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Grävare Silbernagel K, Malliaras P, de Vos RJ, Hanlon S, Molenaar M, Alfredson H, van den Akker-Scheek I, Antflick J, van Ark M, Färnqvist K, Haleem Z, Kaux JF, Kirwan P, Kumar B, Lewis T, Mallows A, Masci L, Morrissey D, Murphy M, Newsham-West R, Norris R, O'Neill S, Peers K, Sancho I, Seymore K, Vallance P, van der Vlist A, Vicenzino B. ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy. Sports Med 2022; 52:613-641. [PMID: 34797533 PMCID: PMC8891092 DOI: 10.1007/s40279-021-01588-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated. OBJECTIVE To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains. DESIGN Systematic review. DATA SOURCES Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series. RESULTS 9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain. CONCLUSION 233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures. PROSPERO REGISTRATION CRD42020156763.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA.
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Robert-Jan de Vos
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC University Medical Centre, Rotterdam, Zuid-Holland, The Netherlands
| | - Shawn Hanlon
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Mitchel Molenaar
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jarrod Antflick
- Department of Bioengineering, School of Engineering, Imperial College, London, UK
| | - Mathijs van Ark
- Department of Physiotherapy, School of Health Care Studies, Hanze University of Applied Sciences and Peescentrum, Centre of Expertise Primary Care Groningen (ECEZG), Groningen, The Netherlands
| | | | - Zubair Haleem
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Arsenal Football Club, London, UK
| | - Jean-Francois Kaux
- Department of Physical and Rehabilitation Medicine and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Paul Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhavesh Kumar
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Trevor Lewis
- Aintree University Hospital, Liverpool Foundation Trust, Liverpool, UK
| | - Adrian Mallows
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, UK
| | - Lorenzo Masci
- Institute of Sport Exercise and Health (ISEH), University College London, London, UK
| | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
| | - Myles Murphy
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Richard Newsham-West
- School of Allied Health, Department of Physiotherapy, La Trobe University, Melbourne, VIC, Australia
| | - Richard Norris
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
- Liverpool University Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Seth O'Neill
- School of Allied Health, University of Leicester, Leicester, UK
| | - Koen Peers
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Igor Sancho
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, University of Deusto, San Sebastian, Spain
| | - Kayla Seymore
- Department of Physical Therapy, University of Delaware, 540 South College Avenue, Newark, DE, 19713, USA
| | - Patrick Vallance
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Clayton, VIC, Australia
| | - Arco van der Vlist
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences: Physiotherapy, The University of Queensland, Brisbane, QLD, Australia
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Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study. Foot Ankle Surg 2020; 26:771-776. [PMID: 31727534 DOI: 10.1016/j.fas.2019.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/04/2019] [Accepted: 10/05/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prospective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance. METHODS Patients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n=8) and a healthy control group (n=8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected. RESULTS Improvements in pain and self-reported function were observed (six months and two years). Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment (p≤.02). CONCLUSIONS Study findings regarding long-term improvements in patient pain, self-reported function and sport participation, and early preservation of ankle function during walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.
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DiLiberto FE, Nawoczenski DA, Tome J, Tan RK, DiGiovanni BF. Changes in Muscle Morphology Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Cohort Imaging Study. Foot Ankle Spec 2020; 13:297-305. [PMID: 31230471 DOI: 10.1177/1938640019857805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Frank E DiLiberto
- Department of Physical Therapy, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois (FED).,Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester, University of Rochester Medical Center, Rochester, New York (DAN, BFD).,School of Health Science and Human Performance, Movement Analysis Laboratory, Ithaca College, Ithaca, New York (JT).,Department of Imaging Sciences, University of Rochester Medical Center, Highland Hospital, Rochester, New York (RKT)
| | - Deborah A Nawoczenski
- Department of Physical Therapy, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois (FED).,Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester, University of Rochester Medical Center, Rochester, New York (DAN, BFD).,School of Health Science and Human Performance, Movement Analysis Laboratory, Ithaca College, Ithaca, New York (JT).,Department of Imaging Sciences, University of Rochester Medical Center, Highland Hospital, Rochester, New York (RKT)
| | - Josh Tome
- Department of Physical Therapy, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois (FED).,Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester, University of Rochester Medical Center, Rochester, New York (DAN, BFD).,School of Health Science and Human Performance, Movement Analysis Laboratory, Ithaca College, Ithaca, New York (JT).,Department of Imaging Sciences, University of Rochester Medical Center, Highland Hospital, Rochester, New York (RKT)
| | - Raymond K Tan
- Department of Physical Therapy, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois (FED).,Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester, University of Rochester Medical Center, Rochester, New York (DAN, BFD).,School of Health Science and Human Performance, Movement Analysis Laboratory, Ithaca College, Ithaca, New York (JT).,Department of Imaging Sciences, University of Rochester Medical Center, Highland Hospital, Rochester, New York (RKT)
| | - Benedict F DiGiovanni
- Department of Physical Therapy, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois (FED).,Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester, University of Rochester Medical Center, Rochester, New York (DAN, BFD).,School of Health Science and Human Performance, Movement Analysis Laboratory, Ithaca College, Ithaca, New York (JT).,Department of Imaging Sciences, University of Rochester Medical Center, Highland Hospital, Rochester, New York (RKT)
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Abstract
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.
