August 2018

Consider the Benefits of Gastrocnemius Recession for Recalcitrant Plantar Fasciitis

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Surgical management of recalcitrant plantar fasciitis has largely been limited to plantar fasciotomy. A potential alternative is effective, relatively safe, and reliable gastrocnemius recession, which addresses the effect of gastrocnemius muscle contracture on these patients.

By Joseph G. Wilson, DPM, T. Craig Wirt, DPM, PhD, Jonathan L. Hook, DPM, MHA

Plantar fasciitis is the most common cause of plantar heel pain, with more than 1 million people seeking medical treatment for this complaint each year in the United States alone.¹ Inflammation of the plantar fascia and pain associated with it can be debilitating.

Anatomically, the plantar fascia is a broad aponeurosis that originates in the medial calcaneal tuberosity and extends distally to the level of the metatarsophalangeal joints, with a lateral band reaching the base of the fifth metatarsal. This deep fascial band supports the longitudinal arch of the foot and provides biomechanical stability throughout the gait cycle.¹

The precise etiology of plantar fasciitis is unknown but is thought to be multifactorial. Various studies point to risk factors such as sports or physical exercise, high body-mass index (BMI), age, prolonged standing, pes planus, increased subtalar joint pronation, and decreased ankle-joint dorsiflexion.1-3

Does posterior leg-muscle tightness play a role in plantar fasciitis?

Key Messages

  1. There is a proven strong correlation between gastrocnemius contracture and plantar fasciitis, suggesting that the treatment of fasciitis should address this underlying association.
  2. Patients whose plantar fasciitis is associated with contracture of the gastrocnemius muscle often benefit from targeted physical therapy to stretch the posterior leg-muscle group.
  3. Studies show that patients respond well to gastrocnemius recession when plantar fasciitis is unresponsive to conservative therapies.

One of the most commonly cited causes of plantar fasciitis is decreased ankle-joint dorsiflexion resulting from tight calf musculature, whether isolated gastrocnemius contracture or combined gastrocnemius–soleus tightness.1,4 Differentiation of isolated gastrocnemius contracture and gastrocnemius–soleus tightness is made clinically, using the Silfverskiöld test.4,5 (Based on the knowledge that the gastrocnemius muscle originates in the posterior surface of the femoral condyles, the test compares the findings of hip and knee extension, in which the muscle is taut, and hip and knee flexion, in which the muscle relaxes. Consistent loss of ankle dorsiflexion, even with flexion of the knee, is a sign of isolated gastrocnemius contracture.1,5)

Plantar fasciitis is defined as chronic or recalcitrant, or both, when 6 to 12 months of conservative treatment yield little or no improvement.4,6 It is estimated that 10% of patients with acute plantar fasciitis progress to chronic symptoms.4

Several studies have demonstrated strong correlation between gastrocnemius contracture and plantar fasciitis, suggesting that treatment regimens for plantar fasciitis should address this important underlying association:

Patel and DiGiovanni, in a prospective study, looked at the percentage of patients with diagnosed plantar fasciitis who also had an isolated gastrocnemius contracture.4 Of 254 patients, 84% (n = 211) had limited ankle dorsiflexion. More specifically, 57% (n = 145) had an isolated gastrocnemius contracture; 26% (n = 66) had contracture of the gastrocnemius–soleus complex; and 17% (n = 43) did not have any limitation in dorsiflexion.4 Diagnosis was based on a modified Silfverskiöld test, in which 1) isolated gastrocnemius contracture was defined as ankle dorsiflexion <5° upon knee extension that resolved when the knee was flexed to 90° and 2) contracture of the gastrocnemius–soleus complex was defined as <10° of ankle dorsiflexion regardless of the position of the knee.

Labovitz and colleagues, in a prospective cohort study of 210 feet, found a similar association between plantar fasciitis and tight gastrocnemius musculature.7 In a control group of 107 patients without plantar fasciitis, 51.4% (n = 55) had gastrocnemius contracture or gastrocnemius-soleus equinus, or both, compared to the plantar fasciitis group (n = 103), in which 96.1% (n = 99) had associated contracture or equinus.

