SLR - October 2015 - Amyn Lakhani
Reference: Nawoczenski DA, Barske H, Tome J, Dawson LK, Zlotnicki JP, DiGiovanni BF. Isolated Gastrocnemius Recession for Achilles Tendinopathy: Strength and Functional Outcomes. J Bone Joint Surg Am. 2015 Jan 21;97(2):99-105.Scientific Literature Review
Reviewed By: Amyn Lakhani, DPM
Residency Program: The Mount Sinai Hospital
Podiatric Relevance: Gastrocnemius equinus is a common finding amongst podiatric patients that may not always be symptomatic in its early stages. Over time, it may lead to chronic Achilles tendinopathy, which can be relatively uncomfortable and even painful. Since conservative care therapy is not always an effective treatment for this pathology, podiatric surgeons often have to resort to surgical treatments. This article attempts to investigate the effects of an isolated gastrocnemius recession on pain, patient reported function, and muscle strength in patients with recalcitrant Achilles tendinopathy and an isolated gastrocnemius contracture.
Methods: To conduct this retrospective cohort study, medical records of 23 individuals were reviewed who sought professional outpatient consultation from a foot and ankle orthopedic surgeon for recalcitrant Achilles tendinopathy of at least six months duration and who were managed with a gastrocnemius recession (Strayer procedure). The patients had to have an isolated gastrocnemius equinus, a diagnosis of unilateral insertional or noninsertional Achilles tendinopathy, failed a minimum of six months of conservative treatment, and no concomitant procedures to be able to participate in this study. The patients underwent a Strayer procedure in which the gastrocnemius and soleus facial layers are separated just distal to the gastrocnemius muscle-fascia confluence. The gastrocnemius is sectioned just distal to the musculotendenous junction and the proximal gastrocnemius tendon is then sutured back to the underlying soleus fascia. The leg was immobilized in a short leg cast and partial weight bearing was permitted. The patients were transitioned into a walking boot after five-seven days and were allowed to walk as tolerated. After a minimum of six months of follow-up post-op, the Achilles tendinopathy group was compared to control subjects who were recruited from the general population. Comparisons were made using the visual analog scale, foot and ankle ability measure, Biodex system three to measure isokenetic concentric ankle planterflexion strength, a limb symmetry index to compare the torque between involved and uninvolved limbs and patient satisfaction.
Results: A total of 13 patients underwent a gastrocnemius recession. The mean age of the patients was 52.1 ± 7.7 years. The investigation revealed a greater dorsiflexion in the involved limb compared to the uninvolved limb of the subjects. The VAS pain score decreased from 6.8 preoperatively to 1.6 postoperatively. While assessing the ability to perform activities of daily living, the performance of individuals who underwent the gastrocnemius recession approached the lower bounds of the 95 percent confidence interval of the control group. At 60 degrees/sec, the limb symmetry index comparison between groups was not significant, however, it was significant at 120 degrees/sec. The subjects demonstrated active ankle dorsiflexion of 17.6 degrees on the involved limb. Nine of the 13 patients were completely satisfied or satisfied with minor reservations, two of the 13 were satisfied with major reservations and another two of 13 were dissatisfied with the post-op results.
Conclusions: An isolated gastrocnemius recession in patients with recalcitrant Achilles tendinopathy allows patients to perform activities of daily life, however functional deficits may persist, particularly for activities that require greater muscle force, torque generation at higher velocities, and other activities that require a push-off function. The procedure provides significant and sustained pain relief associated with contracture of the gastrocnemius muscle in patients with chronic Achilles tendinopathy with unsuccessful non-operative treatments.