Fig 2 - uploaded by Chris Cychosz
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Levels of lengthening for common gastrocnemius recession techniques. The approximate level at which recession is performed during the following techniques is illustrated: Silfverskiö ld (dotted line) and Proximal Medial Gastrocnemius Release (solid line) (A), Baumann (B), Strayer and Vulpius (C), Baker (D).
Source publication
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...
Context in source publication
Context 1
... they begun to study and document the effects of treatment scientifically. Therefore, while the amount of evidence currently available is clearly growing at a rapid pace and early indications suggest that it appears quite promising, the body of evidence on which to base evidence driven recommendations remains rela- tively small. As illustrated in Fig. 2, a variety of methods and techniques can be used to release the gastrocnemius in patients suffering from equinus contracture [27]. Beginning in 1913 Vulpius and Stoffel introduced a technique in which one or more cuts were made through the superficial portion of the gastrocnemius tendon in addition to an incision of the deep tendon and ...
Citations
... La sección de la bandeleta media de la fascia plantar de forma aislada (16) o de la placa glenosesamoidea (17) también podrían ser consideradas para tratar el HLF sin signos artrósicos en la radiografía. Si revisamos la evidencia científica al respecto no encontraremos un grado de recomendación a favor o en contra del alargamiento del gemelo en esta patología (18) . ...
... Although isolated gastrocnemius recession was described more than a century ago [18], reports of this technique being used specifically as a primary intervention to treat foot pain in adults have only recently begun to emerge. Cychosz et al. [19] performed the first systematic review to assign grades of recommendation to gastrocnemius recession as a therapeutic intervention for the indications listed above. More studies are required to establish the true efficacy and indications for gastrocnemius lengthening. ...
... However, as our sample was not sufficiently homogeneous or large, we were unable to perform a complete evaluation of these conditions. More studies treating a single condition with this technique should be conducted in the future [19]. ...
Background
Isolated gastrocnemius contracture has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flatfoot, and metatarsalgia. Although many techniques are available for gastrocnemius recession, potential anesthetic, cosmetic, and wound-related complications can lead to patient dissatisfaction. Open and endoscopic recession techniques usually require epidural or general anesthesia, exsanguination of the lower extremities and stitches and can damage the sural nerve, which is not under the complete control of the surgeon at all stages of the procedure. The purpose of this study is to evaluate the clinical results of a surgical technique for gastrocnemius lengthening with a needle, as previously described in cadaver specimens.
Methods and results
We performed a prospective study of ultrasound-guided gastrocnemius tendon lengthening in level II using a needle in 24 cases (19 patients) of gastrocnemius contracture. The study population comprised 12 males and 7 females. Mean age was 41 years (18–64). All but 5 recessions were bilateral and occurred simultaneously. The indication for the procedure was gastrocnemius contracture; although the patients also presented other conditions such as non-insertional Achilles tendinopathy in 6 patients (2 were bilateral), insertional Achilles calcifying enthesitis in 4 (1 was bilateral), metatarsalgia in 4, flexible flat foot in 1 and plantar fasciitis in 5 (2 were bilateral). The inclusion criteria were the failure of a previous conservative protocol, that the Silfverskiöld test was positive, and that the pathology suffered by the patient was within the indications for surgical lengthening of the patients and were described in the scientific literature. The exclusion criteria were that the inclusion criteria were not met, and patients with surgical risk ASA 3 or more and children. In these patients, although possible, it is preferable to perform the procedure in the operating room with monitoring, as well as in children since they could be agitated during the procedure at the office. We used the beveled tip of an Abbocath needle as a surgical scalpel. All patients underwent recession of the gastrocnemius tendon, as in an incomplete Strayer release. We evaluated pre- and postoperative dorsiflexion, outcomes, and procedural pain (based on a visual analog scale and the American Orthopedic Foot and Ankle Society scores), as well as potential complications. No damage was done to the sural bundle.
Results
Ankle dorsiflexion increased on average by 17.89°. The average postoperative visual analog score for pain before surgery was 5.78, 5.53 in the first week, 1.89 at 1 month, and 0.26 at 3 months, decreasing to 0.11 at 9 months. The mean postoperative American Orthopedic Foot and Ankle Society Ankle-Hindfoot score the average was 50.52 before surgery, 43.42 at 1 week, 72.37 at 1 month, 87.37 at 3 months, and 90.79 at 9 months.
