Function and strength following gastrocnemius recession for isolated gastrocnemius contracture

[Translated article] Medial gastrocnemius proximal fasciotomy in patients with chronic plantar fasciitis: A systematic review

INTRODUCTION

Plantar fasciitis is the main cause of heel pain in middle-aged patients. In chronic cases, limited ankle dorsiflexion caused by isolated gastrocnemius contracture is considered the main risk factor for suffering it. Therefore, in recent years the number of patients operated on by proximal fasciotomy of the medial gastrocnemius (FPGM) has increased to treat chronic plantar fasciitis.

MATERIAL AND METHODS

Systematic review following the PRISMA guidelines. We have carried out a bibliographic search in Pubmed, Science Direct, Cochrane Library and Web of Science databases. One hundred and eighty-four articles were found. Data extraction was performed using the Covidence software, and a quality and risk of bias analysis of the included articles was performed based on the Cochrane risk of bias Tool 2.0.

RESULTS

Three articles were included in the review: two randomised clinical trials and one cohort study with a total of 138 patients. In the analysed studies, patients after proximal fasciotomy of the medial gastrocnemius showed significant improvements in pain and in the AOFAS score with high levels of patient satisfaction. Increases in ankle dorsiflexion angle were found after 12 months of follow-up, with no loss of gastrocnemius strength. The complication rate was low and fewer occurred in the proximal fasciotomy compared to plantar fasciotomy.

CONCLUSION

Proximal fasciotomy of the medial gastrocnemius provides clinical benefit in patients with chronic plantar fasciitis, with a low probability of complications and high patient satisfaction.

Medial gastrocnemius proximal fasciotomy in patients with chronic plantar fasciitis: A systematic review

INTRODUCTION

Plantar fasciitis is the main cause of heel pain in middle-aged patients. In chronic cases, limited ankle dorsiflexion caused by isolated gastrocnemius contracture is considered the main risk factor for suffering it. Therefore, in recent years the number of patients operated on by proximal fasciotomy of the medial gastrocnemius (FPGM) has increased to treat chronic plantar fasciitis.

MATERIAL AND METHODS

Systematic review following the PRISMA guidelines. We have carried out a bibliographic search in Pubmed, Science Direct, Cochrane Library and Web of Science databases. One hundred and eighty-four articles were found. Data extraction was performed using the Covidence software, and a quality and risk of bias analysis of the included articles was performed based on the Cochrane risk of bias Tool 2.0.

RESULTS

Three articles were included in the review: two randomized clinical trials and one cohort study with a total of 138 patients. In the analyzed studies, patients after proximal fasciotomy of the medial gastrocnemius showed significant improvements in pain and in the AOFAS score with high levels of patient satisfaction. Increases in ankle dorsiflexion angle were found after 12 months of follow-up, with no loss of gastrocnemius strength. The complication rate was low and fewer occurred in the proximal fasciotomy compared to plantar fasciotomy.

CONCLUSION

Proximal fasciotomy of the medial gastrocnemius provides clinical benefit in patients with chronic plantar fasciitis, with a low probability of complications and high patient satisfaction.

Outcomes of Isolated Open Gastrocnemius Recession for the Treatment of Chronic Insertional Achilles Tendinopathy: A Retrospective Cohort Study

BACKGROUND

Insertional Achilles tendinopathy (IAT) is a common condition causing pain and dysfunction. Patients with diabetes, hyperlipidemia, hypothyroidism, and obesity are at increased risk of developing IAT. These comorbidities also carry an increased risk of wound healing complications following surgery. Therefore, there is a need for alternative management strategies for this high-risk patient population. This study investigated the potential role of isolated GR in patients with chronic IAT.

METHODS

This study is a single-institution retrospective review of adult patients who underwent isolated GR to address chronic IAT with a minimum 1-year follow-up. Demographics, complications, radiographic findings, and preoperative and postoperative patient-reported outcome scores (PROs) were collected. The primary outcome was improvement in PROMIS scores from preoperative to postoperative. Secondary outcomes were complication and reoperation rates.

RESULTS

Sixteen patients underwent open GR with a mean follow-up of 2.7 years. Postoperative PROMIS domain scores improved significantly from preoperative scores for physical function, pain interference, pain intensity, and global physical function. Two patients (13%) underwent reoperation (open calcaneal exostectomy and tendon debridement) at a mean time of 7 months from gastrocnemius recession. One patient developed a postoperative hematoma that resolved with conservative management.

CONCLUSION

This single-institution series reports on a small cohort of patients with chronic IAT treated with open GR. We found significant improvement in patient-reported outcomes. Rates of complication and reoperation were low. This study supports the potential use of isolated gastrocnemius recession in IAT patients who, because of age or medical comorbidities, may benefit from a less invasive surgery and faster rehabilitation.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Isolated Gastrocnemius Contraction and Gastroc Recession Surgery in Case of Planter Fasciitis: A Systemic Review and Meta-Analysis

Objective

The current systematic and meta-static review aimed to analyze the correlation between isolated gastrocnemius contracture and plantar fasciitis and the effectiveness of gastroc recession surgery in the treatment of plantar fasciitis.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this meta-analysis. A literature search was carried out on the following databases, including Google Scholar, PubMed, EMBASE, and the Cochrane databases with the appropriate medical subject headings (MeSH) to identify the eligible articles.

Results

A total of 13 studies were included in this meta-analysis. In this study, there is a significant difference in chronic plantar fasciitis outcome when comparing experimental and control (RR: 0.02; 95% CI: 0.01 to 0.05; P < 0.001; I2 = 29%). There is a significant difference in pain scale outcome when comparing pre-treatment and post-treatment (RR: 3.25; 95% CI 1.44 to 7.32; P = 0.004 < 0.01; I2 = 0%). A significant difference in VAS scale outcome when comparing pre-treatment and post-treatment (RR: 2.58; 95% CI 1.52 to 4.38; P = 0.0004 < 0.01; I2 = 0%).

Conclusion

In conclusion, the current systematic review and meta-analysis of gastrocnemius recession and proximal medial gastrocnemius release and other treatment measures for plantar fasciitis suggests that the improvement of ankle dorsiflexion, reduction in pain, and patient satisfaction are almost similar in all the treatment measures. Among the five treatment measures, gastrocnemius recession remains the best, followed by proximal medial gastrocnemius release.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession

BACKGROUND

There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate Patient-Reported Outcome Measurement Information Systems (PROMIS) scores in patients with plantar fasciitis before and after gastrocnemius recession.

METHODS

The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with 1-year minimum follow-up. Forty-one patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic.

RESULTS

We followed up 41 patients with a median age of 48 years (interquartile range [IQR] 38-55) and median body mass index of 29.02 (IQR 29.02-38.74) for 1 year post surgery. Preoperative and postoperative PROMIS scores improved for physical function from 39.3 to 44.5 (P = .0005) and for pain interference from 62.8 to 56.5 (P = .0001). PROMIS depression scores were not significantly different (P = .6727). Visual analog scale (VAS) scores significantly decreased from 7.05 to 1.71 (P < .0001).

CONCLUSION

In this case series, we found the gastrocnemius recession to be an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis, although final median scores did not reach normative standards for the population, suggesting some residual pain and/or dysfunction was, on average, present. Based on the results of this study, the authors conclude that gastrocnemius recession is a reasonable treatment option for chronic plantar fasciitis patients who fail nonoperative management.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy

BACKGROUND

Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability.

METHODS

Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession "Baumann" procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry.

RESULTS

Medial gastrocnemius recession and Baumann procedures were equally effective at producing significant increases in passive ankle dorsiflexion. No sural nerve injuries were observed. Thirty-five percent of specimens showed direct muscular fusion of at least a portion of the distal gastrocnemius muscular tissue to the adjacent soleus.

CONCLUSION

The MGR procedure produced comparable dorsiflexion improvement results to the Baumann procedure in our cadaver model. Surgeons must account for certain conjoint tendon anatomical variants when surgically treating IGC as traditional recession methods risk tendo-Achilles overlengthening.

LEVELS OF EVIDENCE

Level V: Cadaver Study.

