Heel pain is one of the most common complaints of patients who present to a podiatrist’s office. Of the various diagnoses that could cause heel pain in adults, plantar fasciitis (fasciosis) will probably be the code that you most often enter into your electronic medical records (EMRs). Estimates say at least one in 10 people will develop plantar fasciitis in their lifetime and plantar fasciitis will account for at least 1 million doctor’s visits annually.1
The single biggest risk factor for plantar fasciitis is equinus. There is more than a 20-fold increased chance for developing plantar fasciitis when equinus is present.1 There is a direct correlation between increased tension on the Achilles tendon and increased tension on the plantar fascia. Cadaveric studies have shown that the paratenon of the Achilles tendon is continuous with the plantar fascia.2 This anatomical marriage explains why it is so crucial to address equinus when dealing with plantar fasciitis. Physicians have recognized tightness of the posterior muscle groups as a major deforming force for over 100 years.3
The Silfverskiold test helps to differentiate the types of equinus but it is not the best method for quantifying the amount of dorsiflexion. Devices such as a goniometer or equinometer can provide an actual number of degrees. The Silfverskiold test will determine if the patient has an isolated gastrocnemius contracture, an inability to dorsiflex at the ankle greater than normal with the knee extended.
• Osseous — a bony block between the talus and distal tibia
• Soleal — isolated contracture or tightness of the soleus
• Gastrocnemius — isolated contracture or tightness of the gastrocnemius muscle
• Gastroc-soleus — contracture or tightness of the soleus and gastroc muscles
• Pseudoequinus — compensatory loss of the ankle joint range of motion due to other conditions
Addressing The Deforming Forces Of Equinus
With such convincing evidence of the detrimental affects that equinus can have, not addressing it seems below the standard of care. One needs to address the deforming forces regardless of whether we are talking about conservative or surgical treatment options. In terms of conservative measures, clinicians can emphasize adjunctive treatment options such as posterior muscle group stretches, specific plantar fascia stretches, physical therapy and night splints. However, studies have shown that even after a strict regimen of posterior muscle group stretches and use of a night splint, there was only an increase of a few degrees in ankle joint flexibility.5,6
Always attempt conservative measures and permit ample time to assess their effectiveness. Saxena and Grady in their 1991 study suggest that while stretching of the triceps surea does not lengthen anything in the superficial posterior compartment, it does stretch weaker, less resistant structures.5 These structures include: plantar tendons, ligaments, fascia and capsular tissues. The stretch on these “lesser” structures prevents further contracture. For instance, the Achilles tendon can only stretch 3 to 5 percent so it is the contracture of the gastrocneumius-soleus complex that one needs to address surgically.7
Surgical procedures to address equinus date back to the early 19th century. In 1913, Vulpius described the surgical techniques for the gastroc recession.3 Surgeons can perform the gastroc recession as an open or an endoscopic procedure with one portal or two. Regardless of the specifics on technique, in our experience, it is crucial to address the equinus surgically to get the optimal results for your patient.
A Guide To Surgical Technique
In our experience, an endoscopic approach has several advantages including ease of patient positioning, decreased postsurgical discomfort due to a minimally traumatic technique and a generally quicker recovery.
Preoperatively, the surgeon should map out the course of the sural nerve, the borders of the Achilles tendon and the gastroc aponeurosis. With the patient supine, ensure appropriate anesthesia. Place the thigh tourniquet and inflate it.
Palpate the gastrocnemius soleus complex inferior to the gastrocnemius muscle. One can determine proper placement of the cannula in several different ways but there are two common techniques. One method is to measure approximately 17 cm proximal to the insertion of the Achilles tendon on the calcaneus. The other technique requires palpation of the Achilles tendon and finding the point where it begins to fan out. Approximately 3 to 4 cm proximal to this fanning area is the ideal place for cannula placement.
The surgeon should proceed to plan out the incision(s) (depending on the technique), keeping the sural nerve course in mind. One pitfall to avoid is placing the incision too far anterior, which would prevent the blade from going straight across. If the blade does not go straight across, there is a significantly greater risk of damaging the sural nerve and other posterior structures.
Make the incision posteriorly and deepen it, taking care to aggressively retract anteriorly. This allows better visualization of the medial aspect of the aponeurosis and the thin peritenon. Proceed to incise the thin peritenon and then insert the blunt dissector to create a channel just superficial to the aponeurosis. Then insert the trocar and cannula.
At this point, insert a slotted obturator with lateral orientation. To visualize the gastrocnemius aponeurosis, orient the slotted aspect of the cannula anteriorly. Insert an endoscopic camera into the cannula to visualize the gastrocnemius complex. While plantarflexing and dorsiflexing the ankle, the gastrocnemius complex fibers are plainly visible. At this point, some surgeons rotate the cannula 180 degrees to visualize the sural nerve and then rotate back to 180 degrees to release the fibers of the gastrocnemius.
