SLR - September 2015 - Cherreen H Tawancy
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: Cherreen H Tawancy, DPM
Residency Program: MedStar Washington Hospital Center
Podiatric Relevance: Achilles tendinopathy is a common foot and ankle disorder affecting an estimated 2.35 in 1000 adults. This is a common condition encountered by podiatric surgeons and treatment methods can range from accommodation to surgical intervention. Knowing the functional outcomes of isolated gastrocnemius recession for Achilles tendinopathy can help the podiatric surgeon determine if this procedure is an appropriate treatment option for patients presenting with Achilles tendinopathy.
Methods: This was a retrospective case-control cohort study investigating the effects of an isolated gastrocnemius recession in patients with chronic Achilles tendinopathy. The study included 13 patients with unilateral Achilles tendinopathy who received a gastrocnemius recession via the Strayer procedure and 10 matched control subjects. Inclusion criteria included (1) an isolated gastrocnemius contracture, (2) a diagnosis of unilateral insertional or non-insertional Achilles tendinopathy, (3) at least six months of failed conservative treatment and (4) no concomitant procedures. Outcome measures included pain which was assessed using a visual analog scale pre- and post-operatively, patient-reported function which was assessed using the validated Foot and Ankle Ability Measure, patient satisfaction which was assessed using a patient-reported survey, and muscle strength which was assessed via isokinetic concentric ankle plantarflexion strength at two different speeds (60 degrees/sec and 120 degrees/sec). The mean follow-up period was 18 months. Statistical significance was defined by a p value of < 0.05.
Results: Regarding pain, the mean pre- and post-operative visual analog scores in the study group were 6.8 and 1.6, respectively (p < 0.05). The findings regarding function in activities of daily living using the Foot and Ankle Ability Measure in the study and control groups were 89.7 and 98.5, respectively (p < 0.05). The same outcome measure tool regarding sports activities in the study and control groups were 71.9 and 95.1 (p < 0.05). These results suggest that gastrocnemius recession may provide relatively good functioning in activities of daily living but may have problematic outcomes for more physically intense activities. Patient satisfaction was measured using a patient survey. Of the 13 study group participants, nine were completely satisfied or satisfied with minor reservations. Regarding strength, isokinetic data showed significant side-to-side differences in both the study and control groups at the slower speed but significant side-to-side differences in only the study group at the higher speed. No between-group differences in peak torque were observed at either speed. The limb symmetry index, which was an outcome tool to measure the percentage of strength deficit between the involved and uninvolved limb, was statistically significant in both groups at both speeds, but was more pronounced at the higher speed. Finally, peak active dorsiflexion in the study group was significantly greater in the involved limb (17.6 degrees) than in the uninvolved limb (13.3 degrees).
Conclusions: Isolated gastrocnemius recession provides significant and sustained pain relief for chronic Achilles tendinopathy. Outcomes for daily living were associated with improved function however the study group had more problems with power and endurance activities than the control group. The authors comment on the fact that isokinetic strength assessment, which was similar between the study and control groups, does not adequately reflect muscle performance during more extreme weight-bearing activities and did not correlate with patient-reported functional deficits in the study group. Based on the findings from this study, it can be determined that isolated gastrocnemius recession may be a viable surgical option in patients with Achilles tendinopathy who wish to return to their pre-operative level of daily functioning, but may not be the best choice in patients who wish to return to a high-level of physical and weight-bearing performance. Patient selection becomes very important in this regard.