Conclusion
Ultrasound-guided needle lengthening of the gastrocnemius tendon is a novel, safe, and effective technique that enables the surgeon to check all the structures clearly, thus minimizing the risk of neurovascular damage. The results are encouraging, and the advantages of this approach include absence of a wound and no need for stitches. Recovery is fast and relatively painless. A specific advantage of ultrasound-guided needle lengthening of the gastrocnemius tendon is the fact that it can be performed in a specialist's office, with a very basic instrument set and local anesthesia, thus reducing expenses.
... The discrepancy between the clinical and laboratory results can be attributed to compensatory mechanisms such as increased knee flexion, which allows gastrocnemius relaxation, thus releasing the ankle dorsiflexion restriction [15]. However, the exact pathophysiological link between IGT and foot pathologies remains unexplained, highlighting the incomplete understanding of gastrocnemius tightness and the potential for management errors such as inappropriate lengthening procedures [16]. Knowing the gait pattern of IGT subjects is still valuable, and we can assume that correcting gait disorders in these subjects could treat or prevent IGT-related pathologies. ...
... Isolated gastrocnemius tightness can be treated in a variety of ways, from simple stretching to surgical lengthening [16][17][18][19]. There is currently no consensus on the type of stretching or physical therapy to use to treat IGT. ...
Citation: Hamza, A.; Martinez, L.; Sacco, R.; Amouyel, T.; Held, E.; Beldame, J.; Billuart, F.; Lalevée, M. Stretching and Eccentric Exercises Normalize Gait Parameters in Gastrocnemius Tightness Subjects. Abstract: Background: Isolated gastrocnemius tightness (IGT) is a prevalent condition linked to various foot pathologies. In a previous quantitative gait analysis study, we identified an increase in knee flexion during the midstance phase in IGT patients compared with controls. Although stretching and eccentric exercises (the Stanish protocol) are commonly used for IGT management, their impact on gait parameters remains poorly understood. This study aimed to assess the influence of a Stanish protocol on gait parameters in bilateral IGT subjects. Methods: We enrolled 10 asymptomatic bilateral IGT subjects and 10 controls. Quantitative gait analysis and dynamic baropodometry were carried out on each subject. A Stanish protocol was applied for 4 weeks (five sessions/week) by the IGT group, followed by a similar gait analysis. The ankle and knee range of motion and foot pressure distribution were assessed during the midstance phase of the gait. Results: An increase in knee flexion was initially present in the IGT group compared with controls (8.9 +/− 4.6 vs. 3.4 +/− 2.3 degrees, p < 0.001). There was no difference in the ankle range of motion and foot pressures between the groups at that time. Significant reductions in knee flexion during gait were observed in the IGT subjects after the Stanish protocol (8.9 +/− 4.6 to 3.7 +/− 2.3 degrees, p < 0.001) with a normalization of this parameter (3.4 +/− 2.3 in controls vs. 3.7 +/− 2.3 degrees in IGT, p = 0.72). There was no change in ankle range of motion and foot pressure after the Stanish protocol. Conclusions: Our findings support the effectiveness of the Stanish protocol in reducing knee flexion and normalizing gait in IGT subjects. This protocol not only offers a noninvasive approach for IGT-related issues management but could also enable prophylactic care in asymptomatic cases.
... Bernand and Cazeu believe that stretching exercises should be the first line of treatment [7,10]. If this fails, there is a Grade B recommendation for gastrocnemius recession surgery for overload symptoms (isolated pain) [13]. ...
Aim Musculus Gastrocnemius Tightness (MGT) has been linked with common foot and ankle pathologies. These symptoms sometimes are not severe enough for the patient to seek treatment. This study aims to determine the incidence rate of MGT among our clinical personnel and if there is any association between foot and ankle symptoms with MGT. Materials and methods This observational cross-sectional study involves clinical personnel from our Specialist Clinics at Hospital Kulim, Malaysia. We interviewed and assessed 85 volunteers of which, we measured the passive ankle dorsiflexion of the volunteers (the Silfverskiöld) test, to diagnose MGT. We then used the Manchester Oxford Foot Questionnaire (MOxFQ) is used to determine the functional outcome of our volunteers. Results Out of a total of 85 volunteers assessed, 12 (14%) volunteers were found to have gastrocnemius tightness. Among this cohort, 11 were symptomatic. Out of the 73 who did not have MGT, there were three symptomatic volunteers. There was a significant association between volunteers with foot and ankle symptoms with gastrocnemius tightness, compared to those without. There was a significant difference in the relationship between the MOxFQ scores in all components (walking, pain, and social) when comparing those with and those without MGT. Conclusion We conclude that there is a significant association between foot and ankle symptoms and MGT in our clinic sample population. However, these symptoms were not severe enough for these symptomatic volunteers to seek treatment. We should consider screening symptomatic staff and implementing stretching protocols.
