The gastrocnemius is a muscle located in the back of the lower leg. It is one of the muscles that make up the calf and is responsible for plantar flexion, or pointing the foot downward. The gastrocnemius has two heads, the medial head, and the lateral head. Both of these heads attach to the Achilles tendon, which inserts on the calcaneus, or heel bone. The gastrocnemius is a “biarticulate” muscle, meaning that it crosses two joints: the knee and the ankle. The gastrocnemius is classified as a fast-twitch muscle, meaning that it is used for quick, explosive movements. It is often used in activities such as sprinting and jumping. The soleus muscle is another muscle located in the back of the lower leg. It also attaches to the Achilles tendon and inserts on the calcaneus. Unlike the gastrocnemius, however, the soleus is a slow-twitch muscle, meaning that it is used for sustained, slower movements. It is often used in activities such as walking and running. Together, these two muscles work through the Achilles tendon to produce plantarflexion at the ankle joint.
What is the plantar fascia?
The plantar fascia is a band of connective tissue that originates in the calcaneus and courses along the plantar foot. It is thick and dense and helps to support the arch of the foot. The plantar fascia inserts into the bones of the toes, and also extends into the skin. This tissue is important for proper foot function and can be damaged by excessive stress or strain. When the plantar fascia is injured, it can lead to pain and inflammation (called plantar fasciitis).
The plantar fascia functions as a passive restraining structure against excessive pronation and serves to stiffen the arch of the foot during activities such as walking and running. Anterior displacement of the center of pressure has been implicated as a risk factor for plantar fasciitis, a condition characterized by inflammation of the plantar fascia. Increased tension in the Achilles tendon during weight-bearing produces plantarflexion moments at the hindfoot, which in turn increases tension on the plantar fascia and results in an increase in forefoot plantar pressure. This increase in plantar pressure can lead to inflammation of the plantar fascia and pain in the heel or arch region of the foot.
Treatment for plantar fasciitis typically includes stretching exercises, weight reduction, and avoidance of high-impact activities. In chronic cases, more advanced techniques like shockwave treatment and platelet-rich plasma injections can be considered. Immobilization of the foot in a cast or boot may be necessary. Surgery is rarely required.
Understandably, this was a rather complex article describing the anatomy of the lower leg and foot including the connection between the gastrocnemius muscle and the plantar fascia. Although they are not directly connected, they attach to the same bone (the heel bone/calcaneus). As such, increased tension in the gastrocnemius muscle will be relayed because of gravity directly into the plantar fascia through the calcaneus. This is known as equinus deformity.
Gastrocnemius muscle which is too tight: Equinus Deformity
Equinus deformity can lead to a variety of issues in the foot other than plantar fasciitis. It can cause and exacerbate arthritis in the midfoot joints, it can cause pain in the ball of the foot (called metatarsalgia), and it can worsen flatfoot deformity and the pain associated with this.
Diabetic patients are susceptible to several complications, including diabetic foot ulcers. Poorly controlled diabetes can lead to sugar/glucose deposition in the body. Sugar can get deposited on the Achilles tendon, which leads to increased stiffness and pressure in the ball of the foot. If an ulcer develops in the ball of the foot, pressure onto the ulcer will increase in the setting of a tighter/stiffer Achilles tendon. To prevent diabetic foot ulcers, diabetic patients need to maintain good blood sugar control. This will help to reduce the risk of sugar deposition in the Achilles tendon and other tissues.
Many issues in the foot and ankle can be explained by tightness in the gastrocnemius muscle. This is why an aggressive gastrocnemius muscle stretching regimen is pivotal to a successful conservative rehabilitation protocol or surgical protocol for several orthopedic issues like pain in the ball of the foot, arch pain, and plantar fasciitis.
What is a gastrocnemius recession procedure?
The gastrocnemius recession procedure is a surgical procedure that is performed to lengthen the posterior muscle group and reduce tension on the Achilles tendon. As you would expect, reducing the tension of the Achilles tendon pull on the heel bone can reduce the load translated into the plantar fascia (and other structures in the foot). This can be a helpful procedure for patients who have failed more conservative treatment options like stretching, activity modification, rest, weight loss, orthotics, and night splinting.
The gastrocnemius recession procedure can be performed in different ways and locations. For example, if the lengthening is performed within the muscle, it is called a Baumann procedure. The procedure can also be performed lower on the calf closer to the Achilles tendon proper. Another example would include the “Strayer” procedure. The gastrocnemius recession procedure is typically followed by a period of immobilization (splint, cast, boot), and physical therapy to help the patient regain range of motion and strength in the affected leg. It is commonly performed in combination with other procedures, like a flatfoot reconstruction.
Gastrocnemius recession procedure to treat plantar fasciitis/fasciopathy
The classic approach to surgically treat chronic plantar fasciitis has been to either cut the fascia, called a fasciotomy, or to possibly perform this in combination with a heel spur removal.
We do not advocate a fasciotomy or heel spur resection surgery. The plantar fascia is such an important structure to stabilize the foot biomechanically. Instead, we recommend a gastrocnemius recession procedure to address chronic heel pain caused by plantar fasciitis. As such, it is extremely important to have a thorough history, exam, and any imaging studies needed to confirm the diagnosis before having any invasive procedures. The medical literature supports this approach. Patients do better with the gastrocnemius recession procedure compared to a fasciotomy. A recent study compared fasciotomy to gastrocnemius recession procedures and found that the fasciotomy group took almost 3 months to get back to work and the satisfaction scores were lower. The gastrocnemius recession patients took less time off from work and were much more satisfied with reduced pain scores. The gastrocnemius muscle and plantar fascia are important structures and are intimately involved together biomechanically. When the gastrocnemius becomes tight, it can lead to a variety of foot and ankle conditions like plantar fasciitis, midfoot arthritis, and issues in the ball of the foot.