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Assessing The Role Of Gastroc Recession For Posterior Heel Pain

Can gastrocnemius recession have an impact on pain relief for patients with chronic Achilles tendinopathy? Reviewing the literature on the efficacy of open and endoscopic gastroc recession, these authors examine the effects of these procedures on insertional and non-insertional Achilles pathology.

Gastrocnemius recession has therapeutic value for various pathologies. More recently, there has been increased attention to using the gastroc recession in treating posterior heel pain, particularly Achilles tendinopathy. Performing an isolated gastroc recession may be an option for treating posterior heel pain that is recalcitrant to conservative treatment.

The superficial posterior muscle group of the lower leg consists of the gastrocnemius, soleus and plantaris muscles. The triceps surae forms via the combination of the gastrocnemius and the soleus muscles. The plantaris muscle is only present in approximately 7.05 percent of the population.1 If it is present, pending the insertion of the plantaris, the three muscles create the Achilles tendon, which inserts into the middle third of the posterior calcaneus. The plantaris and the gastrocnemius muscles cross three joints: the knee, ankle and subtalar joints. The soleus muscle crosses two joints: the ankle and the subtalar joint. When the superficial posterior muscle groups become too tight, Achilles pathology may be present.1

Achilles pathology includes multiple possible diagnoses: equinus, calcaneal apophysitis (Sever’s disease), Achilles tendinopathy (classified as insertional and non-insertional), retrocalcaneal bursitis and Haglund’s deformity. Of these differential diagnoses, we have found those who benefit the most from gastroc recession are patients with non-insertional and insertional Achilles tendinopathy with or without retrocalcaneal spurring. With this in mind, let us take a closer look at those posterior heel pain pathologies that benefit from gastroc recession.

Defining The Forms Of Equinus

One of the most referenced indications for gastroc recession is a gastrocnemius equinus. The classic description of equinus is the inability to dorsiflex the foot to 90 degrees.2 One can clinically evaluate gastroc and gastroc-soleus equinus utilizing the Silfverskiold test. This clinical exam tests ankle joint dorsiflexion with gastroc involvement.

Equinus can be classified into osseous, muscular or a combination of both. The muscular forms consist of either gastrocnemius equinus or gastroc-soleus equinus with their respective spastic and non-spastic forms. Osseous equinus further breaks down into talotibial exostoses, tibiofibular syndesmosis limitations and pseudoequinus. Regardless, once one identifies equinus, it is important to identify compensatory mechanisms both proximally and distally. We can subdivide these categories into proximal and distal associated compensatory changes. With the development of these compensatory changes, posterior heel pathology may present. This pathology may include Achilles tendinopathy (insertional and non-insertional), retrocalcaneal bursitis, Achilles calcifications, Haglund’s deformity, and Sever’s disease.2

Authors have argued over the appropriate amount of dorsiflexion required for normal human bipedal gait for many years. Many have agreed that ankle dorsiflexion past neutral is sufficient.

When referencing the gait cycle, it is well known that maximal ankle dorsiflexion occurs just before the heel lifts from the ground, coinciding with maximal extension of the knee and therefore full extension of the gastroc muscle. When the superficial posterior muscle groups are tight, early heel lift is present. This action provides a cascade of compensatory mechanisms throughout the body including increased forefoot pressure, subtalar joint pronation, lumbar lordosis, hip flexion and genu recurvatum.3

All of these compensatory actions contribute to the attempt of getting the heel to purchase the ground and therefore lead to foot and ankle pathology. One needs to identify the pathomechanics behind posterior heel pathology in order to proceed with any surgical intervention.

A Guide To Conservative Treatment Options For Achilles Pathologies

Varying conservative treatment options for the aforementioned Achilles pathologies include: stretching, ice, rest, immobilization, physical therapy, heel lifts, shoe gear modifications, orthotics, shockwave therapy, platelet-rich plasma, onabotulinumtoxin A (Botox, Allergan), sclerosant injections, oral anti-inflammatories and injectable anti-inflammatories. When these conservative measures fail to treat the existing condition, usually after six to 12 months, consider surgical intervention.

In a study by Stenson and colleagues, the authors identified four parameters for conservative treatment failure.4 These included: a Visual Analog Scale (VAS) score of greater than 4; limited ankle range of motion (ROM); history of steroid injection; and Achilles tendon enthesophyte formation. The authors concluded that if one observed the above parameters in a patient with insertional Achilles tendinosis, it should raise suspicion that non-operative treatment may fail. Regardless, the study authors agree that physicians should exhaust conservative treatment prior to surgical intervention.