... Historically, gastrocnemius recession (GR) procedures were used to treat equinus contractures in cerebral palsy patients; however, with better understanding of various foot and ankle pathologies such as plantar fasciitis (PF), midfoot-forefoot overload syndrome, metatarsalgia, diabetic foot ulcers, pes plano-valgus, and Achilles tendinopathy, this procedure has been increasingly performed to improve patient's symptoms. 5,18,24 Despite its increased utilization in treating various pathologies of the foot and ankle, there is limited evidence to demonstrate the long-term outcomes of this procedure. ...
... Recent studies have proposed GR as a viable treatment option for PF and AT. 5,18,19,24,28 Despite the increasing utility of GR, there is a lack of literature analyzing the factors affecting patient-reported outcomes. Our study is the only study to date that conducts a comprehensive analysis of patient factors for reduced PROMIS scores following GR. ...
... Additionally, multiple studies have found GR to significantly decrease VAS scores. 5,[17][18][19]22 Although these studies are low in power, our study strengthens the conclusions by demonstrating an average decrease in VAS by 3.42 points. ...
Background
Gastrocnemius recession is commonly performed for a variety of pathologies of the foot and ankle, yet studies characterizing risk factors associated with patient-reported outcomes are limited. In this cohort study, patient outcomes were compared against the general population for PROMIS scores with correlation analysis comparing demographics and comorbidities. Our primary goal in this study is to identify risk factors associated with poor patient-reported outcomes following isolated gastrocnemius recession for patients with plantar fasciitis or insertional Achilles tendinopathy.
Methods
A total of 189 patients met inclusion criteria. The open Strayer method was preferred. However, if the myotendinous junction could not be adequately visualized without expanding the excision, then a Baumann procedure was performed. The decision between the two did not depend on preoperative contracture. Patient demographics and visual analog scale (VAS) scores were obtained via the electronic medical record. Telephone interviews were completed to collect postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) and Foot Function Index (FFI) scores. The data were analyzed using the type 3 SS analysis of variance test to identify individual patient factors associated with reduced PROMIS, FFI, and VAS scores.
Results
No demographic variables were found to be significantly associated with postoperative complications. Patients who reported tobacco use at the time of surgery had significantly decreased postoperative PROMIS physical function ( P = .01), PROMIS pain interference ( P < .05), total FFI scores ( P < .0001), and each individual FFI component score. Patients undergoing their first foot and ankle surgeries reported numerous significant postoperative outcomes, including decreased PROMIS pain interference ( P = .03), higher PROMIS depression ( P = .04), and lower FFI pain scores ( P = .04). Hypertension was significantly associated with an increased FFI disability score ( P = .03) and, along with body mass index (BMI) >30 ( P < .05) and peripheral neuropathy ( P = .03), significantly higher FFI activity limitation scores ( P = .01). Pre- and postoperative VAS scores demonstrated improvement in patient-reported pain from a mean of 5.53 to 2.11, respectively ( P < .001).
Conclusion
We found in this cohort that numerous patient factors were independently associated with differences in patient-reported outcomes following a Strayer gastrocnemius recession performed for plantar fasciitis or insertional Achilles tendinopathy. These factors include, but are not limited to, tobacco use, prior foot and ankle surgeries, and BMI. This study strengthens previous reports demonstrating the efficacy of isolated gastrocnemius recession and elucidates variables that may affect patient-reported outcomes.
Level of Evidence
Level III, retrospective cohort study.
... Spastic gastrocnemius contracture is caused by cerebral palsy, spinal cord injury, stroke, etc., and most patients have muscle lesions or denervation of muscle. Non-spastic gastrocnemius contracture is often associated with plantar fasciitis, flatfoot, hallux valgus, etc. [1,[6][7][8]. For the treatment of non-spastic gastrocnemius contracture, the traditional open gastrocnemius recession is still the gold standard [9]. ...