Reliability and Reference Norms of Single Heel-Rise Test Among Children: A Cross-sectional Study

There is a lack of data regarding the single heel-rise test (SHRT) among children. Hence, we aimed to establish reliability and reference norms of SHRT among children aged 8 to 12 years. About 500 healthy children were randomly selected from the recognized school and community settings. After demographic measurements, SHRT was conducted to evaluate the strength of each plantar flexors. SHRT repetitions were assessed by the same rater on 2 occasions for intrarater (on the same day) and test-retest reliability (on different days) and by 2 raters for inter-rater reliability. Relative reliability was described in terms of the intraclass correlation coefficient (ICC) and Pearson correlation coefficient (r). Absolute reliability was indicated by the standard error of measurement (SEm), minimal detectable change (MDC), and Bland-Altman graph. The mean of the number of repetitions of SHRT was calculated to derive the reference norm of SHRT. The anthropometric parameters were correlated with SHRT for multiple regression analysis. Intrarater, test-retest, and inter-rater reliability of SHRT were, ICC = 0.81, ICC = 0.70, and ICC = 0.57, respectively. The Bland-Altman graph confirmed limits of agreement for intrarater, test-retest, and inter-rater reliability. The reference norm of SHRT is documented to be 20.6 ± 4.8. SEm and MDC are found to be 2 and 3, respectively. Multiple regression analysis predicted a correlation of age, weight, and calf muscle girth with SHRT. SHRT is moderate to good reliable in assessing the strength of plantar flexors. The reference norms of SHRT have been derived for healthy children aged 8 to 12 years.

The effect of gastrocnemius resection on knee flexion in a total knee arthroplasty model

INTRODUCTION

Flexion contracture in knee arthritis and total knee arthroplasty (TKA) is a common and significant problem. An improvement in knee extension in patients with TKA and mild flexion contractures has been observed clinically when a gastrocnemius recession was performed for other concomitant conditions. The goal of this study was to quantify the effect of gastrocnemius recession on knee flexion in TKA cadaver model.

MATERIALS AND METHODS

Range of motion (ROM) of 23 cadaveric knees was determined with a navigation system before and after performing TKA using a medial parapetallar approach and after performing a gastrocnemius recession. Varus-valgus, flexion-extension, and internal-external rotation angles of the knee joint were recorded with leg in full extension and in 90°of knee flexion. Extension and flexion gaps were measured using a gap tensioning device. Dorsiflexion of the foot was measured with a goniometer when a torque moment of 10 Nm was applied to the ankle joint.

RESULTS

A statistically significant improvement of 5° in knee extension was observed following gastrocnemius recession (P = 0.015). Varus and valgus angles, internal, and external rotation were unaffected by gastrocnemius recession. Ankle dorsiflexion increased by 9° following gastrocnemius recession (P ≤ 0.001).

CONCLUSIONS

Performing a gastrocnemius recession improves the knee extension in TKA knees with flexion contractures. Gastrocnemius recession may be a useful technique to improve terminal extension in TKA.

Gastrocnemius Release in the Management of Chronic Plantar Fasciitis: A Systematic Review

BACKGROUND

This systematic review aims to summarize the outcomes of gastrocnemius recession in the treatment of plantar fasciitis.

METHODS

A systematic review was performed according to PRISMA guidelines using the PubMed, Embase, Emcare, Web of Science, Scopus, and CINAHL databases. A 2-stage title/abstract and full text screening process was performed independently by 2 reviewers. Randomized controlled trials, cohort, and case-control studies reporting the results of gastrocnemius recession in patients with plantar fasciitis were included. The MINORS and Joanna Briggs Institute Criteria were used to assess study quality and risk of bias.

RESULTS

A total of 285 articles were identified, with 6 of these studies comprising 118 patients being ultimately included. Significant postoperative improvement in American Orthopaedic Foot & Ankle Society, visual analog scale, 36-Item Short Form Health Survey, Foot Forum Index, and Foot and Ankle Ability Measure scores were reported. Included studies also described an increase in ankle dorsiflexion range of motion and plantarflexion power. An overall pooled complication rate of 8.5% was seen, with persistent postoperative pain accounting for the most common reported complication. Gastrocnemius recession is associated with greater postoperative improvement than plantar fasciotomy and conservative stretching exercises.

CONCLUSION

The current evidence demonstrates that gastrocnemius recession is effective in the management of plantar fasciitis, specifically in patients with gastrocnemius contracture who do not respond to conservative treatment.

LEVEL OF EVIDENCE

Level III, Systematic review of level I-III studies.

Gastrocnemius Recession in Recalcitrant Plantar Fasciitis: A Systematic Review

Plantar fasciitis is a common cause of heel pain. Recalcitrant plantar fasciitis can be difficult to manage. Medial gastrocnemius recession is increasingly being used to treat recalcitrant plantar fasciitis, with advocates describing fewer complications and quicker recovery time than other surgical options. This systematic review aimed to determine the effectiveness of gastrocnemius recession for the treatment of patients with recalcitrant plantar fasciitis. Multiple databases were searched using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The level of evidence of each study was assessed according to the American Academy of Orthopaedic Surgeons Levels of Evidence. The level of bias for each study was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Seven studies were retrieved: 3 retrospective case series, 1 retrospective study that compared gastrocnemius recession to open plantar fasciotomy, 1 prospective cohort study (pre-post study with no control group), and 2 randomized controlled trials. All 6 studies that assessed pre- and postoperative pain using the Visual Analogue Scale showed a large reduction in pain postoperatively. Four studies that assessed pain at 12 months postoperatively showed a weighted mean of 76.06 ± 10.65% reduction in pain. No major complications were reported. Minor complications included sural neuritis. This review found a consistent reduction in pain following gastrocnemius release in patients with recalcitrant plantar fasciitis, suggesting it is a very promising treatment. However, the included studies are limited by low quality study designs and inherent biases, limiting the strength of recommendation. Further definitive, well-designed trials are required.

Ankle plantar flexor muscle performance and patient reported outcomes in people following total ankle arthroplasty

BACKGROUND

The purpose of this study was to prospectively evaluate ankle power generation during gait in people with total ankle arthroplasty, and examine the relationships between postoperative plantar flexor strength, ankle power, and patient outcomes.

METHODS

Nineteen people with end-stage ankle arthritis who received a total ankle arthroplasty and 19 healthy matched controls participated in this case-control study. Patient reported outcomes included a region specific measure of foot function and a generic measure of physical function. Gait speed was recorded with the 6-min walk test. Isokinetic plantar flexor strength was measured with an instrumented dynamometer. Motion capture and force plate data were used to calculate peak ankle power generation during walking. Paired or independent t-tests were used to compare ankle power across time and between groups, respectively. Bivariate correlations were performed to examine the interplay of postoperative strength, ankle power, gait speed, and patient reported outcomes.

FINDINGS

Ankle power was not different between the preoperative and 6-month postoperative time points (d = 0.20). Six-month postoperative ankle power was less than controls (d = 1.32). Strength, ankle power, and gait speed were directly correlated in the patient group 6-months postoperatively (r or ρ ≥ 0.47). Six-month postoperative strength and ankle power were directly correlated to select 2-year patient reported outcomes (both ρ = 0.54).

INTERPRETATION

Lower than normal 6-month postoperative ankle power, which was correlated to strength, gait speed, and longer-term patient reported outcomes, suggests efforts toward improving ankle plantar flexor muscle performance may improve patient outcomes.

The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis

BACKGROUND

The aetiology of chronic therapy resistant plantar fasciitis (CTRPF) is multifactorial with more focus in recent times on the gastroc-soleus complex. This study evaluates the effect of lengthening the gastrocnemius muscle in CTRPF.

METHODS

All patients with CRTPF complaints for at least one year underwent the same standard conservative treatment prior to surgery. 32 patients failed this treatment and underwent gastrocnemius recession. Silfverskiöld test, questionnaires and plantar pressure measurements were obtained at 5 visits.

RESULTS

One year follow up showed a significantly increase in dorsiflexion of the ankle (16 degrees), a decrease in VAS; 78 (SD: 19) to 20 (SD: 24) and significant improved functional scores. Plantar pressure measurements showed an increase of pressure under the medial proximal part of the midfoot and the 1 st metatarsal and a decrease under the hallux.