Using the EPF Uniportal Endoscopic Plantar Fascia Release (Wright Medical), affix a blade to the end of the endoscopic camera and introduce the blade into the cannula. While dorsiflexing the ankle, release the longitudinal bands of the intramuscular septum. It is important to ensure that the blade is not violating the underlying muscle tissue.
Once you have released the longitudinal bands of the intramuscular septum, remove the instrumentation from the patient. Inspect the medial portion of the surgical site for any medial fibers that are still intact. If any fibers are still present, transect them per your choice of methods. Often one retracts the anterior tissues inferiorly in an aggressive fashion in order to release all of the medial fibers, which may be the most important part of the procedure. DiDomenico showed that most of the release comes from the medial fibers.8
Follow this with irrigation and layered closure as per your preference. Allow the patient protective weightbearing in a controlled ankle motion (CAM) walker for approximately three to four weeks. Then allow the patient to transition gradually into rigid tennis shoes and perform non-strenuous activities for approximately one month. After that, the patient will gradually resume activities. We also recommend that patients sleep in a night splint or CAM boot for six to eight weeks to help maintain correction.
Further Insights On Surgical Solutions
Few would contend against the important place that the gastroc recession holds in the surgical management of equinus and plantar fasciitis. Is it possible to simply address the equinus without performing a plantar fascial release? Separate studies by Monteagude and Maskill have shown that the gastroc recession alone can be an effective treatment for plantar fasciitis.9,10
Would there be any benefit of using platelet-rich plasma (PRP) with the gastroc recession? Platelet rich plasma has gained notoriety in sports medicine for its use on prominent athletes. Some clinicians have been utilizing the powerful treatment for over 10 years. The procedure originated with veterinarians who used the treatment on horses. At this point, there have not been enough large scale, controlled clinical trials to prove the safety and efficiency of PRP. The authors of one study called PRP “promising, but not a proven treatment option.”11
A simplified definition of PRP would be a concentration of plasma that one harvests from the patient and injects into the area of concern. The PRP contains high concentrations of growth factors. The hypothesis is that these growth factors speed up the healing process. As evidence continues to amass on the effectiveness of PRP, each clinician needs to make his or her own decision on its use. Even though the success of PRP is still questionable, the risks associated with using it are minimal.
In our practice, we look for a surgical solution that will resolve the symptoms. Our baseline surgical treatment is to perform the endoscopic gastrocnemius recession in isolation. We consider gastroc recession as a primary procedure instead of an ancillary one. We resist the temptation to perform a plantar fascia release. Our criterion for determining whether to perform the endoscopic plantar fasciotomy is contracture of the plantar fascia, which is most often present in a high arched foot type. An alternative to consider would be utilization of PRP at the site of the plantar fasciosis. When we perform it on the appropriate patient, we have found the endoscopic gastroc recession/platelet-rich plasma combination to be very successful.
Even if the endoscopic gastroc recession and PRP do not adequately reduce the patient’s plantar fasciitis symptoms, you could make it a staged procedure. Inform the patient that you will attempt this less invasive procedure, which works the majority of the time but if it does not work, then you will perform a plantar fascia release.
One could utilize the same protocol for insertional Achilles tendinopathy, starting with endoscopic gastroc recession and PRP. If symptoms persist, then perform your preferred procedure such as detaching or reattaching the Achilles tendon.
The reality is that the causes of heel pain may not be clear-cut but they may in fact be multifactorial. Traction of the Achilles tendon could contribute to plantar fasciitis in one foot type and cause tarsal tunnel syndrome in another (i.e. flexible flatfoot).
What You Should Know About Complications And The Post-Op Course
Sural nerve injury is always a concern with a gastroc recession regardless of whether it is an open or endoscopic procedure. One can reduce the chances of a direct insult to the sural nerve by using a uniportal technique, arthroscopic examination, preoperative mapping of the anatomy and meticulous surgical technique. Indirect insult to the sural nerve may present itself in the form of a tractional neuropathy. This localized neuropraxia is theoretically a result of the increase in dorsiflexion that the gastroc recession achieves. This condition is usually self-limiting by six to eight weeks after surgery. If symptoms persist, the physician must evaluate the patient for an axonotmesis of the sural nerve. When a patient has this condition, the physical exam may demonstrate a positive Tinel’s sign. To fully evaluate the extent of the nerve injury, one could order electromyography or perform a diagnostic nerve block.
Another possible complication of a gastroc recession is long-term muscle weakness. Is this weakness real or just perceived? Is it a short-term or permanent consequence of the procedure? A study by Sammarco and colleagues looked at patients who underwent a gastroc recession and they followed the patients for two years assessing their plantarflexory strength.12 Strength testing showed an increase over an 18-month period to 82 percent strength relative to the non-operative contralateral side. The weakening of the gastroc muscle following a recession is present. However, the decrease in strength is not a significant amount. The weakness the patient observes (if any) will largely vary depending on the activity level. As would be expected, a high-level athlete is more likely to notice the approximate 20 percent decrease in strength.