What Are The Most Effective Imaging Techniques For The Achilles?

Prior to surgical intervention, obtain appropriate imaging. As we mentioned above, there are many types of equinus and posterior heel pain, and complete identification of these requires imaging. Useful studies include X-ray, computed tomography (CT) scans, musculoskeletal ultrasound and magnetic resonance imaging (MRI).

X-ray and CT can determine bony abnormalities, such as bone blocks or enthesophyte formation, as well as the overall structure of the foot and ankle. Musculoskeletal ultrasound and MRI can define tendinous and muscular pathology as well as determine the vascularity of the Achilles tendon and bursae formation. Solan and colleagues describe musculoskeletal ultrasound as the initial choice in imaging. Additionally, clinicians can combine musculoskeletal ultrasound with color Doppler to further assess neurovascularity.3 After obtaining appropriate imaging, one may commence with surgical planning.

Essential Surgical Considerations

Before deciding on surgery, one must perform all of the following: clinical/biomechanical exam, appropriate imaging studies and exhaustion of conservative treatment (six to 12 months). Additionally, a surgeon should identify whether a patient is an appropriate surgical candidate by obtaining the patient’s pertinent medical history. In addition, the surgeon should gauge whether a patient is emotionally stable enough to undergo surgery and/or if he or she is able to get appropriate care following surgery, whether it is self-care or assisted care.2 After determining these factors and deeming the patient an appropriate surgical candidate, one can proceed to select a procedure.

Muscle-associated equinus procedures consist of tendo-Achilles lengthening (TAL) and gastrocnemius recession. Typically, TAL is for patients with a gastroc-soleus equinus and one would reserve a gastroc recession for those with gastroc equinus only. As TAL has been associated with overlengthening, plantarflexion and push-off weakness in the gait cycle, calcaneal gait, a greater recovery time, and wound complications, gastroc recession variations are preferable.2 Gastroc recessions include various levels (2-4) of lengthening distal to proximal. These procedures from proximal to distal include: Silfverskiold (level 5), Baumann (level 4), Strayer (level 3), Vulpius (level 2) and Baker (level 2). The level 1 procedures pertain to TAL.

Solan and coworkers report level 4 is where the aponeurosis covers the deep surface of the gastrocnemius.3 Solan and colleagues have noted this is the safest zone for gastroc recession as there is no damage to either the insertion or the origin of the muscle, and the risk of neurovascular complication is very low.3 The debate remains whether an open or endoscopic approach provides the best patient outcome.

What The Literature Says About Open And Endoscopic Gastrocnemius Recession

Vulpius and Stoeffel first described open gastroc recession over a century ago for spastic contractures.5 Strayer described the first transverse recession in 1950 and it remains the most popular form of gastroc recession reported in the literature.6

Whether performing open or endoscopic gastroc recession, consider the risks, benefits and complications. The most common complications of gastroc recession include scar cosmesis and adhesions, wound healing risks, infection, deep vein thrombosis (DVT), sural nerve injury, recurrent gastroc contracture, weakness, and complex regional pain syndrome.4 Scar cosmesis, adhesions and wound complications relate to open procedures more often than endoscopic procedures. The most reported complication with endoscopic gastroc recession is sural nerve injury secondary to not being able to visualize the nerve well. Overall, sural neuritis was the most commonly reported complication of gastroc recession in the reviewed literature.1–4,7–13

Nawoczenski and colleagues studied power and endurance outcomes for 18 months following open gastrocnemius recession on 14 patients with unilateral Achilles tendinopathy.7 The results included VAS score reduction (6.8 to 1.6), ankle power reduction and deficits in endurance. More significant, the Foot and Ankle Ability Measure (FAAM) between the gastroc recession group and the control group had the greatest difference in scores. The authors noted that the gastroc recession seemed to affect the athletic population more than the non-athletic subgroup. The FAAM of activities of daily living in non-athletic patients with gastroc recession was 90.0 in comparison to 98.3 in control patients. The FAAM of activities of daily living in athletic patients who had gastroc recession was 70.6 in comparison to 94.6 in control patients. The study authors agree that the gastroc recession is great for pain relief for patients with chronic Achilles tendinopathy. They report good outcomes with activities of daily living but they also note power and endurance deficits, especially in the athletic population.