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Affiliation(s)
- Patrick A DeHeer
- Surgery Department, Indiana University Health North Hospital, Carmel, IN, USA; Surgery Department, Johnson Memorial Hospital, Franklin, IN, USA; Department of Podiatric Medicine and Radiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
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Noninsertional Achilles Tendinopathy Pathologic Background and Clinical Examination. Clin Podiatr Med Surg 2017; 34:129-136. [PMID: 28257670 DOI: 10.1016/j.cpm.2016.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The term tendinopathy includes a series of pathologies, all of which have a combination of pain, swelling, and impaired performance. The terms tendinosis, tendinitis and peritendinitis are all within the main heading of tendinopathy; this terminology provides a more accurate understanding of the condition and highlights the uniformity of clinical findings while distinguishing the individual histopathological findings of each condition. Understanding the clinical features and the underlying histopathology leads to a more accurate clinical diagnosis and subsequent treatment selection. Misuse of the term tendinitis can lead to the underestimation of chronic degenerative nature of many tendinopathies, affecting the treatment selection.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review the current literature of Achilles tendon injuries, specifically chronic tendinopathy and acute ruptures in regard to etiology, diagnosis, treatment options, and outcomes. RECENT FINDINGS The incidence of Achilles tendon injuries is increasing, but the necessity for surgical intervention is decreasing due to improved conservative therapies, which may provide comparable outcomes without the implied surgical risk. If surgery is undertaken, no difference has been noted between open and minimally invasive techniques. The majority of patients are able to return to pre-injury level of activity, with the elite athlete as an unfortunate exception. Achilles injuries can be devastating injuries, but if addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality implemented. Further research is needed into the etiology, potential preventative measures, and longer-term outcomes of the different treatment options for wide range of Achilles pathology.
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Affiliation(s)
- Anthony C Egger
- Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, 2049 E 100th St, Desk A40, Cleveland, OH, 44195, USA.
| | - Mark J Berkowitz
- Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, 2049 E 100th St, Desk A40, Cleveland, OH, 44195, USA
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Molund M, Lapinskas SR, Nilsen FA, Hvaal KH. Clinical and Functional Outcomes of Gastrocnemius Recession for Chronic Achilles Tendinopathy. Foot Ankle Int 2016; 37:1091-1097. [PMID: 27621265 DOI: 10.1177/1071100716667445] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Marius Molund
- Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Østfold Hospital, Grålum, Norway
| | | | - Fredrik Andre Nilsen
- Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Østfold Hospital, Grålum, Norway
| | - Kjetil Harald Hvaal
- Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
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Nawoczenski DA, DiLiberto FE, Cantor MS, Tome JM, DiGiovanni BF. Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy. Foot Ankle Int 2016; 37:766-75. [PMID: 26989087 DOI: 10.1177/1071100716638128] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Deborah A Nawoczenski
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Frank E DiLiberto
- Department of Physical Therapy, Rosalind Franklin University of Medicine & Science, North Chicago, IL, USA
| | - Maxwell S Cantor
- Physical Therapist, Wellesley Therapeutic Services, Holliston, MA, USA
| | - Josh M Tome
- School of Health Science and Human Performance, Ithaca College, Ithaca, NY, USA
| | - Benedict F DiGiovanni
- Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Effects of gastrocnemius recession on ankle motion, strength, and functional outcomes: a systematic review and national healthcare database analysis. Knee Surg Sports Traumatol Arthrosc 2016; 24:1355-64. [PMID: 26685692 DOI: 10.1007/s00167-015-3939-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
Abstract
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.
