLR and 205 patients who underwent 2-stage revision ACLR. Two studies compared outcomes of 1- versus 2-stage revision ACLR; 4 studies reported outcomes after 2-stage revision ACLR; and the remaining 7 studies documented outcomes after 1-stage ACLR. The mean follow-up was 4.1 years. The 2 studies that compared 1- versus 2-stage ACLR reported no differences in functional, radiologic, or patient-reported outcomes or failure risk. Overall, 9 studies reported subjective International Knee Documentation Committee (IKDC) scores; 4 studies, Knee injury and Osteoarthritis Outcome Score values; 8 studies, Lysholm scores; and 7 studies, Tegner scores; 8 studies measured anterior laxity with a KT-1000 arthrometer. The mean weighted subjective IKDC score for all studies including this outcome at final follow-up was 66.6 for 1-stage revisions and 65.9 for 2-stage revisions. Conclusion: The available evidence comparing 1- versus 2-stage revision ACLR is retrospective and limited. The results of each approach are similar in appropriately selected patients.

Category: Other; Ankle; Ankle Arthritis; Bunion Introduction/Purpose: Foot and ankle surgeries are often be accompanied by a peripheral nerve block as a method of reducing post-operative pain. The major nerve targeted is the popliteal nerve. The nerve can be supplemented with a target of the adductor canal or saphenous nerve. Higher than expected complication rates with peripheral nerve blocks has led to increased concern among both surgeons as well as patients. To our knowledge, no study has been able to identify risk factors that may predispose a patient to one of these complications. Our goal was to attempt to identify those risk factors. Methods: We reviewed patient charts who underwent a foot and ankle procedure between 2014 and 2018 as performed by the senior author. The review yielded 992 procedures performed across four surgical locations. Of these, 137 procedures were removed because no regional block was used. The remaining cases were analyzed for nerve complications, defined as sensory (paresthesia, numbness, tingling, or burning pain) or motor (weakness or paralysis) deficits along the distribution of a peripheral nerve. The patients were divided into blocked patients with and without complications. The groups were evaluated for demographic differences. The categories consisted of age, sex, diabetic status, smoking, previous procedures, previously diagnosed neuropathies, surgical location, body mass index (BMI), race, and insurance provider. Statistical analysis was performed using SAS software. To determine significance of these different factors, Chi-square values were obtained for each data set. Additionally, a regression analysis was performed to identify odds ratio for individual factors. Results: The overall complication rate was 10.1% with a total of 855 blocks given. The significant factors associated with a complication were age (p=0.0061), BMI (p=0.0031), location (p=0.0016), and smoking status (p=0.0026). Factors that were not significantly associated with complications were sex, diabetes status, previous procedures requiring a block, previously diagnosed neuropathies, race, and insurance provider. A regression analysis was performed to determine odds ratio for individual factors. Those with significant higher odds ratio were age between 40-65 years, normal or underweight BMI, surgery occurring at an Outpatient Surgery Center, and current smoker. Conclusion: Current literature has reviewed operative variables such as tourniquet time and epinephrine use, while others have looked at diabetes and age as predictors of nerve block complications. Our study focuses more on epidemiological factors that can predict an increased risk. Our study helped to reinforce the findings previous literature has found in regards to age and diabetes status. This study has also introduced some new factors that can help the surgeon decide if a nerve block is necessary for each surgical patient.