Harris and coworkers conducted a retrospective study of 74 patients having either open or endoscopic gastroc recession for gastrocnemius equinus.8 Of the 74 patients, 39 had open gastroc recession and 35 had endoscopic gastroc recession. The open gastroc recession group had significantly more follow-up time than the endoscopic group, 12 months versus nine months respectively. Of the 80 procedures performed, 12 patients had complications with the most from the open recession group. They concluded that the endoscopic approach has the least associated complications in comparison to open gastroc recession. This study suggests that the endoscopic technique is favorable when considering postoperative complication rates. However, the presence of associated risk leaves room for the discovery of safer procedure options.

Villanueva and colleagues performed a pilot and prospective study utilizing ultrasound guidance for gastroc recession.9 They describe an ultra-minimally invasive procedure on patients with chronic non-insertional Achilles tendinopathy, equinus and other conditions. The pilot study consisted of 22 cadaver specimens and there was excellent safety and efficacy. In a subsequent prospective study, the authors performed the procedure on 23 patients with much success. Patients maintained improved dorsiflexion at the six-month follow-up, the VAS score went from 7 to 0 and the American Orthopaedic Foot and Ankle (AOFAS) ankle-hindfoot score improved from 30 to 93 on average. The authors concluded that ultrasound guidance allowed for complete visualization of the sural nerve throughout the procedure and maintained this ultra-minimally invasive procedure was advantageous for many reasons including: pain reduction, reducing the need for tourniquet use and eliminating the need for general anesthesia.

What You Should Know About The Gastroc Recession For Posterior Heel Pain

Much of the current literature pertaining to gastroc recession for foot and ankle pathologies focuses on plantar fasciitis, neurological disorders, osteoarthritis, diabetic ulcers and forefoot overload syndrome. Literature supporting the use of gastroc recession for Achilles tendinopathy is limited.

However, the topic is gaining interest. In 2015, Cychosz and coworkers evaluated gastroc recession for surgical treatment of various foot and ankle conditions in the adult population.10 The authors gave grades of recommendation to each pathological condition based on supporting evidence in the literature (Grades A, B, C and I). When considering surgical treatment of Achilles tendinopathy, the researchers concluded that gastroc recession benefited non-insertional tendinopathy more than insertional tendinopathy (Grade C versus I). However, insufficient data supporting gastroc recession for chronic Achilles tendinopathy remains.

A case study by Gentchos and colleagues involved a 46-year-old female factory worker with recalcitrant non-insertional Achilles tendinosis (for a duration of 18 months).11 Magnetic resonance imaging (MRI) revealed fusiform swelling with signal intensity changes in the distal tendon at the watershed region. After six months of failed conservative treatment including work restrictions, non-steroidal anti-inflammatory drugs (NSAIDs), stretching and two immobilization attempts (length of time not reported), the patient had a modified Vulpius gastrocnemius recession. At six weeks post-op, she had complete resolution of pain. The authors of this study recommend the use of gastrocnemius recession in cases of chronic, recalcitrant Achilles tendinopathy. However, they did not indicate whether gastroc recession was best suited for insertional versus non-insertional tendinopathy.

In further support of gastroc recession for chronic Achilles tendinopathy, Tallerico and coworkers performed a retrospective review of 11 patients who had open or endoscopic gastroc recession for chronic insertional Achilles tendinopathy.12 Patients had conservative care for an average of 6.2 months prior to intervention and postoperative follow-up lasted 13.8 months. The study resulted in a 91 percent satisfaction rate with pain relief, no residual equinus deformity, no loss in muscle strength and ability to return to all activities of daily living. There was also significant improvement in AOFAS scores to a median of 94.8. The authors concluded that gastroc recession is a viable option for patients with chronic insertional Achilles tendinopathy. However, they did state that those with spurring did not do as well as those without.

In a more recent study from 2017, Smith and colleagues evaluated isolated gastroc recession for various types of chronic Achilles tendinopathy.13 The authors further subdivided Achilles tendinopathy into two groups (insertional versus non-insertional) and then divided insertional tendinopathy into two further subgroups: insertional with and without heel spurring. The study included 25 patients with an average age of 53.2 and was comprised of mostly women (20:5). Sixteen of the patients had insertional Achilles tendinopathy, five had non-insertional tendinopathy and the rest had both. Of these 25 patients, 70 percent had calcific changes to the tendon confirmed by radiology.