CONCLUSIONS

A gastrocnemius recession results in a significant gain in dorsiflexion, altered loading of the foot and good clinical outcome in patients with CTRPF.

LEVEL OF EVIDENCE

Level 2.

Effect of Achilles Tendon Lengthening and Gastrocnemius Recession on Radiographic Tibiotalar Motion Following Total Ankle Replacement

BACKGROUND

Surgeons frequently add an Achilles tendon lengthening or gastrocnemius recession to increase dorsiflexion following total ankle replacement. Previous studies have looked at the effects of these procedures on total tibiopedal motion. However, tibiopedal motion includes motion of the midfoot and hindfoot as well as the ankle replacement. The current study examined the effects of Achilles tendon lengthening and gastrocnemius recession on radiographic tibiotalar motion at the level of the prosthesis only.

METHODS

Fifty-four patients with an average of 25 months follow-up after total ankle replacement were divided into 3 groups: (1) patients who underwent Achilles tendon lengthening, (2) patients who had a gastrocnemius recession, (3) patients with no lengthening procedure. Tibiotalar range of motion was measured on lateral dorsiflexion-plantarflexion radiographs using reference lines on the surface of the implants.

RESULTS

Both Achilles tendon lengthening and gastrocnemius recession significantly increased tibiotalar dorsiflexion when compared to the group without lengthening. However, the total tibiotalar range of motion among the 3 groups was the same. Interestingly, the Achilles tendon lengthening group lost 11.7 degrees of plantarflexion compared to the group without lengthening, which was significant.

CONCLUSION

Both Achilles tendon lengthening and gastrocnemius recession increased radiographic tibiotalar dorsiflexion following arthroplasty. Achilles tendon lengthening had the unexpected effect of significantly decreasing plantarflexion. Gastrocnemius recession may be a better choice when faced with a tight ankle replacement because it increases dorsiflexion without a compensatory loss of plantarflexion.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Total ankle arthroplasty: Strength, pain, and motion

BACKGROUND

While outcomes such as pain and ankle motion are well researched, information regarding the effect of total ankle arthroplasty on ankle plantarflexion strength is extraordinarily limited. The purpose of this study was to evaluate ankle plantarflexion strength before and after total ankle arthroplasty, and examine the interplay of pain, motion, and strength.

METHODS

This prospective case-control study included 19 patients with end-stage ankle arthritis who received a total ankle arthroplasty and 19 healthy control participants matched for age, sex, and body mass index. Pain was measured with a numeric pain rating scale. Passive sagittal plane ankle range of motion (°) and isokinetic ankle plantarflexion torque (Nm/kg) at 60 and 120°/s were measured with an instrumented dynamometer. t-tests or non-parametric tests were used to evaluate outcomes across time and between groups. Bivariate correlations were performed to evaluate the interplay of postoperative pain, motion, and torque.

FINDINGS

Patient pain and motion improved between the preoperative and six-month postoperative time points (d ≥ 0.7). Ankle plantarflexion torque was not different across time (d ≤ 0.5), but was lower than control group values postoperatively (d ≥ 1.4). Significant correlations between pain and motion (r = -0.48), but not torque (-0.11 ≤ r ≤ 0.13), were observed.

INTERPRETATION

Unchanged following surgery, impairments in muscle performance following total ankle arthroplasty do not appear to be changed by improved pain or motion. These findings provide impetus for postoperative strengthening interventions.

[Adult Acquired Flatfoot Deformity: Diagnosis and Surgical Treatment]

The adult acquired flatfoot is a deformity with slow progression, which may leads to pain and restrictions of activities of daily living if untreated. Various treatment strategies, depending on the clinical and radiological presentation, exist. Therefore, an individual therapy approach is necessary for optimal treatment. This article covers etiopathologic aspects, conservative and operative treatments as well as postoperative mobilization and rehabilitation.

Outcomes and Incidence of Complications Following Endoscopic Gastrocnemius Recession: A Systematic Review

Introduction: Equinus contracture of the ankle can lead to a multitude of foot and ankle pathologies. The gastrocnemius recession has been used to address equinus deformity via various methods, including either an open or an endoscopic approach. Open techniques require increased intraoperative time and complication risks of sural nerve injury, wound complications, and poor cosmesis. Resultantly, the aim of the current study is to review the complications and outcomes of the endoscopic gastrocnemius recession. Methods: A systematic review of electronic databases was performed. The authors compiled data from retrospective and prospective patient studies including general patient demographics, outcomes, qualitative scoring measures, complications, and surgical technique. Results: Eleven studies met our inclusion criteria. A total of 697 feet in 627 patients were included in the current systematic review. The weighted mean age was 45.3 years and weighted mean follow-up was 18.4 months. The most common indication for an endoscopic gastrocnemius recession was equinus contracture. The weighted mean preoperative ankle range of motion was -2.3° and the weighted postoperative ankle range of motion was 10.9°. The most common complications included plantarflexion weakness of the ankle at 3.5%, a sural nerve injury of 3.0% and wound complication rate was 1.0% with no deep infection. The overall complication rate was 7.5%. Conclusion: The endoscopic gastrocnemius recession is a valuable surgical tool in the treatment of ankle equinus. The endoscopic approach has satisfactory outcomes including low incidence of plantarflexion weakness and sural neuritis. Patients should be counseled on these risks preoperatively. Compared with previously reported systematic review of the open technique, the endoscopic approach has a lower overall incidence of complications. Prospective clinical trials comparing open and endoscopic techniques are warranted.Levels of Evidence: Level IV.

Proximal medial gastrocnemius release: Muscle strength evaluation

BACKGROUND

Contracture of the gastrocnemius has been associated with different foot and ankle pathologies. The present study's aim is to evaluate the effect of the proximal medial gastrocnemius release (PMGR) in triceps surae strength.

METHODS

Prospective study with 14 patients (12 women; mean age 52 years). Inclusion criteria were patients undergoing PMGR due to forefoot and/or hindfoot injury with medial gastrocnemius contracture that has not improved with physical therapy. Isometric and isokinetic force evaluation tests with an isokinetic dynamometer (Con-Trex) were performed preoperatively, at 6 and 12 months postoperative, of both limbs.

RESULTS

After isokinetic assessment, the statistically significant difference in the preoperative isometric strength of the triceps between the two ankles was confirmed, being stronger the asymptomatic limb. An improvement in the triceps strength in isokinetics was observed at 60°/s at 6 months after surgery (p=0.008), that was maintained after one year (p=0.05). No differences were observed at 120°/sec speed.

CONCLUSION

Patients with gastrocnemius contracture present a decrease in isometric force with respect to the asymptomatic limb preoperatively. There is an improvement in isokinetic strength after 6 months postoperatively.

Changes in Muscle Morphology Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Cohort Imaging Study

Background. The purpose of this study was to evaluate changes in posterior compartment muscle volume and intramuscular fat content following gastrocnemius recession in people with Achilles tendinopathy (AT). Methods. Eight patients diagnosed with unilateral recalcitrant AT and an isolated gastrocnemius contracture participated in this prospective cohort study. Magnetic resonance imaging was performed on both limbs of each participant before and 6 months following an isolated gastrocnemius recession. Involved limb muscle volumes and fat fractions (FFs) of the medial gastrocnemius, lateral gastrocnemius, and soleus muscle were normalized to the uninvolved limb. Preoperative to postoperative comparisons were made with Wilcoxon signed-rank tests. Results. Soleus or lateral gastrocnemius muscle volumes or FFs were not significantly different between study time points. A significant difference was found in medial gastrocnemius muscle volume (decrease; P = .012) and FF (increase; P = .017). Conclusion. A major goal of the Strayer gastrocnemius recession, selective lengthening of the posterior compartment while preserving soleus muscle morphology, was supported. The observed changes isolated to the medial gastrocnemius muscle may reduce ankle plantarflexion torque capacity. Study findings may help inform selection of surgical candidates, refine anticipated outcomes, and better direct postoperative rehabilitation following gastrocnemius recession for AT.Levels of Evidence: Level IV: Prospective cohort study.