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Baumbach SF, Polzer H. Letter to the editor on "Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations". Foot Ankle Surg 2015; 21:224-5. [PMID: 26235870 DOI: 10.1016/j.fas.2015.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 06/11/2015] [Indexed: 02/04/2023]
Affiliation(s)
- Sebastian F Baumbach
- Munich University Hospital, Department of Trauma Surgery - Campus Innenstadt, LMU Nussbaumstr. 20, 80336 Munich, Germany
| | - Hans Polzer
- Munich University Hospital, Department of Trauma Surgery - Campus Innenstadt, LMU Nussbaumstr. 20, 80336 Munich, Germany.
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Tallerico VK, Greenhagen RM, Lowery C. Isolated Gastrocnemius Recession for Treatment of Insertional Achilles Tendinopathy: A Pilot Study. Foot Ankle Spec 2015; 8:260-5. [PMID: 25389232 DOI: 10.1177/1938640014557077] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Many surgeries exist for treatment of insertional Achilles tendinopathy. Another surgical option to consider is an isolated gastrocnemius recession. Recent studies have demonstrated the success of a gastrocnemius recession for noninsertional Achilles tendinitis. We hypothesize that an isolated gastrocnemius recession can be a successful, effective, and less invasive surgery for patients with chronic insertional Achilles tendinopathy. MATERIALS AND METHODS This article presents a retrospective review of one surgeon's results of 11 patients (2010-2012), with an average age of 59 years who presented with chronic insertional Achilles tendinopathy. Gastrocnemius recessions, either endoscopic or open, were performed after an average of 6.2 months of conservative treatment. All patients' radiographs were reviewed preoperatively for any calcaneal spurs and divided into groups accordingly. Average follow-up time postoperatively was 13.8 months. Plantarflexion strength, equinus deformity, as well as the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot instrument was assessed. RESULTS In all, 10/11 (91%) patients had high patient satisfaction, pain relief, no residual equinus deformity, loss in muscle strength and returned to regular activities successfully at 1-year follow up. All patients and groups had significant improvement in AOFAS scores. The median postoperative AOFAS score was 94.8. All patients and patient groups had significant improvement pre- to postoperatively. Patients without spurs appear to do better than patients with spurs. One patient developed recurrence of insertional heel pain and equinus deformity. Other complications included 2 sural nerve parasthesias, which resolved. CONCLUSION An isolated gastrocnemius recession for chronic insertional Achilles tendinopathy can provide high satisfaction, pain relief, and a faster recovery period with few or no complications. LEVELS OF EVIDENCE Therapeutic, Level IV: Case series.
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Affiliation(s)
- Valerie K Tallerico
- UnityPoint Health-St Lukes Hospital, UnityPoint Clinic-Podiatry, Sioux City, Iowa (VKT)Foot and Ankle Center of Nebraska, P.C., Omaha, Nebraska (RMG)Podiatric Medicine and Surgery Residency, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (CL)
| | - Robert M Greenhagen
- UnityPoint Health-St Lukes Hospital, UnityPoint Clinic-Podiatry, Sioux City, Iowa (VKT)Foot and Ankle Center of Nebraska, P.C., Omaha, Nebraska (RMG)Podiatric Medicine and Surgery Residency, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (CL)
| | - Clinton Lowery
- UnityPoint Health-St Lukes Hospital, UnityPoint Clinic-Podiatry, Sioux City, Iowa (VKT)Foot and Ankle Center of Nebraska, P.C., Omaha, Nebraska (RMG)Podiatric Medicine and Surgery Residency, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (CL)
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Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. Foot Ankle Surg 2015; 21:77-85. [PMID: 25937405 DOI: 10.1016/j.fas.2015.02.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 11/13/2014] [Accepted: 02/13/2015] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Chris C Cychosz
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Daniel A Belatti
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
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Nawoczenski DA, Barske H, Tome J, Dawson LK, Zlotnicki JP, DiGiovanni BF. Isolated gastrocnemius recession for achilles tendinopathy: strength and functional outcomes. J Bone Joint Surg Am 2015; 97:99-105. [PMID: 25609435 DOI: 10.2106/jbjs.m.01424] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Deborah A Nawoczenski