Category: Ankle Introduction/Purpose: Insertional Achilles tendinopathy can be a distressing problem for an active patient. Treatment begins conservatively, and when this fails a patient’s next best option may involve operating on the affected tendon. Depending on the disease state of the tendon, the surgeon may decide to repair or augment the Achilles with a flexor hallucis longus (FHL) transfer. The current literature supports the gastrocnemius recession for non-insertional cases, but is inconsistent in its efficacy for insertional cases. Our study looks at how patients with insertional Achilles tendinopathy with a small tear involving 20% of the tendon or less responded to an isolated gastrocnemius recession. Our hypothesis was that patients could do well without the need for a large repair or FHL transfer procedure. Methods: We retrospectively reviewed patients who underwent an isolated gastrocnemius recession for recalcitrant insertional Achilles tendinopathy between January 2015 and July 2018. Patients were included based on the diagnosis of insertional Achilles tendinopathy, having an MRI confirming tendinopathy, a tear involving less than 20% of the tendon or no tear, and no other concurrent pathologies. These criteria yielded 14 patients. One of these 14 patients was removed from the data analysis due to non-surgical complaints after surgery stemming from new onset posterior ankle pain. The patient charts were reviewed for their subjective VAS pain scores during office visits pre and postoperatively. Immediate preoperative visit, initial postoperative visit and final visit VAS scores were recorded. Results: The average time of chart follow up for the 13 patients included in the study was 15.5±10.5 weeks postoperatively (range 4-38). 2 patients were found to have a tear <20% (15%), and the remaining 11 patients were found to have no tear on their MRI (85%). The average final preoperative VAS pain score for the patients was 5.4±1.8 (range 3-9). The average final postoperative VAS pain score for the patients was 0.9±1.3 (range 0-5). These values were found to be statistically different (p<0.001). Of note all patients saw a reduction in their pain score of at least 2 points. Conclusion: Previous literature is inconclusive on the efficacy of the gastrocnemius recession for insertional Achilles tendinopathy. No other study has identified the amount or type of tendon involvement by advanced imaging. Our study supports the notion that patients with MRI confirmed tendinopathy and a tear involving less than 20% of the tendon or no tear, often do quite well in reaching a reduction in their pain. Our study is limited in power due to our small sample size, but the results suggest that this procedure deserves more attention for the treatment of insertional Achilles tendinopathy when appropriate.

Complex lower extremity wounds present a unique problem to foot and ankle clinicians, with many obstacles to achieving a successful outcome. The decreased vasculature of the lower extremities creates environments where wounds lack the resources to properly heal on their own. Conditions such as diabetes mellitus and smoking can exacerbate these issues by further decreasing vascular flow providing resources to the wound. For physicians trained in orthopedic foot and ankle surgery, they often do not receive training in advanced wound care, whereas podiatric surgeons can obtain fellowship training in wound care management. This dynamic presents a unique opportunity for tandem management of complex lower extremity wounds, which can decrease patient morbidity and the costs associated with care. We present three cases of complex wounds managed in a tandem fashion that achieved optimal outcomes after both orthopedic surgery and podiatric surgery were involved. These cases illustrate the potential benefits associated with tandem wound management in foot and ankle surgery,