Proximal Medial Gastrocnemius Release Versus Open Plantar Fasciotomy for the Surgical Treatment in Recalcitrant Plantar Fasciitis

BACKGROUND

Plantar fasciitis is a common cause of foot pain. If conservative treatment fails, there is no consensus as to the best surgical management for recalcitrant plantar fasciitis (RPF). The aim of this study was to compare the results obtained from proximal medial gastrocnemius release (PMGR) with those obtained from open plantar fasciotomy (OPF) in terms of pain, satisfaction, health-related quality of life, and American Orthopaedic Foot & Ankle Society (AOFAS) score.

METHODS

This is a prospective randomized trial conducted between 2012 and 2016. Patients with RPF for at least 9 months were included. Diagnosis was clinically made. The exclusion criteria were neuropathic heel pain; a history of previous foot fracture, surgery, or deformity; rheumatoid arthritis; or the need for long-term analgesic administration. After ruling out other conditions with magnetic resonance or ultrasound imaging, patients were randomized to be operated on with OPF or PMGR independently of the Silfverskjold test. Follow-up was carried out for up to 1 year. The AOFAS, visual analog scale (VAS) for pain, SF-36, and Likert scale for satisfaction were used to evaluate the results obtained. The analysis was done with 21 patients in the OPF group and 15 in the PMGR group. The demographic data (age, sex, body mass index, duration of symptoms, and positivity to the Silfverskjold test) of the groups were comparable.

RESULTS

No differences were found in terms of the AOFAS (P = .24), VAS (P = .14), or any item of the SF-36. Satisfaction was very good in 85.8% of the PMGR group and 89.5% of the OPF group (P = .27). Faster recovery was observed in the PMGR group.

CONCLUSION

OPF and PMGR provided good results for patients with RPF. Neither was superior to the other relative to pain, AOFAS score, satisfaction, or the SF-36. We recommend PMGR as the first option in RPF surgical management in order to avoid potential biomechanical complications related to OPF.

LEVEL OF EVIDENCE

Level I, therapeutic randomized controlled trial.

Scientific Evidence in the Treatment of Metatarsalgia

Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.

The Role of First Ray Insufficiency in the Development of Metatarsalgia

Two theories exist in the development of central or transfer metatarsalgia. First, as the severity of hallux valgus increases, there is mechanical overload of the second metatarsal. Second, increased relative lesser metatarsal length is thought to contribute to metatarsalgia. It is imperative, in the treatment of first ray disorders (hallux valgus or hallux rigidus), to not overshorten the first ray when addressing the first ray pathologic condition. Treatment of metatarsalgia in the setting of failed hallux valgus correction can be treated with both conservative and surgical options.

Gastrocnemius Recession in the Setting of Metatarsalgia: The Baumann Procedure

A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics.

Clinical and radiological outcomes of concomitant endoscopic gastrocnemius release with scarf osteotomy

BACKGROUND

Studies showed patients with hallux valgus also have tight gastrocnemius concomitantly. This study aims to investigate (1) prevalence of tight gastrocnemius in symptomatic hallux valgus (2) clinical and radiological outcomes of concomitant endoscopic gastrocnemius release with scarf osteotomy.

METHODS

Between January 2011 to December 2013, 224 patients underwent hallux valgus surgery were evaluated. They were categorized into 2 groups: scarf osteotomy (n=195), scarf and endoscopic gastrocnemius release (combine, n=29). Clinical outcome measures assessed included VAS, AOFAS Hallux MTP-IP and SF-36 scores. Radiological outcomes included HVA, IMA, HVI and TSP. All patients were prospectively followed up for 6 and 24 months.

RESULTS

The prevalence of ipsilateral gastrocnemius tightness in symptomatic hallux valgus is 12.9%. No significant difference in preoperative clinical outcomes between the two groups (all p>.05). Although AOFAS was 6±2 points poorer in the combine group compared to the scarf group at 6 months follow up (p=0.021), at 24 months, all clinical outcomes were comparable between the two groups (all p>0.05). Significant difference in the HVA change between the groups were observed but comparable radiological outcomes in IMA, TSP and HVI at 24 months follow up.

CONCLUSIONS

We conclude clinical and radiological outcomes of concomitant endoscopic gastrocnemius release and scarf osteotomy are comparable with scarf osteotomy alone at 24 months.

Gastrocnemius Recession for Metatarsalgia

Metatarsalgia is a common cause of plantar forefoot pain. Causes of metatarsalgia include foot anatomy, gait mechanics, and foot and ankle deformity. One specific cause, mechanical metatarsalgia, occurs because of gastrocnemius muscle contracture, which overloads the forefoot. Muscular imbalance of the gastrocnemius complex alters gait mechanics, which increases recruitment of the toe extensor musculature, thereby altering forefoot pressure. Patients with concomitant metatarsalgia and gastrocnemius contracture demonstrate ankle equinus and a positive Silfverskiold test. Nonoperative therapeutic modalities are mainstays of treatment. In patients in whom these treatments fail to provide metatarsalgia symptomatic relief, gastrocnemius muscle lengthening is a therapeutic option.

Cadaveric Study of the Junction Point Where the Gastrocnemius Aponeurosis Joins the Soleus Aponeurosis

Purpose

To study the location of the junction point where the gastrocnemius aponeurosis joins the soleus aponeurosis to form the Achilles tendon.

Methods

Twelve lower limb specimens were used. The distance between the medial tibial plateau and the superior border of the posterior calcaneal tubercle (A) was measured and the distances of the junction point to the superior border of the posterior calcaneal tubercle (B) were measured.

Result

The ratio B/A averaged 0.45. The gastrocnemius muscle reached or extended beyond the junction point in eight specimens (67%). The average distance from the lowest border of the muscle to the junction point was 0±12mm (-25-25).

Conclusion

There are great anatomical variations of the gastrocnemius insertion. Resection of muscle bound portion of the gastrocnemius aponeurosis is a more appropriate approach of endoscopic gastrocnemius aponeurosis recession.

Clinical Relevance

This report suggests that resection of muscle bound portion rather than the muscle void portion of the gastrocnemius aponeurosis is a more appropriate approach of endoscopic gastrocnemius aponeurosis recession.

Cadaveric Anatomical Study of Sural Nerve: Where is The Safe Area for Endoscopic Gastrocnemius Recession?

Purpose:

To ascertain in cadavers where the sural nerve crosses the gastro-soleus complex and where the gastrocnemius tendon merges with the Achilles tendon in relation to the calcaneal tuberosities.

Methods:

Twelve cadaveric lower limbs (6 right and 6 left) were dissected. The distances between the calcaneal tuberosities and the lateral border of the Achilles tendon where the sural nerve crosses from medial to lateral, as well as to the gastrocnemius tendon insertion into the Achilles tendon, were measured.

Results:

The mean and median longitudinal distances from the calcaneal tuberosity to where the sural nerve crosses the lateral border of the Achilles tendon are 9.9cm and 10cm respectively (range 7cm to 14cm). The mean and median longitudinal distances from the calcaneal tuberosity to where the gastrocnemius tendon inserts into the Achilles tendon are 19.9cm and 18.5cm (range 17cm to 25cm) respectively.

Conclusion:

It is generally safe to place the posterolateral incision more than 14cm above the calcaneal tuberosity to avoid the sural nerve if surgeons plan to use a posterolateral incision for endoscopic recession. The distance between the calcaneal tuberosity to the gastrocnemius tendon insertion into the Achilles tendon is too highly variable to be used as a landmark for locating the gastrocnemius insertion.

Efficacy of pedobarographic analysis to evaluate proximal medial gastrocnemius recession in patients with gastrocnemius tightness and metatarsalgia

PURPOSE

Proximal medial gastrocnemius recession (PMGR) is a surgical procedure performed in patients with gastrocnemius tightness (GT). The purpose of this study is to evaluate the efficacy of pedobarographic analysis on PMGR in patients with GT and metatarsalgia.

METHODS

This prospective study included 52 patients diagnosed with GT treated surgically with PMGR and 49 non-operated upon patients (control group). A total of 55 PMGRs (three bilateral) were performed as an isolated or combined procedure in the treatment group. Passive ankle dorsiflexion with knee flexion and extension was evaluated in all patients. In addition, pedobarographic analysis was performed before and after surgery.