- Center for Foot and Ankle Research, Rochester Center, Ithaca College, 1100 South Goodman Street, Rochester, NY 14620. E-mail address for D.A. Nawoczenski:
| | - Heather Barske
- Winnipeg Regional Health Authority, Pan Am Clinic, 75 Poseidon Bay, Winnipeg, Manitoba R3M 3E4, Canada
| | - Joshua Tome
- Center for Foot and Ankle Research, Rochester Center, Ithaca College, 1100 South Goodman Street, Rochester, NY 14620. E-mail address for D.A. Nawoczenski:
| | - Laura K Dawson
- Department of Orthopaedic Surgery, Blanchfield Army Hospital, 650 Joel Drive, Fort Campbell, KY 42223
| | - Jason P Zlotnicki
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642. E-mail address for B.F. DiGiovanni:
| | - Benedict F DiGiovanni
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642. E-mail address for B.F. DiGiovanni:
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Awogni D, Chauvette G, Lemieux ML, Balg F, Langelier È, Allard JP. Button fixation technique for Achilles tendon reinsertion: a biomechanical study. J Foot Ankle Surg 2014; 53:141-6. [PMID: 24556479 DOI: 10.1053/j.jfas.2013.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Indexed: 02/03/2023]
Abstract
Chronic insertional tendinopathy of the Achilles tendon is a frequent and disabling pathologic entity. Operative treatment is indicated for patients for whom nonoperative management has failed. The treatment can consist of the complete detachment of the tendon insertion and extensive debridement. We biomechanically tested a new operative technique that uses buttons for fixation of the Achilles tendon insertion on the posterior calcaneal tuberosity and compared it with 2 standard bone anchor techniques. A total of 40 fresh-frozen cadaver specimens were used to compare 3 fixation techniques for reinserting the Achilles tendon: single row anchors, double row anchors, and buttons. The ultimate loads and failure mechanisms were recorded. The button assembly (median load 764 N, range 713 to 888) yielded a median fixation strength equal to 202% (range 137% to 251%) of that obtained with the double row anchors (median load 412 N, range 301 to 571) and 255% (range 213% to 317%) of that obtained with the single row anchors (median load 338 N, range 241 to 433N). The most common failure mechanisms were suture breakage with the buttons (55%) and pull out of the implant with the double row (70%) and single row (85%) anchors. The results of the present biomechanical cadaver study have shown that Achilles tendon reinsertion fixation using the button technique provides superior pull out strength than the bone anchors tested.
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Affiliation(s)
- David Awogni
- Orthopaedic Resident, Postgraduate Year 4, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke Faculty of Medicine, Sherbrooke, Quebec, Canada.
| | - Guillaume Chauvette
- Mechanical Engineer, Mechanical Engineering Department, Centre Hospitalier Universitaire de Sherbrooke Faculty of Medicine, Sherbrooke, Quebec, Canada
| | - Marie-Line Lemieux
- General Medicine Resident, Postgraduate Year 2, Department of Family Medicine, Centre Hospitalier Universitaire de Sherbrooke Faculty of Medicine, Sherbrooke, Quebec, Canada
| | - Frédéric Balg
- Orthopaedic Surgeon, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke Faculty of Medicine, Sherbrooke, Quebec, Canada
| | - Ève Langelier
- Biomechanical Engineer, Mechanical Engineering Department, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-Pascal Allard
- Orthopaedic Surgeon, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke Faculty of Medicine, Sherbrooke, Quebec, Canada
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Gurdezi S, Kohls-Gatzoulis J, Solan MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. Foot Ankle Int 2013; 34:1364-9. [PMID: 23687335 DOI: 10.1177/1071100713488763] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Sabahat Gurdezi
- Trauma and Orthopaedics, Royal Surrey County Hospital, Guildford, UK
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Laborde JM. Bilateral Proximal Fifth Metatarsal Nonunion Treated with Gastrocnemius-Soleus Recession: A Case Report. JBJS Case Connect 2013; 3:e68. [PMID: 29252468 DOI: 10.2106/jbjs.cc.m.00021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Barske HL, DiGiovanni BF, Douglass M, Nawoczenski DA. Current concepts review: isolated gastrocnemius contracture and gastrocnemius recession. Foot Ankle Int 2012; 33:915-21. [PMID: 23050719 DOI: 10.3113/fai.2012.0915] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Heather L Barske
- Department of Orthopaedic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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