Nakale and co-workers more recently examined the relationship between gastrocnemius contracture and plantar fasciitis in a cross-sectional prospective study.8 The researchers looked at 223 patients across 3 groups—those who had:

  • a clinical diagnosis of plantar fasciitis (Group 1)
  • foot and ankle pathology other than plantar fasciitis (Group 2)
  • no foot and ankle pathology (Group 3).

In total, 101 (45.3%) of patients had isolated gastrocnemius tightness: specifically, 36 of 45 (80%) in Group 1; 53 of 117 (45.3%) in Group 2; and 12 of 61 (19.7%) in Group 3. The difference in the prevalence of isolated gastrocnemius contracture among the groups was statistically significant (P <.001). In Group 1, the prevalence of gastrocnemius contracture was 78.9% in acute plantar fasciitis and 80.6% in chronic plantar fasciitis.

Conservative treatment

Ninety percent of patients respond positively to conservative treatment of plantar fasciitis, commonly consisting of posterior muscle and plantar fascia-specific stretching; orthotics interventions, including foot orthoses and night splints; pharmacotherapy, including nonsteroidal anti-inflammatory drugs, oral methylprednisolone (e.g., Medrol Dosepak), and corticosteroid injections; and physical therapy modalities, including extracorporeal shock wave therapy, ultrasound, cryotherapy, and taping.2,3,6,9 Determining whether a patient has associated contracture of the gastrocnemius muscle is essential because these patients often benefit from a more-targeted physical therapy regimen to stretch the posterior leg-muscle group.4,8

Operative treatment for recalcitrant plantar fasciitis

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Often, surgical intervention for plantar fasciitis is indicated when 6 to 12 months of conservative treatment fail. Procedures include:

Plantar fascial release. In patients with recalcitrant plantar fasciitis, a common surgical procedure includes either partial or total release of the plantar fascia from its origin at the calcaneal tuberosity, using either an endoscopic or open technique, plus nerve decompression.2,4,6 However, several experts have postulated that surgical release destabilizes the static supportive forces of the longitudinal arch1,3,4; moreover, surgical plantar fascial release can increase midfoot and forefoot pressure during stance phase and has been shown to cause collapse of the arch over time.1,8 In reporting the results of a study that looked at the function of the plantar fascia during the gait cycle, researchers cautioned that procedures that include release of part or all of the plantar fascia compromise efficient propulsion during gait, due to the role of the plantar fascia in transmitting force from the Achilles tendon to the forefoot.10

Gastrocnemius recession. Several researchers have examined the advantages of gastrocnemius recession—ie, releasing the proximal medial head of the gastrocnemius muscle—compared to the traditional approach of direct surgical release of the plantar fascia:

Abbassian and co-workers were the first to look at the effectiveness of gastrocnemius recession for the treatment of recalcitrant plantar fasciitis (defined as >1 year without improvement in symptoms with non-operative treatment).3 Of 17 patients (21 heels) evaluated over a 3-year follow-up, total or significant pain relief was reported in 17 (81%) heels. Fifty-eight percent (n = 10) of patients noted improvement 1 or 2 weeks after surgery; the remaining 42% noted improvement over 3 to 6 months. Subjective calf weakness was reported in 1 patient; 1 case of wound dehiscence occurred and resolved over 2 weeks. Fifteen patients (88%) were satisfied with the outcome of the procedure and said they would recommend it to others who require treatment of plantar fasciitis.3

Monteagudo and colleagues, in their retrospective study, reviewed the charts of 60 patients with chronic plantar fasciitis, which they defined as pain and other symptoms persisting >9 months despite conservative treatment.9 Patients were divided into 2 treatment groups:

  • 30 received surgical treatment, entailing isolated, proximal medial gastrocnemius release (PMGR)
  • 30 underwent partial proximal fasciotomy (PPF)—ie, traditional plantar fascial release.

Based on pain scores using a visual analogue scale (0, no pain, to 10, maximum pain), patients in the PMGR group experienced an average improvement from 8.2 preoperatively to 1.8 at 6 months and then to 0.9 at 12 months postoperatively, compared to scores in the PPF group, in which the average score was 8.1 preoperatively and, postoperatively, 4.5 at 6 months and 3.1 at 12 months. Patient satisfaction scores reached 95% in the PMGR group; patients in that group were back to work and prior sports activities in, on average, 3 weeks. In the PPF group, the satisfaction rate was 60%; patients returned to work and sports after a significantly longer interval—on average, 10 weeks.