RESULTS

Median preoperative ankle dorsiflexion was -10.0° (equinus) with extended knee and 10.0° with flexed knee and postoperative differences in median ankle dorsiflexion was 12.5° (extended knee) (p = 0.000) and 5.0° (flexed knee) (p = 0.002). After the PMGR, the median area of the contact surface (-3.0 cm²) (p = 0.009), the maximum (-13,239.0 Pa) (p = 0.019) and mean pressure (-2,942.0 Pa) and the forefoot force (-70.0 N) (p = 0.000) decreased. An increase in hindfoot force (20.0 N), hindfoot bearing time (4.0 ms) (p = 0.005), and forefoot bearing time (1.0 ms) was also observed.

CONCLUSIONS

Pedobarographic analysis is an efficient tool to evaluate surgical procedures that assess metatarsal overload. PMGR is an effective surgical procedure to improve passive ankle range of motion and decrease forefoot plantar overload.

Gastrocnemius Recession Leads to Increased Ankle Motion and Improved Patient Satisfaction After 2 Years of Follow-Up

The isolated gastrocnemius contracture present in neurologic healthy patients results in a significant limitation of ankle dorsiflexion causing pathologic gait patterns and a greater risk of further foot disorders. Gastrocnemius recession is an established procedure to increase ankle dorsiflexion. However, little evidence is available of the use of gastrocnemius recession in these patients. Complication rates, recurrence of gastrocnemius contracture, and the prevalence of additional foot disorders needs further evaluation. A study group of 64 operated limbs undergoing gastrocnemius recession was evaluated to determine the prevalence of foot disorders, pre- and postoperative ankle dorsiflexion, and incidence of complications. A subgroup of 15 (23.4%) patients without additional operative procedures was examined regarding ankle dorsiflexion, strength (Janda method), sensitivity in the operated limb, and the pre- and postoperative Foot Function Index scores. The prevalence of foot disorders showed pes planus (41%), hallux valgus (38%), metatarsalgia (19%), hammertoe deformity (13%), and symptomatic Haglund exostosis (11%). At 31 months of follow-up, the patients had significantly benefited from increased ankle dorsiflexion of 13.3° ± 7.9° (p < .001). Postoperatively, 16% patients experienced complications. In the subgroup of 15 patients, the follow-up examination after 44 months showed ankle dorsiflexion of 14° ± 7.1°. The plantarflexion strength was 4 of 5 (Janda method). The Foot Function Index score had improved significantly from 65.4 ± 26.5 points to 33.4 ± 19.5 points (p < .001). Patients with isolated gastrocnemius contracture seem to have a high prevalence of symptomatic foot disorders. At a mid-term follow-up examination, gastrocnemius recession (Strayer) was shown to be an effective procedure to significantly improve ankle dorsiflexion, functionality, and pain symptoms. More attention should be given to the development of postoperative complications.

Equinus and Lengthening Techniques

Equinus is linked to most lower extremity biomechanically related disorders. Defining equinus as ankle joint dorsiflexion less than 5° of dorsiflexion with the knee extended is the basis for evaluation and management of the deformity. Consistent evaluation methodology using a goniometer with the subtalar joint in neutral position and midtarsal joint supinated while dorsiflexing the ankle with knee extended provides a consistent clinical examination. For equinus deformity with an associated disorder, comprehensive treatment mandates treatment of the equinus deformity. Surgical treatment of equinus offers multiple procedures but the Baumann gastrocnemius recession is preferred based on deformity correction without weakness.

Operative Anatomy of the Medial Gastrocnemius Recession vs the Proximal Medial Gastrocnemius Recession

BACKGROUND

Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pathologies. To address the problem of IGC, a number of gastrocnemius lengthening procedures have been described. Although proximal medial gastrocnemius recession (PMGR) has shown to be an effective operative treatment for IGC, it poses risks to various anatomic structures around the knee joint and requires the patient to be positioned prone. As an alternative, we proposed to release the medial gastrocnemius at the division between the proximal one-third and distal two-thirds of the gastrocnemius muscle to correct equinus contracture, while minimizing risk to other structures. The aim of this study was to describe an anatomic basis for a medial gastrocnemius recession (MGR) and to investigate the anatomic structures at risk in comparison to PMGR.

METHODS

Eight cadaveric lower leg specimens were used in the study. The standard PMGR and the novel MGR were performed on each specimen. After completion of the 2 procedures, complete dissection was performed to investigate the distances between surgically released fascia margins and surrounding anatomic structures, including the greater saphenous vein, small saphenous vein, saphenous nerve, medial sural cutaneous nerve, semimembranosus tendon, tibial nerve, and popliteal artery. The mean distances were calculated and the shortest distances for each structure were reported.

RESULTS

Proximities of anatomic structures to surgically released gastrocnemius fascia at the medial and lateral margins were notably different between the 2 techniques. For the PMGR, the semimembranosus tendon (95% confidence interval of 2.4-7.4 mm), small saphenous vein (3.4-10.0 mm), popliteal artery (3.9-9.3 mm), and tibial nerve (5.0-11.1 mm) were in greater proximity to the operative margin. For the MGR, the greater saphenous vein (5.3-17.6 mm) and saphenous nerve (5.1-18.6 mm) were at greater risk.

CONCLUSIONS

MGR at the proximal one-third of the gastrocnemius muscle may be a safe alternative for operative treatment of IGC.

CLINICAL RELEVANCE

We identified the major structures at risk when performing the proximal medial gastrocnemius release and propose a novel, possibly safer alternative for the medial gastrocnemius release.

Clinical and Functional Outcomes of Gastrocnemius Recession for Chronic Achilles Tendinopathy

BACKGROUND

Although gastrocnemius recession has been proposed and used in the treatment of chronic noninsertional Achilles tendinopathy, only weak evidence exists to support this operative indication. The purpose of our study was to assess the clinical and functional outcomes of patients treated with gastrocnemius recession at 2 institutions for this problem.

METHODS

Thirty-four patients were identified through our medical records and asked to participate in this study. Thirty patients (35 legs) responded to the invitation. Sixteen patients were eligible for clinical follow-up, and 14 patients responded by letter or telephone interview. Two patients did not want to participate, and 2 patients could not be reached. Data were collected by a satisfaction questionnaire, the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, a visual analog scale (VAS) for pain, a functional test battery, and a clinical examination.

RESULTS

A subgroup with preoperative data (n = 8) showed an increase in the mean VISA-A score from 39.5 to 91.9. The mean overall VISA-A score (n = 30) was 91.4 at follow-up. The mean VAS for pain score when walking decreased from 7.5 before surgery to 0.8 after surgery. Twenty-eight of 30 patients reported that they were satisfied with their results after surgery. Functional testing showed no difference in gastrocnemius-soleus function between the operated and nonoperated leg (n = 10).

CONCLUSION

The findings support the promising results from other studies regarding gastrocnemius recession as an effective and safe way of treating chronic Achilles tendinopathy. The patients recovered both in terms of pain and function.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy

BACKGROUND

Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemius recession (GR) procedure. However, changes in muscle performance during functional activities are not known. The purpose of this study was to determine the effect of an isolated GR on ankle power and endurance in patients with Achilles tendinopathy.

METHODS

Fourteen patients with chronic unilateral Achilles tendinopathy and 10 healthy controls participated in this study. Patient group data were collected 18 months following GR. Pain was compared to preoperative values using a 10-cm visual analog scale (VAS). Patient-reported outcomes for activities of daily living (ADL) and sports were assessed using the Foot and Ankle Ability Measure (FAAM). Kinematic and kinetic data were collected during gait, stair ascent (standard and high step), and repetitive single-limb heel raises. Between-group and side-to-side differences in ankle plantarflexor muscle power and endurance were evaluated with appropriate t tests.

RESULTS

Compared with preoperative data, VAS pain scores were reduced (pre 6.8, post 1.6, P < .05). Significant differences were observed between GR and Control groups for FAAM scores for both ADL (GR 90.0, Control 98.3, P = .01) and Sports subscales (GR 70.6, Control 94.6, P = .01). When compared to controls, ankle power was reduced in the involved limb of the GR group for all activities (all P < .05). Between-group and side-to-side deficits (GR group only) were also found for ankle endurance.

