Clinical Diagnosis of

G a s t ro c n e m i u s T i g h t n e s s
a, b
Pierre Barouk, MD *, Louis Samuel Barouk, MD

KEYWORDS
 Gastrocnemius  Equinus  Triceps surae

KEY POINTS
 The diagnosis of gastrocnemius tightness is primarily clinical using the Silfverskiold test,
which shows an equinus deformity at the ankle with the knee extended but that disap-
pears with the knee flexed.
 The manner in which the Silfverskiold test is performed must be consistent with respect to
the applied strength of the maneuver, correction of a flexible hindfoot valgus deformity
while performing the test, and reproducibility.
 Additional clinical signs that can help to make the diagnosis when the retraction is not clin-
ically evident include knee recurvatum, hip flexion, lumbar hyperlordosis, and forefoot
overload.

INTRODUCTION

The diagnosis of gastrocnemius tightness is based on the clinical examination alone,

with an essential point that is common to every examination: the Silfverskiold sign,1 an
equinus of the ankle that is present when the knee is extended but that disappears
when the knee is flexed.
Gastrocnemius tightness is also associated with physical signs caused by the equi-
nus, and must be detected during the clinical examination: forefoot overload, knee
recurvatum, hip flexion, and hyperlordosis.

CLINICAL EXAMINATION: THE SILFVERSKIOLD TEST

There is gastrocnemius tightness when passive ankle dorsal flexion is negative or at

neutral when the knee is in extension, during application of a load using moderate
strength under the forefoot; and this loss of dorsiflexion normalizes when the knee
is in flexion, with a minimum of 13 degrees of difference (Fig. 1A and B).
This passive ankle dorsal flexion difference is common and once identified, it is
important to assess the diagnosis. Some elements of this examination must be precise.

a
Foot Surgery Center of the Sport Clinic, 2 Rue Georges Nègrevergne, Merignac 33700, France;
b
39 Chemin de la Roche, Yvrac 33370, France
* Corresponding author.
E-mail address: pierre.barouk@wanadoo.fr

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660 Barouk & Barouk

Fig. 1. Gastrocnemius tightness. (A) Equinus with knee in extension, but with moderate
strength applied. (B) Equinus disappears when the knee is flexed. (Adapted from Barouk S.
Forefoot reconstruction. New York: Springer-Verlag; 2003.)

The Force Under the Foot Is Applied

Force is applied under the head of the second metatarsal, but it can be applied to a
larger area under the entire forefoot.

Correction of Hindfoot Valgus Deformity

In the presence of a flexible flatfoot, the heel is usually in a valgus position. When the
hindfoot is in valgus, true ankle dorsiflexion does not occur, and most of the dorsiflex-
ion motion occurs in an oblique plane through the transverse tarsal and subtalar joints.
To perform the test correctly, the hindfoot must be reduced from valgus into a neutral
or varus position. This is only possible to perform if the hindfoot is flexible. We have
noted that flexible hindfoot valgus deformity is present in 15% to 25% of the cases
when there is gastrocnemius tightness (Fig. 2).2

Correction of an Eventual Contraction of the Foot Extensors

This occurs essentially when the knee is flexed. The Silfverskiold test is based on pas-
sive examination of the foot, and the examiner has to avoid attempted active contrac-
tion of the extensors, in particular the tibialis anterior (Fig. 3). This commonly occurs
when the patient is asked to flex the knee. To avoid this we perform the examination
in a prone position, which is more reliable but not as convenient (Fig. 4). An alternative
method of performing the test is to flex the knee passively and hold it in that position
while doing the test (Fig. 5).

Strength Applied, and Definition of Gastrocnemius Tightness

The degree of dorsiflexion depends on the strength applied under the forefoot.
Although some force has to be exerted under the forefoot when testing for equinus,
this should not be more than approximately 2 kg of force. In the example in Fig. 6,
 Clinical Diagnosis of Gastrocnemius Tightness 661

Fig. 2. (A) Avoid examination of gastrocnemius tightness with the hindfoot in valgus. The
test is performed with the foot in a neutral (B) or varus position (C).

it seems that there is no equinus but this is because considerable force had to be
applied to the foot, which leads to a false-positive result (see Fig. 6).
Di Giovanni3,4 has recommended applying a force no more than 10 nm, which cor-
responds approximately to 2 kg and can be reliably measured with the equinometer
(Fig. 7).
Di Giovanni defined subjectively two types of a short gastrocnemius: when the ankle
dorsi flexion is equal or inferior to 110 degrees or 15 degrees when the knee is
extended, or with a differential when the knee is flexed an average of 11.3 degrees.
662 Barouk & Barouk

Fig. 3. With the knee flexed note an active contraction of the foot extensors; this leads to a
false-positive result.