Complications in the PPF group were painful scars (5 patients), neuropraxia (1), and superficial infection with wound dehiscence (1). In the PMGR group, 1 postoperative complication, a calf hematoma that resolved spontaneously, was reported.9

These findings suggest that patients in the PMGR group, compared to those who received a PPF, had, on average, a higher patient satisfaction score, quicker recovery, and faster return to work and prior activities, and had a lower rate of complications.

Ficke and colleagues conducted a smaller study of 17 overweight and obese patients (total cases, 18; average BMI, 34.7* [range, 26.6 to 57.8]) who underwent gastrocnemius recession. The study population included 3 patients with diabetic peripheral neuropathy, 4 with Achilles tendinitis , and 3 active smokers. The researchers observed significant improvement in the self-administered Foot Function Index, on average (from 66.4, preoperatively, to 26.5, postoperatively) and pain (on a visual analogue scale, a score of 8 preoperatively and 2 at final evaluation).6 Average time to return to work and preoperative activities was 8 weeks.

Complications included 1 case of sural neuritis, which resolved spontaneously, and 1 case of calcaneal stress fracture, which resolved with treatment with a walking boot and weight-bearing restrictions.6

Findings of this study suggest that, despite high BMI and other comorbidities, patients respond well to gastrocnemius recession for treatment of plantar fasciitis that is unresponsive to conservative therapies.

* Calculated as weight in kilograms divided by height in meters squared.

Conclusion

Recalcitrant plantar fasciitis can be a challenging pathology to treat; traditionally, surgical management has largely been limited to plantar fasciotomy. Of concern is that researchers have reported a number of complications of plantar fasciotomy, including persistent pain, medial arch collapse, incisional pain, and complex regional pain syndrome; furthermore, the satisfaction rate with traditional plantar fascial release is only about 60%.4

Gastrocnemius recession is an effective, relatively safe, and reliable procedure that addresses the often underappreciated effect of gastrocnemius muscle contracture on patients with recalcitrant plantar fasciitis. Studies have shown that this procedure offers significant improvement in pain, quality of life, activity level, and speed of recovery, and causes minimal complications. It is crucial, therefore, that practitioners carefully evaluate plantar fasciitis patients for associated gastrocnemius contracture and tailor nonoperative and operative treatments accordingly.

Dr. Wilson is a second-year podiatric resident at Mercy Hospital and Medical Center, Chicago, Illinois, where Dr. Wirt is chief podiatric resident and Dr. Hook is affiliated with the podiatric residency program. Dr. Hook also is in podiatric practice, specializing in foot, rearfoot reconstruction, and ankle surgery, at Midland Orthopedic Associates in Chicago.

Disclosures: None reported.

REFERENCES
  1. Solan MC, Carne A, Davies MS. Gastrocnemius shortening and heel pain. Foot Ankle Clin. 2014;19(4):719-738.
  2. Bolívar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot Ankle Int. 2013;34(1):42-48.
  3. Abbassian A, Kohls-Gatzoulis J, Solan MC. Proximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis. Foot Ankle Int. 2012;33(1):14-19.
  4. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011;32(1):5-8.
  5. Silfverskiöld N. Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand.1924;56:315-330.
  6. Ficke B, Elattar O, Naranje SM, et al. Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients. Foot Ankle Surg. 2017. pii: S1268-7731(17)30111-X.
  7. Labovitz JM, Yu J, Kim C. The role of hamstring tightness in plantar fasciitis. Foot Ankle Spec. 2011;4(3):141-144.
  8. Nakale NT, Strydom A, Saragas NP, Ferrao PNF. Association between plantar fasciitis and isolated gastrocnemius tightness. Foot Ankle Int. 2018;39(3):271-277.
  9. Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthop. 2013;37(9):1845-1850.
  10. Erdemir A, Hamel AJ, Fauth AR, et al. Dynamic loading of the plantar aponeurosis in walking. J Bone Joint Surg. 2004;86(3):546-552.

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