CONCLUSION

The gastrocnemius recession procedure provided significant pain reduction that was maintained at the 18-month follow-up for patients with chronic Achilles tendinopathy who failed nonoperative interventions. There were good patient-reported outcomes for activities of daily living. However, compared to controls, ankle plantarflexion power and endurance deficits in the GR group were noted. The functional implications of the muscle performance deficits are unclear, but may be reflective of patients' self-reported difficulty during more challenging activities.

LEVEL OF EVIDENCE

Level III, comparative study.

Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia

BACKGROUND

Gastrocnemius shortening causes an equinus deformity that may clinically manifest in foot disorders, including metatarsalgia. We use this term to describe pain localized to the metatarsal heads. The purposes of this prospective study were to review the effect of medial gastrocnemius proximal release on ankle dorsiflexion and assess the outcome of this technique on pain and functional limitations in patients who have mechanical metatarsalgia and isolated gastrocnemius shortening.

METHODS

We prospectively followed a consecutive series of 78 feet in 52 patients with metatarsalgia who had an isolated gastrocnemius contracture assessed with the Silfverskiöld test. Surgical release was evaluated with visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scales. Ankle dorsiflexion was measured at 1, 3, and 6 months postoperatively.

RESULTS

Preoperative values of VAS and AOFAS were 7.4 and 46.8, respectively. After 3 months postoperatively, the values were 3.0 and 81.7, and 6 months after surgery these values were 3.5 and 83.6. No patient worsened clinically. There were no major complications. Thirty-six patients (69.2%) were completely satisfied with the results of the surgery. Preoperatively, ankle dorsiflexion with the knee straight was -17.5 degrees, which improved to 2.5 degrees at 6 months postoperatively.

CONCLUSION

We believe proximal medial gastrocnemius recession is an alternate procedure to treat selected patients with mechanical metatarsalgia and gastrocnemius shortening. It had acceptable morbidity and cosmetic results.

LEVEL OF EVIDENCE

Level IV, case series.

Effects of gastrocnemius recession on ankle motion, strength, and functional outcomes: a systematic review and national healthcare database analysis

PURPOSE

The purpose of this systematic review was to report the effects of gastrocnemius recession on ankle dorsiflexion range of motion, function, and push-off power.

METHODS

The MEDLINE and EMBASE databases were reviewed with terms "gastrocnemius recession". The inclusion criteria were: (1) clinical studies, (2) published in a peer-reviewed journal within the past 10 years, and (3) published in English. Excluded were: (1) review articles, (2) cadaveric studies, (3) studies including patients under the age of 18 years, (4) studies evaluating a neurologic condition, (5) level of evidence 5, and (6) Quality of Evidence Score <3. Data were then extracted and analysed for trends. The PearlDiver Database was also used to review de-identified patient information retrospectively between 2007 and 2011.

RESULTS

Full-text review yielded 23 articles that fit the inclusion criteria. Twenty-one of 23 (91%) and 2/23 (9%) studies were level of evidence 4 and 3, respectively. Twelve of 23 (52%) studies reported follow-up assessment between 12 and 36 months, and no studies reported longer-term follow-up. Twelve of 12 (100%) studies reported improved dorsiflexion range of motion 9/9 (100%) reported improved AOFAS, and 11/11 (100%) reported improved VAS. Five of 23 (22%) studies reported strength in a measured and controlled fashion with variable results, but of these, no study reported a return to normal power. The mean complication rate was 14%.

CONCLUSION

The available evidence supports that GR improves functional outcomes and increases dorsiflexion range of motion. Furthermore, GR affects gait kinematics, which may cause compensatory effects at the knee, ankle, and subtalar joints. Evidence has shown that power does not return to normal levels. Clinicians may utilize these data clinically to determine whether patients may benefit from GR or not.

LEVEL OF EVIDENCE

IV.

Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations

BACKGROUND

Gastrocnemius recession is a surgical technique commonly performed on individuals who suffer from symptoms related to the restricted ankle dorsiflexion that results when tight superficial posterior compartment musculature causes an equinus contracture. Numerous variations for muscle-tendon unit release along the length of the calf have been described for this procedure over the past century, although all techniques share at least partial or complete release of the gastrocnemius muscle given its role as the primary plantarflexor of the ankle. There exists strong evidence to support the use of this procedure in pediatric patients suffering from cerebral palsy, and increasingly enthusiastic support-but less science-behind its application in treating adult foot and ankle pathologies perceived to be associated with gastrocnemius tightness. The purpose of this study, therefore, was to evaluate currently available evidence for using gastrocnemius recession in three adult populations for whom it is now commonly employed: Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers.

METHODS

A systematic review of the literature was performed on December 21, 2013 using the PubMed, Scopus, and Cochrane databases along with the search term "(gastrocnemius OR gastrocsoleus) AND (recession OR release OR lengthening)." This search generated 1141 results; 12 articles found in the references of these papers were also screened for inclusion. In total, 18 articles met our inclusion criteria. These articles were reviewed and assigned a classification (I-V) of Level of Evidence, according to the criteria recommended by the Journal of Bone & Joint Surgery. Based on these classifications, a Grade of Recommendation was assigned for each of the indications of interest.

RESULTS

Grade B evidence-based literature ("fair") exists to support the use of gastrocnemius recession for the treatment of isolated foot pain due to midfoot/forefoot overload syndrome in adults. There are some data in support of utilizing gastrocnemius recession to treat midfoot or forefoot ulcers and non-insertional Achilles tendinopathy in adults, but to date this evidence remains Grade Cf. Insufficient evidence (Grade I) is currently available to make any recommendation either for or against this procedure for the treatment of insertional Achilles tendinopathy.

CONCLUSION

Scientific literature continues to grow in support of using isolated gastrocnemius recession as an effective treatment strategy for a variety of lower limb pathologies, although it remains clear that higher evidence levels and more carefully controlled investigations will be necessary to more convincingly define the true efficacy and ideal applications of gastrocnemius recession in the adult population.

LEVEL OF EVIDENCE

Level IV systematic review.

Isolated gastrocnemius recession for achilles tendinopathy: strength and functional outcomes

BACKGROUND

Gastrocnemius recession has emerged as a viable intervention for patients with recalcitrant foot and ankle disorders associated with isolated gastrocnemius contracture. The purpose of this case-control study was to investigate the effects of an isolated gastrocnemius recession on pain, patient-reported function, and strength in patients with chronic Achilles tendinopathy and an isolated gastrocnemius contracture.

METHODS

Thirteen patients with unilateral Achilles tendinopathy (mean age [and standard deviation], fifty-two ± 7.7 years) who received a gastrocnemius recession and ten matched-control subjects participated. A visual analog scale was used to assess pain, and the Foot and Ankle Ability Measure was used to evaluate patient-reported function in activities of daily living and sports. Patients were asked about their satisfaction with the results of the gastrocnemius recession. Ankle plantar flexion peak torque was assessed at 60°/sec and 120°/sec. Appropriate t tests were used to assess limb symmetry and strength differences between the groups.

RESULTS

The mean duration of follow-up was eighteen months (range, twelve to twenty-eight months). Gastrocnemius recession provided significant pain relief (mean preoperative visual analog scale score [and standard deviation], 6.8 ± 1.8; mean follow-up visual analog scale score, 1.4 ± 2.7; p < 0.05). Foot and Ankle Ability Measure outcomes showed between-group differences in activities of daily living (Achilles tendinopathy group, 89.7; control group, 98.5; p = 0.05) and sports subscales (Achilles tendinopathy group, 71.9; control group, 95.1; p = 0.05). The activities reported to be the most challenging included going up hills, climbing stairs, running, and jumping. Eleven of the thirteen patients in the Achilles tendon group were satisfied with treatment. Side-to-side strength comparisons showed no differences at 60°/sec. Significant differences were observed at 120°/sec (Achilles tendinopathy group, 21%; control group, 3%; p < 0.05); however, the involved limb reached a peak torque similar to that in the control limb.