Fig. 4. Prone position examination can avoid active contraction of the foot extensors, both
knee extended (A), and knee flexed (B).

Fig. 5. The best position to avoid foot extensor contraction is when the knee is flexed.
 Clinical Diagnosis of Gastrocnemius Tightness 663

Fig. 6. (A) Usually the equinus is tested with a high strength applied under the forefoot. (B)
For the gastrocnemius examination this strength must be moderate (<2 kg).

It is certain that the measurement with an equinometer is very accurate, and the pre-
cision is less than 2 degrees for a trained examiner, but it requires time and special
computer equipment, which makes the routine examination difficult. However, it is
very useful for experimental investigations in trained hands.
These definitions are quite severe, especially the one that considers a short gastroc-
nemius when the ankle dorsi flexion is less than 110 degrees, with the knee extended.
It is useful for comparative study when the examination is reproducible, but too severe
for routine examination.
We started with an examination made in patients with cerebral palsy in whom we
determined an angle of dorsiflexion that corresponds to the beginning of the stretching
resistance. This degree of dorsiflexion was called “L0” by Tardieu.5 Our experience6
gave us the same conclusion as others7: the clinical signs (type of walking digitigrade,

Fig. 7. The equinometer.

664 Barouk & Barouk

appearance of the tonic reflex of stretching) occur when the ankle is at the negative
dorsal flexion degree that correspond to the L0.
We applied the principle of the L0 to patients without cerebral palsy because here
also the negative effects of the gastrocnemius tightness occur at this level of dorsi
flexion, and this resistance to the passive stretching is easy to determine. What is
the strength corresponding to an L0 in a nonspastic patient? We could measure this
force with a balance: it is approximately 1.7 kg (Fig. 8).
With this pressure, in nonspastic patients we obtain in cases of a short gastrocne-
mius knee extended 13 degrees of dorsal flexion; and knee flexed, 1 5 degrees of dor-
sal flexion. So, the difference is 18 degrees on average, but it can be 13 degrees. With
these numbers we consider short gastrocnemius.
For other authors, the pressure used to determine tightness of the gastrocnemius is
slightly greater. These authors consider a short gastrocnemius when dorsiflexion with
the knee extended is equal or inferior to 0 degrees, and that this difference with flexed
knee is 15 degrees.8–10 These differences are small, but all the authors agree with the
principle of a slight pressure of around 1.5 to 2 kg when examining the leg.
In some cases, one has to use the clinical differences of extension and flexion of the
knee according to clinical pathology, so that if the dorsiflexion is only slightly positive
the differential may then be important. In this case, the lengthening can still be of some
benefit, especially in case of metatarsalgia, or plantar fasciitis as observed by Maceira
and Orejana.11
When there is gastrocnemius and soleus tightness, the dorsiflexion with the knee
extended is very limited, and stays negative with the knee flexed. In this case, the sur-
gery has to adapt to the severity and type of contracture of the triceps surae as

Fig. 8. Common pressure to diagnose gastrocnemius tightness: between 1.7 and 2 kg.
 Clinical Diagnosis of Gastrocnemius Tightness 665

Fig. 9. (A, B) Taloche sign. (Courtesy of M. Maestro, MD, Nice, France.)

Fig. 10. Round forefoot.

666 Barouk & Barouk

proposed by Rippstein12: the lengthening is “global” (ie, just distal to the

gastrocnemius-soleus junction [gastrocnemius tendon and soleus aponeurosis], or
just on the gastrocnemius [distally to the musculotendinous junction, or at the proximal
insertion]).

The Taloche Sign (Maestro)

If a patient with a tight gastrocnemius tries to stand on an inclined plane, it is immedi-
ately evident that it is impossible for the patient to be stable in this position (Fig. 9).

CLINICAL EXAMINATION: THE ASSOCIATED SIGNS CAUSED BY THE EQUINUS

In forefoot overload the typical sign is the round forefoot, as described by Colombier
(Fig. 10).8 Note also on Fig. 10 the narrow heel. The signs of knee recurvatum, hip
flexion, and hyperlordosis are often associated with gastrocnemius tightness as
described by Downey and Banks13 or Kowalski.14

SUMMARY

There is a gastrocnemius tightness when on examination there is a negative or neutral

ankle dorsiflexion when the knee is extended, with moderate (no more than 2 kg) pres-
sure applied under the forefoot; and there is a differential at least of 13 degrees of
dorsiflexion (that becomes positive) when the knee is flexed.
It is necessary during examination to ensure that the heel is reduced, particularly in a
flexible flatfoot deformity to reduce hindfoot valgus, and to avoid the contraction of the
foot extensors. The assessment with an equinometer is the most accurate way to
assess deformity, but this is not clinically practical. The clinical signs caused by equi-
nus must be looked for including forefoot overload, knee recurvatum, hip flexion, and
hyperlordosis.

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