Background and Objectives: This study aimed to evaluate the effectiveness and safety of endoscopic gastrocnemius recession using the self-developed Modified Soft Tissue Release Kit. Materials and Methods: This retrospective review followed up 22 patients (34 feet) who underwent endoscopic surgery and 20 patients (30 feet) who received open surgery between January 2020 and January 2022. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the maximum ankle dorsiflexion angle were evaluated preoperatively and at the last follow-up. Postoperative complications were recorded. Patient satisfaction was surveyed at the last follow-up. The comparison between quantitative data was analyzed with the Wilcoxon signed-rank test. The comparison between qualitative data was analyzed with the chi-square test. Results: There was no significant difference in the baseline characteristics between the two groups. The AOFAS score in the endoscopic group increased from 50 (18) points preoperatively to 90 (13) points at the last follow-up; the maximum ankle dorsiflexion angle increased from −7.7 (2.8) degrees to 10.6 (3.6) degrees. The AOFAS score in the open group improved from 47 (15) points preoperatively to 90 (18) points at the last follow-up; the maximum ankle dorsiflexion angle increased from −7.6 (4.0) degrees to 10.7 (3.3) degrees. The change values of the AOFAS scores in the endoscopic and open groups were 39 (15) and 40.5 (11) points, respectively, and there was no significant difference between them. The change values of the maximum ankle dorsiflexion angles in the endoscopic and open groups were 19.5 (4.3) and 19.1 (4.9) degrees, respectively, and there was no significant difference between them. There were no complications, such as sural nerve injury, in both groups. There was no significant difference between the two groups in satisfaction with the surgical outcome. Conclusions: Endoscopic gastrocnemius recession using the Modified Soft Tissue Release Kit can significantly improve the foot function with significant mid-term efficacy and high safety.
... Idiopathic toe walking (ITW) is a common exclusionary diagnosis describing when a child has limited or absent heel strike at the contact phase of the gait cycle without any medical reason for the gait disturbance. 1 Sustained toe walking has been associated with ankle equinus, 2 which can contribute to poor performance in motor tasks, 3 lower participation in physical activity, 4 musculoskeletal deformity 5 and pain. 6 These are the common driving factors for parents to seek care from physiotherapists when their child is diagnosed with ITW. 7 Clinicians and families express significant challenges in navigating effective, evidencebased interventions for children with ITW. 8 9 Parents have described seeking care from multiple health providers and experiencing contradictory messages and treatment options. 7 9 Clinicians have also described challenges in knowing when to initiate treatment. ...
Objectives
To explore how motor control interventions are conceptualised during treatment of children with idiopathic toe walking (ITW) by physiotherapists in Australia and USA.
Design
A thematic content framework qualitative design was used to triangular the theories underpinning motor control interventions and participant responses.
Participants
Ten paediatric physiotherapists were recruited from Australia and USA. Participation was only open to physiotherapists who provided treatment to children with ITW.
Results
Physiotherapists defined the motor control interventions used for children with ITW as having the following non-hierarchical key elements: use of repetition; task scaffolding; encouraging error recognition; and, active and/or passive movements . Physiotherapists also described two superordinate themes; ( 1) We see motor control through the lens of how we view management and ( 2) Idiopathic toe walking treatment is a game with rules that are made to be broken .
Conclusions
Treatment of ITW continues to challenge clinicians. Physiotherapists viewed their approach to ITW management being evidence- informed, underpinned by motor learning theories, movement strategies and organisational treatment frameworks or guidelines to fit their individual childrens’ needs. Future research should investigate if this approach affords more favourable outcomes for children with ITW gait.
... 21,23 Limited clinical evidence supports the use of TSL for the treatment of midfoot and forefoot overload syndromes, forefoot ulcers, and Achilles tendinopathy. 9 TSL procedures, and particularly variations of the gastrocnemius recession, are also advocated by some surgeons as adjunctive interventions in the treatment of foot and ankle trauma. [4][5][6]16,19 Proponents argue that these procedures aid in the restoration of hindfoot and midfoot alignment, 16,19 facilitate fracture reduction, [4][5][6] and improve final range of motion. ...
Background
The prevalence, indications, and preferred methods for gastrocnemius recession and tendo-Achilles lengthening—grouped as triceps surae lengthening (TSL) procedures—in foot and ankle trauma are supported by a scarcity of clinical evidence. We hypothesize that injury, practice environment, and training heritage are significantly associated with probability of performing adjunctive TSL in the operative management of foot and ankle trauma.
Methods
A survey was distributed to members of the American Orthopaedic Foot & Ankle Society and the Orthopaedic Trauma Association. Participants rated how likely they would be to perform TSL at initial management, definitive fixation, and after weightbearing in the presence and absence of a positive Silfverskiöld test in 10 clinical scenarios of closed foot and ankle trauma.