CONCLUSIONS

Isolated gastrocnemius recession provides significant and sustained pain relief for chronic Achilles tendinopathy. Good function can be expected for activities of daily living, but power and endurance activities were more problematic for the Achilles tendinopathy group. Isokinetic strength assessment may not effectively capture patient-reported functional deficits.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Results after gastrocnemius recession in 73 patients

BACKGROUND

Very few studies describe the clinical results and complications following the surgical procedure of gastrocnemius recession.

PURPOSE

To survey the patient reported outcomes in patients operated with gastrocnemius recession as single procedure for various foot conditions.

MATERIAL AND METHODS

93 patients operated with gastrocnemius recession as single procedure between 2006 and 2011 were detected in the database. 73 patients responded to the invitation for study participation. Questionnaires containing patient reported satisfaction, complications, plantar flexion power and visual analog pain score were used for evaluation of the postoperative result.

RESULTS

45/73 (62%) patients reported a good or excellent result. 8/73 (11%) patients reported a significant postoperative complication. 16/73 (22%) patients noted reduced or severely reduced plantar flexion power after surgery. VAS pain score significantly decreased from 7.0 before surgery to 1.8 (p=0.015) after surgery for patients with plantar fasciitis (n=18) and from 5.6 to 2.3 (p<0.01) for patients with metatarsalgia (n=28).

CONCLUSION

Patients treated with gastrocnemius recession for plantar fasciitis demonstrated good clinical results. The complication rate was higher than reported by others.

The use of ultrasound to isolate the gastrocnemius-soleus junction prior to gastrocnemius recession

Gastrocnemius recession has become a popular procedure to release isolated gastrocnemius tightness. Using visual anatomic landmarks alone to plan the incision can be deceiving. The use of ultrasound preoperatively has been highly reproducible in isolating the gastrocnemius-soleus junction in the authors' practice. This provides confidence for incision placement, a smaller incision, and isolated release of the gastrocnemius fascia while leaving the underlying soleus undisturbed.

Release of the medial head of the gastrocnemius for Achilles tendinopathy in sedentary patients: a retrospective study

PURPOSE

Our aim was to ascertain whether releasing the medial head of he gastrocnemius improves clinical and functional outcomes of sedentary patients with long-standing tendinopathy of the main body of the Achilles tendon and allows return to daily activities.

METHODS

Eighteen patients (seven men, 11 women) underwent release of the gastrocnemius medial head to manage chronic unilateral Achilles tendinopathy. Pre- and postoperatively, each patient completed the Victorian Institute of Sports Assessment-Achilles tendon (VISA-A) questionnaire. The maximum calf circumference and isometric plantar flexion strength of the gastrocsoleus complex were measured in both the affected and the contralateral leg. Function was scored using the 4-point Boyden scale at the last assessment.

RESULTS

At the last appointment, at an average follow-up of 54 months, maximum calf circumference and strength of the operated leg were not significantly different than pre-operatively and were significantly lower than the contralateral leg. All patients could satisfactorily perform the same work and daily activities as before symptom onset. At the last follow-up, the average VISA-A score was improved from a preoperative average value of 52.3 to 75 (range 51-94) (p < .001).

CONCLUSIONS

This approach to managing isolated Achiles tendinopathy is safe, effective, low cost and allows safe return to preinjury daily activities.

Fibrous Tendon Hypertrophy after Gastrocnemius Recession: A Case Report

Surgical complications after gastrocnemius recession have been rare in published studies. We report a case of symptomatic fibrous tendon hypertrophy requiring revision surgery. Additionally, we have provided a review of the published data on the complications related to this procedure.

Endoscopic Gastrocnemius Recession for the Treatment of Isolated Gastrocnemius Contracture: A Prospective Study on 320 Consecutive Patients

BACKGROUND

Endoscopic gastrocnemius recession has been proposed as a minimally invasive technique for the treatment of isolated gastrocnemius contracture. We report on the safety and efficacy of endoscopic gastrocnemius recession, as an isolated procedure or combined with other concomitant procedures in terms of improvement in ankle dorsiflexion, functional outcome, and postoperative morbidities.

METHODS

The data were prospectively collected in this case series. Endoscopic gastrocnemius recession was performed by a single surgeon in 320 consecutive patients (344 feet) who were diagnosed with isolated gastrocnemius contracture and failed nonoperative treatments between March 2009 and December 2012. There were 180 women and 140 men with mean age, 47.1 ± 15.7 years. The minimum follow-up was 1 year (mean, 18 months; range, 12 to 53 months). Pre- and postoperative ankle dorsiflexion, pain (Visual Analog Scale [VAS]), SF-36, and Foot Function Index (FFI) were obtained and compared using paired sample t test and Wilcoxon signed-rank test.

RESULTS

The mean ankle dorsiflexion significantly improved from -0.8 ± 5.4 degrees preoperatively to 11.0 ± 6.6 degrees at average of 13 months postoperatively (n = 294) (P < .001). Complete preoperative and 1-year postoperative pain (VAS) (n = 274) and functional outcome scores (n = 185) were collected when possible. The mean pain (VAS) decreased from 7/10 to 3/10 postoperatively (all P < .01). The mean SF-36 including physical component summary score (PCS) and mental component summary score (MCS) increased from 34 and 44 to 45 and 51, respectively (P < .01 for both PCS and MCS). The mean FFI improved from 63 to 42 for pain, 63 to 43 for disability, 68 to 44 for activity limitation, and 61 to 41 for total score postoperatively (all P < .01). Postoperative morbidity included weakness of ankle plantarflexion (N = 11/320; 3.1% respectively) and sural nerve dysesthesia (N = 10/320; 3.4%). Wound complications or Achilles tendon rupture did not occur. There was no difference in the average improvement in ankle dorsiflexion, outcome scores, and rate of complications between the isolated and combined procedures.

CONCLUSION

Endoscopic gastrocnemius recession demonstrated promising results in the treatment of isolated gastrocnemius contracture. Ankle dorsiflexion was significantly improved with minimal morbidity. The procedure was found effective in improving functional outcomes and relieving pain as a sole operative treatment and as a part of combined procedures in our patients.

LEVEL OF EVIDENCE

Level IV, case series.

Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession

PURPOSE

The purpose of this study was to compare results of partial proximal fasciotomy (PPF) with proximal medial gastrocnemius release (PMGR) in the treatment of chronic plantar fasciitis (CPF).

METHOD

This retrospective study compares 30 patients with CPF that underwent PPF with 30 that underwent isolated PMGR. Both groups were matched in terms of previous treatments and time from onset of symptoms to surgery. Different standardised evaluation scales (VAS, Likert, AOFASh) were used to evaluate results.

RESULTS

Plantar fasciotomy had satisfactory results in just 60 % of patients, with an average ten weeks needed to resume work and sports. Patient satisfaction in the PMGR group reached 95 %, being back to work and sports at three weeks on average. Functional and pain scores were considerably better for PMGR and fewer complications registered.

CONCLUSION

In our series, isolated PMGR is a simple and reliable procedure to treat patients with CPF. It provides far better results than conventional fasciotomy with less morbidity and better patient satisfaction, and thus has become our surgical procedure of choice in recalcitrant CPF.

Silfverskiold's test in total ankle replacement with gastrocnemius recession

BACKGROUND

For patients undergoing primary total ankle replacement (TAR) with an equinus contracture, gastrocnemius recession may be performed to increase dorsiflexion. We examined whether gastrocnemius recession would significantly increase dorsiflexion even with a negative Silfverskiöld test.

METHODS

Data were prospectively collected on a consecutive series of 29 patients who underwent TAR. All were deemed to require lengthening of the posterior soft tissue structures for unacceptable equinus contracture. Once each patient was under anesthesia, Silfverskiöld's test was performed. A digital photograph was taken with the ankle at maximum passive dorsiflexion with the knee at 0 degrees of flexion and again with the knee at 30 degrees of flexion. Strayer gastrocnemius recession was then performed in standard fashion in every patient. After recession, Silfverskiöld's test was again performed with photographs obtained in the same manner. The digital photographs demonstrating the results of the preoperative and postoperative Silfverskiöld's tests in both knee positions were analyzed and the degree of ankle dorsiflexion measured.