Category: Bunion Introduction/Purpose: The Lapidus procedure is becoming more popular in the surgical correction of hallux valgus deformities. Bunion correction surgeries in general demonstrate good patient outcomes, however the recurrence rates are variable and are a concern for patient morbidity. The senior author of this study performs a modified Lapidus procedure where the first intermetatarsal, and first intercuneiform joints are fused along with the standard fusion of the first tarsometatarsal joint. We believe that this fusion will address the recurrence rate associated with the Lapidus procedure. Our theory is that recurrence occurs at the normally unfused intermetatarsal and intercuneiform joints, and when these joints are fused recurrence will be unable to occur. Methods: We reviewed the charts of patients who underwent the modified Lapidus procedure between 2014 and 2017 performed by the senior author. This review yielded 47 cases, of which 34 met the study criteria as a primary bunion repair with a preoperative X-ray, a postoperative X-ray at first surgical follow up, and a final postoperative X-ray =90 days postoperatively. Of the 13 charts that did not qualify, 11 had inadequate follow up data/radiographs, and 2 cases were revisions. The 34 remaining cases were then analyzed for IMA, HVA, and evidence of fusion on X-ray. Two patient subsets were created for additional analysis of the first and last postoperative X-rays with no patient overlap. 19 cases created subgroup A as they contained patients whose last postoperative X-rays were weight bearing. 6 cases were analyzed as subgroup B having final postoperative X-rays that were non-weight bearing. All first postoperative X-rays were non-weight bearing. Results: The average time of radiographic follow up was 10.5±8.9 months (range 3.1-41.5). There was evidence of fusion failure at the IMT joint in 7 cases (21%), and these patients were removed from group data analysis. Another case was excluded due to the great toe falling into varus. In the remaining 26 cases, the difference in IMA and HVA was significant between the last preoperative and first postoperative X-ray (p<0.001; p<0.001), but not significant between the first and final postoperative X-rays (p=0.26; p=0.77). Subgroups A and B did not see statistically significant changes in IMA (p=0.40; p=0.19) or HVA (p=0.78; p=0.34) measurements between the first and last postoperative X-rays. Of note, the cases with IMT fusion failure saw a statistically significant increase in IMA measurements (p=0.001). Conclusion: Our study results suggest that the modified Lapidus procedure has good results in the short term, maintaining the operative reduction at a mean follow up time of 10 months. Our hypothesis that the intermetatarsal and intercuneiform joint fusion prevents bunion recurrence is supported by the fused cases showing no significant differences after at least 90 days postoperatively, while the unfused cases showed significant changes to their IMA angles after at least 90 days postoperatively. Although the study population is small, our data suggests that this procedure can maintain the correction achieved in surgery.

Category: Ankle, Sports Introduction/Purpose: Chronic lateral ankle instability (LAI) is a common cause of ankle pain. Surgical interventions have been shown to be highly effective in alleviating patient’s symptoms once conservative care has failed. Stress radiographs have not demonstrated a clear efficacy in diagnosing ankle instability. Currently, MRI is considered to be superior to stress radiographs in the available literature. Unfortunately, the literature comparing these methods is limited. The purpose of this study is to compare the results of an MRI and manual inversion stress radiographs, in order to assess the accuracy of each modality in assessing the lateral ankle ligament competence. We believe that stress radiographs may have more value in confirming chronic ankle instability than the more expensive MRI imaging. Methods: A retrospective chart review was performed between January 2016 - July 2018 for patients diagnosed with LAI. The review identified 318 cases, of which 57 met the study criteria of having both an AP manual inversion stress radiographs, assessed by the senior author, and MRI, interpreted by a musculoskeletal radiologist, occurring within 6 months of each other without an acute injury within 12 weeks of the first image. For the remaining 57 cases, the imaging was reviewed in the following manner. For the MRI studies, the report was read from the radiologist assessing the lateral ankle complex. A positive MRI was denoted as pathology being reported by the radiologist. For the manual inversion stress radiograph, measurements were made to assess the degree of talar tilt while being stressed. A positive stress radiograph was identified based on asymmetry of the ankle joint during the stress. Results: The average time between imaging studies was 7.2±7.4 weeks (range 0.5-24 weeks). Of the 57 cases that qualified for the study, 43 (75%) had a positive stress radiograph, and 21(37%) had a positive MRI. 24 cases (42%) demonstrated a positive stress radiograph with a negative MRI, while 2 cases (4%) demonstrated a negative stress radiograph with a positive MRI. In respect to talar tilt, those patients identified as having a positive stress radiograph also had a higher average talar tilt when compared to those who did not. The degree of talar tilt for each set of criteria is summarized in Table 1. Conclusion: Historically, lateral ankle instability has been a clinical diagnosis. When further imaging is needed, our data suggests stress radiographs may demonstrate a higher reliability than MRI when assessing the competence of the lateral ankle ligaments. Asymmetry in a joint during an inversion stress examination has been shown to be indicative of multi ligament involvement. Few studies have attempted to define a talar tilt consistent with instability and our data does not meet those numbers. However, with the addition of bundled care and rising health care costs, we believe this provides a potential alternative in confirming a diagnosis of ankle instability.

