What is gastrocnemius recession surgery and who is a good candidate for it
Gastrocnemius recession surgery is a type of surgery that is used to treat chronic plantar fasciitis. This surgery involves lengthening the gastrocnemius muscle to allow for increased ankle dorsiflexion. This surgery is usually recommended for people who have not responded to other treatments for chronic plantar fasciitis, such as physical therapy, corticosteroid injections, functional orthotics, radial shockwave treatment, and PRP injections.
The gastrocnemius muscle is a muscle in the calf that gives rise to a tendon that joins with another tendon to form the Achilles tendon. The Achilles tendon is the largest and strongest tendon in the body and attaches to the back of the heel bone. This muscle is responsible for the plantarflexion of the ankle.
Having a tight Achilles tendon is called equinus contracture/deformity and is heavily implicated in the underlying reason for multiple foot issues including plantar fasciitis. A tight tendon imposes an increased strain on the bottom of the foot with standing/walking/activities and can lead to an overuse injury to the fascia. With time, it becomes more chronic and the ligament becomes degenerated, thickened, and more difficult to heal.
Stretching the calf muscle is one of the most successful conservative treatments for plantar fasciitis. Actual positional stretching, night splints, and a variety of sock designs that help stretch out the calf muscle are examples of stretching.
A good candidate for gastrocnemius recession surgery is a patient who has been suffering from chronic fasciitis and unfortunately has not responded satisfactorily to non-surgical treatment options. It is also important for the gastrocnemius muscle to be tight (measured on physical examination) for this procedure to be successful.
How is the surgery performed?
The gastrocnemius recession surgery is performed under general anesthesia. There are a variety of techniques available, but the technique most frequently employed by Dr. Nodelman is called the “Baumann Gastrocnemius Recession”.
An incision is made in the inner area of the calf and the gastrocnemius muscle is exposed. There is a thin layer of connective tissue on the front of the muscle belly called the aponeurosis. The aponeurosis is cut completely across and this allows the muscle fibers to elongate and effectively “stretch”.
The benefits of performing the surgery in the muscle belly away from the actual Achilles tendon include less weakness post-op, easier recovery, less likelihood for an unfortunate Achilles tendon rupture to occur, and less chance of a nerve injury.
What to expect after surgery
After the surgery, you will be immediately placed in a splint for an average of two weeks if no other adjunctive procedures are performed. Weightbearing is permitted once tolerated and transition back to regular sneakers can occur around 2 weeks after surgery and sutures have been removed.
Risks and complications
Risks are rare but can occur with any surgery including pain, infection, swelling, blood clots, and inadequate response to the surgery.
It is imperative to ensure a patient having heel pain is truly having heel pain due to chronic fasciitis/fasciosis. If a patient is having chronic pain, and not responding to typical plantar fasciitis treatment options, it could be because the diagnosis is incorrect. Some other causes of heel pain include lower back issues (like sciatica), nerve entrapment, and inflammatory arthritis. Check out this article to review in more detail other causes of heel pain that are not plantar fasciitis.
As one would expect, if an individual has gastrocnemius recession surgery and has heel pain due to nerve entrapment in the back, their pain will not be relieved.
Benefits of gastrocnemius recession surgery
The benefits of gastrocnemius recession surgery include relieving pain from plantar fasciitis and increasing range of motion. This surgery may also help to improve your ability to walk and run.
Alternatives to gastrocnemius recession surgery
The alternatives to gastrocnemius recession surgery include physical therapy, corticosteroid injections, functional orthotics, radial shockwave treatment, and PRP injections. These are all nonsurgical treatments that can be used to treat plantar fasciitis but typically are employed before surgical correction is considered.
We do not advocate plantar fascia release surgery or heel spur resection surgery. The plantar fascia is such an important ligament that stabilizes the arch. Cutting it the relieve the pressure on the fascia can lead to significant structural changes in the foot and other issues.
Multiple studies have been undertaken to compare gastrocnemius recession surgery to the classic plantar fasciotomy and the majority favor a gastrocnemius recession procedure.
As an example, one study compared 30 patients who had a plantar fasciotomy to 30 patients who had undergone a gastrocnemius recession. The plantar fasciotomy patients reported greater dissatisfaction with the procedure and took much longer to get back to activities, athletics, and work. The gastrocnemius recession patients were more satisfied and on average only took about 3 weeks (versus 10) to get back to work.
Here is the citation:
Monteagudo, M., Maceira, E., Garcia-Virto, V. et al. Chronic plantar fasciitis: Plantar fasciotomy versus gastrocnemius recession. International Orthopaedics (SICOT) 37, 1845–1850 (2013).
This is only one of many examples.
Other conditions where a gastrocnemius recession surgery is helpful
Tightness in the Achilles tendon can exacerbate a variety of other conditions.
One very relevant example would be diabetic foot ulcers in the ball of the foot. This is a very complicated condition which requires significant expertise. One of the most important aspects of wound care is appropriate offloading of the ulceration (this means reducing pressure from the ulcer). With less pressure, the ulcer has a greater chance of healing. Diabetes can lead to deposition of sugar/glucose on all tissues in the body including the Achilles tendon. When this happens, the structural make-up of the tendon changes, it becomes stiffer and tighter. A release of the tight gastrocnemius muscle can lead to pressure reduction in the ball of the foot and help the ulcer heal (pending other issues are addressed as well including blood flow, treating infections, etc…).
Other conditions where a gastrocnemius recession can be helpful include pain in the ball of the foot, arthritis in the forefoot/midfoot and Achilles tendon issues.
Conclusion
Gastrocnemius recession surgery is a type of surgery that is used to treat chronic plantar fasciitis. This surgery involves releasing the gastrocnemius muscle to allow for increased ankle dorsiflexion. This surgery is usually recommended for people who have not responded to other treatments for chronic plantar fasciitis, such as physical therapy, corticosteroid injections, functional orthotics, radial shockwave treatment, and PRP injections.
Most patients eventually respond to these non-invasive measures but some do not. In those cases, if the diagnosis is confirmed to be chronic plantar fasciitis and not another diagnosis, then a gastrocnemius recession procedure can be considered.
While any surgery has risks, gastrocnemius recession surgery is a procedure with a low risk of complications. The majority of patients who have this surgery report satisfaction with the results and experience an increased range of motion and decreased pain.