If the weakness persists and is problematic for the patient, then one should have the patient undergo a very specific physical therapy regimen. The majority of the time in physical therapy should focus on combining resistive exercises with balance and proprioception drills that isolate the soleus and gastroc individually as well as combining the lower leg as a whole function unit.
The patient should perform resistive exercise while weightbearing. Non-weightbearing and non-dynamic activities will not be sufficient to develop the force needed to restore this most difficult and resistant muscle group. Contractions with all exercises (with or without stimulation) should be six to ten seconds in length for each repetition to maximize muscle recruitment. The patient must experience a sense of fatigue during the exercise or the level of intensity will be insufficient. Patients should start treatment sessions with a light warm-up followed by high intensity weightbearing exercises and weightbearing balance training that should occur for 30 to 45 minutes depending on the individual’s tolerance and level of fatigue.
If the patient experiences more than mild pain during the treatment, the clinician should be wary of causing an inhibitory response. Restoring full high-level functional strength in the posterior compartment often takes several months.
Resolving a patient’s symptoms is every physician’s goal regardless of whether one is using conservative or surgical measures. What is enough to resolve the symptoms? Often the results that we seek for our patients involve the ability to improve or resolve the chronic symptoms of heel pain. The diagnosis of heel pain can be very complex and the causes can be multifactorial. Is it plantar fasciitis, Achilles tendinopathy, nerve compression or a combination of factors? Regardless, a gastroc recession will reduce the mechanical stress that contributes to many of these cases. Considering that the “exact” causes of the pain can be due to a multitude of factors, why not do something that has potential benefits with relatively modest morbidity?
The gastroc recession is a powerful procedure that can be beneficial for many foot and ankle conditions. Reducing the pull and traction of the Achilles tendon with an endoscopic gastroc recession may be the “tipping point” that allows a patient’s pain to resolve. By combining a gastroc recession with other supportive measures such as effective orthotic therapy, activity modifications and supportive shoes, we can create the proper environment to allow heel pain symptoms to resolve. The strong association between heel pain and equinus makes addressing the tight posterior muscle groups paramount. Once you become comfortable and confident performing the endoscopic gastroc recession, you will be able to produce positive and consistent results.
In a chemical reaction, the reagents transform into products when the chemical equilibrium alters or tips toward the opposite side of the equation. Maybe the key to treating our patients is to find this tipping point where any more would be too much and any less would not be enough.
Dr. Mozen is in private practice at Foot Healthcare Associates in Michigan. He is a Diplomate of the American Board of Podiatric Surgery, and a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Belken is in private practice at Foot Healthcare Associates in Michigan. He is an Associate of the American College of Foot and Ankle Surgeons.
- Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003; 85-A(5):872-877.
- Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. J Anat. 2013; 223(6):665-676.
- Nutt J. Diseases and Deformities of the Foot. E.B. Treat & Co., New York, 1913, p. 293.
- Subotnick SI. Equinus deformity as it affects the forefoot. J Am Poditar Assoc. 1971; 61(11):423-427.
- Grady JF, Saxena A. Effects of stretching the gastrocnemius muscle. J Foot Surg. 1991; 30(5):465-9.
- Evans A. Podiatric medical applications of posterior night stretch splinting. J Am Podiatr Med Assoc. 2001; 91(7):356-60.
- DiGiovanni CW, Kuo R, Tejwani M, et al. Isolated gastrocnemius tightness in patients without neurological impairment. J Bone Joint Surg. 2002; 84-A(6):962-70.
- DiDomenico LA, Adams HB, Garchar D. Endoscopic gastrocnemius recession for the treatment of gastrocnemius equinus. J Am Podiatr Med Assoc. 2005; 95(4):159-74.
- Maskill J, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010; 31(1):19-23.
- Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy vs. gastroc recession. Int Orthop 2013 Sep; 37(9):1845-50.
- Griffin XL, Smith CM, Costa CL. Clinical use of PRP in promotion of bone healing: a systematic review. Injury. 2009; 40(2):158-62.
- Sammarco GJ, Bagwe MR, Sammaro VJ. The effects of unilateral gastroc recession. Foot Ankle Int. 2006; 27(7):508-11.
For further reading, see “How Effective Is The Gastroc Recession For Plantar Fasciitis?” in the February 2015 issue of Podiatry Today or the DPM Blog “Resistant Plantar Fasciitis: Why We Should Opt For A Gastrocnemius Recession Before Even Considering A Plantar Fasciotomy,” by Patrick DeHeer, DPM, FACFAS at http://tinyurl.com/8wl5kuy .