RESULTS

Regardless of the results of Silfverskiöld's test, after gastrocnemius recession, patients had an average increase of 12.6 ± 1.6 degrees of dorsiflexion with the knee extended compared to the same position preoperatively (P < .0001) and an increase of 10.1 ± 2.0 degrees with the knee flexed (P < .001). In 6 patients Silfverskiöld's test was markedly positive preoperatively; in this group, recession resulted in an average increase of dorsiflexion of 17.8 ± 3.6 degrees with the knee extended (P = .004) and 13.4 ± 5.4 degrees with the knee flexed (P = .055). For the remaining 23 patients with a negative preoperative Silfverskiöld's test, dorsiflexion increased by 11.3 ± 1.6 (P < .0001) and 9.3 ± 2.2 degrees (P = .0003) with the knee extended and flexed, respectively.

CONCLUSION

Our data show that a gastrocnemius recession resulted in a significant, reproducible increase in dorsiflexion regardless of the results of the Silfverskiöld test while avoiding potential push-off and plantarflexion weakness associated with an Achilles lengthening.

LEVEL OF EVIDENCE

Level IV, case series.

The effect of kinesio tape application on hamstring and gastrocnemius muscles in healthy young adults

BACKGROUND

Scarce evidence exists about effectiveness and mechanisms of action of Kinesio tape (KT) application.

OBJECTIVES

To evaluate the effect of KT application over the gastrocnemius or hamstring on range of motion and peak force.

METHODS

Thirty-six physical therapy students participated (18 per group). KT was applied with 30% tension for 48 h to: Group 1 - the gastrocnemius; Group 2 - the hamstrings. The straight leg raise (SLR), knee extension angle (KEA), weight bearing ankle dorsiflexion, gastrocnemius, quadriceps and hamstrings peak forces were evaluated prior to application, 15 min and 48 h after.

RESULTS AND CONCLUSIONS

A significant increase of peak force in the gastrocnemius group appeared immediately and two days later; no immediate change of peak force in the hamstrings group, however, two days later, peak force significantly increased. SLR and ankle dorsiflexion increased immediately in the gastrocnemius group; KEA improved significantly only after two days. It is possible that certain muscles react differently when KT is applied, and the effect may be subsequently detected.

Results of proximal medial gastrocnemius release for Achilles tendinopathy

BACKGROUND

Most patients with Achilles tendinopathy (AT) are treated successfully with physiotherapy involving eccentric calf training. In some patients, gastrocnemius contracture persists and there are reports of improvement following gastrocnemius release. We present the first series of patients to have proximal medial gastrocnemius release (PMGR) for AT.

METHOD

16 PMGRs (12 patients) were performed at our institution over a 2-year period. Nine patients (10 PMGRs) were available for follow-up. The mean age of patients was 45 years (range, 25-63 years), with 5 female and 4 male subjects. The average follow-up period was 2.5 years (range, 1.7-3.3 years). The sample was divided into noninsertional and insertional tendinopathy, with 5 PMGRs per group. Outcome measures were visual analog scale (VAS) scores, Victorian Institute of Sport Assessment-Achilles (VISA-A) scores, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and overall satisfaction. Complications and further procedures were also recorded.

RESULTS

At an average of 2.5 years of follow-up, 6 out of 9 patients were highly satisfied. The noninsertional tendinopathy group enjoyed better results than the insertional group: mean VISA-A scores improved by 59% (noninsertional) versus 22% (insertional); mean AOFAS scores improved by 29% (noninsertional) versus 15% (insertional). The improvement in the noninsertional group was statistically significant (P < .05) for all 3 outcome measures.

CONCLUSION

PMGR was an outpatient procedure that was well tolerated without wound healing concerns due to the proximally based incision. Patients with noninsertional tendinopathy who have failed conservative treatment can expect notable improvement, with VISA-A scores possibly normalizing after the procedure. We recommend PMGR for patients suffering recalcitrant noninsertional AT in whom gastrocnemius contracture persists despite an eccentric stretching program.

LEVEL OF EVIDENCE

Level IV, case series.

Kinetics and kinematics after the Bridle procedure for treatment of traumatic foot drop

BACKGROUND

The Bridle procedure restores active ankle dorsiflexion through a tri-tendon anastomosis of the tibialis posterior, transferred to the dorsum of the foot, with the peroneus longus and tibialis anterior tendon. Inter-segmental foot motion after the Bridle procedure has not been measured. The purpose of this study is to report kinetic and kinematic variables during walking and heel rise in patients after the Bridle procedure.

METHODS

18 Bridle and 10 control participants were studied. Walking and heel rise kinetic and kinematic variables were collected and compared using an ANOVA.

FINDINGS

During walking the Bridle group, compared with controls, had reduced ankle power at push-off [2.3 (SD 0.7) W/kg, 3.4 (SD 0.6) W/kg, respectively, P<.01], less hallux extension during swing [-13 (SD 7)°, 15 (SD 6)°, respectively, P<.01] and slightly less ankle dorsiflexion during swing [6 (SD 4)°, 9 (SD 2)°, respectively, P=.03]. During heel rise the Bridle group had 4 (SD 6)° of forefoot on hindfoot dorsiflexion compared to 8 (SD 3)° of plantarflexion in the controls (P<.01).

INTERPRETATION

This study provides evidence that the Bridle procedure restores the majority of dorsiflexion motion during swing. However, plantarflexor function during push-off and hallux extension during swing were reduced during walking in the Bridle group. Abnormal mid-tarsal joint motion, forefoot on hindfoot dorsiflexion instead of plantarflexion, was identified in the Bridle group during the more challenging heel rise task. Intervention after the Bridle procedure must maximize ankle plantarflexor function and midfoot motion should be examined during challenging tasks.

The effect of isolated gastrocnemius contracture and gastrocnemius recession on lower extremity kinematics and kinetics during stance

BACKGROUND

Isolated gastrocnemius contracture limits ankle dorsiflexion with full knee extension and is potentially problematic during mid-stance of gait when 10° of dorsiflexion and full knee extension are needed. It is during this time that patients with isolated gastrocnemius contracture may demonstrate altered kinematics and/or kinetics. When conservative management fails to resolve painful foot pathologies associated with non-spastic isolated gastrocnemius contracture, gastrocnemius recession surgery has been suggested to resolve contracture and improve function and strength. However, there are no published reports on lower extremity kinematics/kinetics in the non-spastic isolated gastrocnemius contracture population. Assessment of alterations in gait mechanics is necessary to examine the effects of this potential surgical intervention.

METHODS

Lower extremity kinematics and kinetics were assessed in 6 patients clinically diagnosed with isolated gastrocnemius contracture pre- and post-surgical recession compared with 33 healthy control participants.

FINDINGS

Pre-operatively, patients with isolated gastrocnemius contracture demonstrated significantly increased peak knee flexion angles and knee flexion moments during mid-stance. There were no differences in peak ankle dorsiflexion angle or peak plantar flexion moment. Gastrocnemius recession did not alter gait kinematics/kinetics following surgery. Joint kinematic strategies utilized to compensate for isolated gastrocnemius contracture varied minimally between participants with IGC; most employed a flexed knee strategy, while one participant utilized a reduced ankle dorsiflexion strategy.

INTERPRETATION

Select post-surgical gait mechanics were unaltered; however, gait mechanics were not similar between non-spastic isolated gastrocnemius contracture patients and healthy control participants. Surgical intervention for patients with isolated gastrocnemius contracture does not appear to create any negative gait adaptations; however, patients may benefit from gait retraining post-recession as maladaptive gait patterns persist post operatively.

Endoscopic surgery of the Achilles tendon

The value of endoscopic surgery as a minimally invasive treatment is well recognized and includes less perioperative pain, less scarring, minimal blood loss, and faster recovery. While open surgery on the Achilles tendon is notorious for wound complications, the tendon is situated in a well-formed tunnel allowing surgical procedures to be performed endoscopically. Various endoscopic techniques have been successfully applied to the treatment of non-insertional Achilles tendinopathy, Haglund's syndrome, Achilles tendon rupture, and equinus contracture. Although the evidence is currently limited, results from authors acquainted with the techniques have been encouraging. Both an understanding of surgical anatomy of the hindfoot and familiarity in soft tissue endoscopy are required to achieve successful outcomes while minimizing complications.