Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients

Background

Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese.

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

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

Technique tip: using a vaginal speculum for gastrocnemius recession

Gastrocnemius tightness is commonly found in patients with foot/ankle dysfunction. Gastrocnemius lengthening or recession is commonly performed as part of the treatment for plantar fasciitis, hallux valgus, symptomatic adult acquired flatfoot, metatarsalgia, and/or diabetic foot ulcers. We describe a technique using a vaginal speculum that allows safe completion of the procedure through a very limited incision.     

Macroscopic changes in sural nerve after gastrocnemius recession: a cadaver study

BackgroundGastrocnemius recession is a common foot and ankle procedure and various techniques that have been utilized are mainly delineated by the anatomic position of the gastrocnemius transection; the 2 common ones are the Baumann and Strayer procedure. Both can adversely affect the sural nerve. The objective of this study was to evaluate the macroscopic changes in the sural nerve following gastrocnemius recession, and to compare the efficacy of the two procedures, regarding the improvement of maximal ankle dorsiflexion.MethodsTen fresh-frozen, above knee cadaveric legs were assigned to one of two gastrocnemius recession techniques: Baumann (n = 5) or Strayer (n = 5). A goniometer was used to measure degree of ankle dorsiflexion before and after the surgery. The sural nerve was meticulously dissected and marked with two suture knots, 2 cm apart. The ankle was passively dorsiflexed from 90° to maximal dorsiflexion in 5° degree increments, and the distance between two suture knots was measured at each increment. The distance between the two cut ends of gastrocnemius muscle was measured with the ankle at 90° and at maximal dorsiflexion.ResultsOverall, a mean increase in length between the suture knots on the sural nerve was 0.2 cm, from 90° to maximum ankle dorsiflexion (130°); both the Baumann and Strayer techniques resulted in 0.2 cm increase. The mean improvement in maximal ankle dorsiflexion in the Baumann and Strayer group was 22.6° and 22°, respectively. The mean change in distance between the two cut ends of the gastrocnemius muscle in the Baumann and Strayer group was 1.0 cm and 0.9 cm, respectively.ConclusionIncreased dorsiflexion of the ankle following Strayer or Baumann gastrocnemius recession resulted in similar macroscopic change in the sural nerve, which may contribute to the development of sural neuritis. Further clinical studies are warranted to assess clinical implications of these findings.