Results
A total of 258 surgeons with median 14 years’ experience responded. Eighty-five percent reported foot and ankle fellowship training, 24% reported traumatology fellowship training, 13% both, and 4% no fellowship. Ninety-nine percent reported performing TSL with a median 25 TSL procedures per year, 72% open gastrocnemius recession, and 17% percutaneous tendo-Achilles lengthening). Across all scenarios, we observed low overall 8% probability with fair agreement (κ = 0.246) of performing TSL (range, 1% at initial management of an unstable Weber B bimalleolar ankle fracture with negative contralateral Silfverskiöld test to 29% at definitive fixation of tongue-type calcaneus fracture with positive contralateral Silfverskiöld test). Silfverskiöld testing significantly influenced TSL probability at all time points. University of Washington training (β = 1.5, P = .007) but not trauma vs foot fellowship training, years in practice, academic practice, urban setting, or facility trauma designation were significantly associated with likelihood of performing TSL.
Conclusion
Orthopaedic traumatology and foot and ankle surgeons report similar indications, methods, and low perceived propensity to use TSL in the management of foot and ankle trauma. We found that graduates of 1 fellowship training site were more likely to perform TSL in the setting of acute trauma potentially indicating the need for better scientific data to support this practice.
Level of Evidence
Level V, therapeutic.
... While many open techniques have been described, these are associated with poor cosmetic results, neurovascular compromise, and wound dehiscence. Complications can lead to patient dissatisfaction [11,[22][23][24][25][26][27]. ...
Background
Gastrocnemius tendon lengthening is performed to treat numerous conditions of the foot and ankle. Gastrocnemius shortening has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flat foot deformity, and metatarsalgia. Ultrasound-guided ultraminimally invasive lengthening of the gastrocnemius is a step forward in this type of surgery. It can be performed in both legs simultaneously without ischemia using only local anesthesia plus sedation and without the need for a cast or immobilization. The truly novel advantage of the procedure is that it can be performed in the office, without specific surgical instruments. The aim of our research was to prove the effectiveness and safety of a new closed needle-based ultrasound-guided surgical procedure for lengthening the gastrocnemius tendon.
Methods and results
We performed ultrasound-guided gastrocnemius tendon lengthening using a needle in eight fresh frozen specimens (3 left and 5 right). None of the specimens had been affected by disease or undergone previous surgery that could have affected the surgical technique. We used a linear transducer with an 8- to 17-MHz linear transducer and the beveled tip of an Abbocath as a surgical blade to perform the lengthening procedure. The gastrocnemius Achilles tendon recession was entirely transected in all eight specimens, with no damage to the sural nerve or vessels. The improvement in dorsal flexion was 15°.
Conclusion
Needle-based ultrasound-guided gastrocnemius tendon lengthening is safe, since the surgeon can see all structures clearly, thus minimizing the risk of damage. The absence of a wound obviates the need for stitches, and recovery seems to be faster. The procedure can be performed in a specialist's office, as no specific surgical instruments are required. This technique could be a valid option for gastrocnemius lengthening and may even be less traumatic than using a hook-knife, as in our previous description.
... asignaron a la liberación del gastrocnemio medial un grado de recomendación B según los distintos estudios de nivel III, IV y V evaluados. 24 En 1995, Tomczak y Haverstock 25 llevaron a cabo un estudio retrospectivo que comparó la endoscopia con la cirugía abierta (fasciotomía plantar con resección del espolón calcáneo). A los nueve meses, los pacientes de ambos grupos estaban asintomáticos, pero el grupo con tratamiento endoscópico reanudó el trabajo y todas sus actividades 55 días antes que el grupo de cirugía abierta. ...
El objetivo de este artículo es analizar las distintas opciones de tratamiento. Se realizó una encuesta virtual a diferentes traumatólogos especialistas en pierna y pie, sobre el tratamiento de la fascitis plantar. Los resultados fueron variados, lo que demuestra que no hay una respuesta concreta ante el tratamiento crónico. Conclusiones: La fascitis plantar es un cuadro doloroso frecuente. Su origen es desconocido, pero está relacionada con múltiples factores. Se han recomendado muchas modalidades terapéuticas, como fármacos, fisioterapia, ortesis y cirugía, pero no existe un estudio que analice la eficacia de cada una de ellas por separado ni que confirme categóricamente su utilidad.