Overall, their results revealed improvement in VAS in both insertional and non-insertional groups. Reportedly, patients with non-insertional Achilles tendinopathy had a slightly better VAS than the insertional group and there was no significant difference between patients with or without calcific changes/heel spurring. They concluded that isolated gastroc recession is well-suited for patients with both insertional and non-insertional Achilles tendinopathy with or without heel spurring.

In Conclusion

While most of the studies we reviewed were case studies, literature reviews and retrospective series, there is strong support for the use of gastroc recession for chronic Achilles tendinopathy. There is agreement in the literature that gastroc recession is a safe procedure with a minimal complication profile with sural neuritis being the most common complication.

Debate remains on the overall indications for use of the gastroc recession related to insertional and non-insertional Achilles tendinopathy. Recent reports have shown excellent results for both. Authors agree that gastroc recession has a lower risk profile than TAL and recommend this over direct Achilles procedures. Further research and Level I evidence is needed to support the use of gastroc recession for Achilles tendinopathy. Currently, it remains a widely supported viable option for the treatment of chronic Achilles tendinopathy.

Dr. Erfle is board-certified in foot and ankle surgery. He is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Erfle is in private practice in Media and Phoenixville, Pa.

Dr. Thatcher is a third-year resident within the Podiatric Medicine and Surgery Program at Phoenixville Hospital in Phoenixville, Pa.

Dr. Anselmo is a second-year resident within the Podiatric Medicine and Surgery Program at Phoenixville Hospital in Phoenixville, Pa.

References
1.    Barske H, DiGiovanni B, Douglass M, Nawoczenski D. Current concepts review: isolated gastrocnemius contracture and gastrocnemius recession. Foot Ankle Int. 2012; 33(10):915-921.
2.    Southerland J. Ankle equinus. In: McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Fourth Edition, Chapter 43. Lippincott Williams & Wilkins, New York, 2012, pp. 541-584.
3.    Solan M, Carne A, Davies M. Gastrocnemius shortening and heel pain. Foot Ankle Clin N Am. 2014; 19(4):719-738.
4.    Stenson J, Reb C, Danieal J, Saini S, Albana M. Predicting failure of nonoperative treatment for insertional Achilles tendinosis. Foot Ankle Specialist. 2017; 20(10):1-4.
5.    Vulpius O, Stoffel A. Tenotomie der end schnen der mm. gastrocnemius el soleus mittels rutschenlassens nach Vulpius. Orthopadische Operationslehre. Ferdinand Enke, Stuttgart, 1913, pp. 29-31.
6.    Strayer LM. Recession of the gastrocnemius: an operation to relievespastic contracture of the calf muscles. J Bone Joint Surg Am. 1950; 32-A(3):677-6
7.    Nawoczenski D, DiLiberto F, Cantor M, Tome J, DiGiovanni B. Ankle power and endurance outcomes following isolated gastrocnemius recession for Achilles tendinopathy. Foot Ankle Int. 2016; 37(7):766-775.
8.    Harris R, Strannigan K, Piraino J. Comparison of the complication incidence in open vs. endoscopic gastrocnemius recession: a retrospective medical record review. J Foot Ankle Surg. 2018 (Article In Press).
9.    Villanueva M, Iborra A, Rodriguez G, Sanz-Ruiz P. Ultrasound-guided gastrocnemius recession: a new ultra-minimally invasive surgical technique. BMC Musculoskeletal Disorders. 2016; 17(409):1-9.
10.    Cychosz C, Phisitkul P, Belatti D, Glazebrook M, DiGiovanni C. Gastrocnemius recession for foot and ankle conditions in adults: Evidence based recommendations. Foot Ankle Surgery. 2015; 21(2):77-85.
11.    Gentchos C, Bohay D, Anderson J. Gastrocnemius recession as treatment for refractory Achilles tendinopathy: a case report. Foot Ankle Int. 2008; 29(6):620-623.
12.    Tallerico V, Greenhagen R, Lowery C. Isolated gastrocnemius recession for treatment of insertional Achilles tendinopathy, a pilot study. Foot Ankle Specialist. 2014; 8(4):260-265.
13.    Smith K, Jones C, Pinter Z, Shah A. Isolated gastrocnemius recession for the treatment of Achilles tendinopathy. Foot Ankle Specialist. 2017; 11(1):49-53.

Features
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By David Erfle, DPM, FACFAS, Lisa Thatcher, DPM, and Derek Anselmo, DPM
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