Category: Bunion Introduction/Purpose: An arch collapse model has been described for a multitude of foot and ankle problems that is based on a gastrocnemius equinus contracture producing a predictable collapse that has been described in five distinct phases. Previous studies have evaluated the presence of pes planovlagus in hallux valgus patients and concluded that this is a rare occurance. The Grand Rapids arch collapse model reviews adult foot pathology and believes there is a link between bunions and flatfeet. We wanted to evaluate patients with flatfeet and determine if they had an associated bunion deformity. Based upon the arch collapse model, there should be a significant number of flatfeet with an associated bunion deformity and our goal was to see if this proved to be true. Methods: We retrospectively reviewed the radiographs of patients diagnosed with a flatfoot based upon their ICD 9 and 10 codes in the senior author’s practice. For each patient, we used standard anteroposterior and lateral foot radiographs obtained on all new patients. Initially, we had 254 feet but had to exclude 93 feet due to inadequate radiographs, normal radiographs (normal meary’s angle and talonavicular coverage angle) or in patients who already had surgical procedures to the foot. This left 161 feet radiographs for review. We then measured the Meary’s angle on the lateral images and the talonavicular coverage angle, hallux valgus angle, intermetatarsal angle and sesamoid position on the anteroposterior radiographs. Results: Of the 161 feet that remained in the study, only 6 feet (3.7%) had no radiographic evidence of a bunion based upon sesamoid position, hallux valgus angle or the intermetatarsal angle. We did find a correlation with the severity of the flatfoot based upon the Meary’s angle and the talonavicular coverage angle with the severity of the bunion deformity defined by the sesamoid position, hallux valgus angle and the intermetatarsal angle. As the flatfoot got worse, the bunion did so as well. Conclusion: Our findings would seem to fit with the Grand Rapids arch collapse model. The hypermobility of the first ray that creates the bunion deformity then allows the arch to ultimately collapse. It also does not seem to contradict what has been found previously. Earlier studies showed a low association between patients with bunions who also had flatfeet. This would make sense as the deformity may not have progressed to the flatfoot yet. However, in our study the deformity has already progressed to a flatfoot and almost all have some radiographic evidence of a bunion.

Category: Pathophysiology Introduction/Purpose: Gastrocnemius eqiunus has been associated with a wide range of foot and ankle pathologies in the literature, however, many still question it’s involvement or existence. A recent response in Foot & Ankle International pointed out an incorrect demonstration of the Silfverskold test in a prior study. With a growing body of literature supporting gastrocnemius equinus as a contributing factor in foot and ankle pain, why do many feel that it still does not exist? It was our hypothesis that unless the examination is performed correctly, the diagnosis can be missed and could be the potential cause for disbelief in its existence or effect on foot and ankle pain. We sought to demonstrate the difference in examination findings when performing the test correctly and incorrectly. Methods: Thirty consecutive patients with conditions associated with gastrocnemius equinus in the literature were included in the study. Each patient was consented and had a Silverskold test performed correctly by inverting and locking the subtalar joint as well as stabilizing the talonavicular joint in order to isolate the ankle joint. We then performed the exam incorrectly without stabilizing the same two joints, allowing motion through the ipsilateral hindfoot and midfoot joints. A long arm goniometer was used to measure the angles with each arm along the length of the fibula and fifth metatarsal. The senior author performed all of the examinations to maintain consistency. The angles were recorded for later review. Results: We found that when the subtalar and talonavicular joints were stabilized, there was almost fifteen degrees less dorsiflexion than when the same joints were not stabilized. The average dorsiflexion when performed in the correct manner was seventy-eight degrees, while the average dorsiflexion with the exam performed incorrectly was ninety-three degrees. Conclusion: We demonstrated that if the examination is not performed correctly, the equinus contracture could go undiagnosed as motion through the hindfoot and midfoot joints can alter the findings. It is important to understand and perform the technique correctly to evaluate for the contracture as it has been shown to be a contributing factor in many foot and ankle problems. If we standardize the examination, there may be less disagreement about its existence or affect on foot and ankle pain.