Abstract
Background
The aim of this study is to evaluate the use of isolated gastrocnemius release in the treatment of Achilles tendinopathy. The primary outcome is the change in patient-reported pain outcomes. Secondary outcomes include the change in patient-reported foot and ankle function, ankle range of motion and strength, patient satisfaction and rate of surgical complications.
Methods
A systematic review was undertaken of studies involving patients treated with an isolated gastrocnemius release for Achilles tendinopathy. Randomised controlled trials, cohort studies, case–control studies and case series were eligible and identified from the following databases: MEDLINE and EMBASE.
Results
Isolated gastrocnemius release results in improved patient-reported outcome scores for pain and foot and ankle function. There is an increase in ankle range of motion but a reduction in ankle strength. Patients report a high rate of overall satisfaction. The most common surgical complications are sural nerve injury and wound infection.
Conclusions
Isolated gastrocnemius release may offer maintained and clinically meaningful improvements in pain and foot and ankle function with an associated reduction in ankle strength.
Keywords: Gastrocnemius release, Achilles tendinopathy, Systematic review
Introduction
Achilles tendinopathy is a common condition that is characterised by localised tendon pain, swelling and impaired performance [1]. Achilles tendinopathy can affect athletes and non-athletes of all ages [2]. Patients with early stages of the condition can experience pain following strenuous activities but as the condition progresses pain can persist at rest. Achilles tendinopathy can be insertional, affecting the calcaneal insertion of the tendon, or non-insertional which involves the tendon body [3, 4]. A gastrocnemius equinus contracture may contribute to the development of Achilles tendinopathy and can be clinically diagnosed using the Silfverskiold test [5–9].
Eccentric calf training is recommended as the first-line of non-surgical treatment, with which many patients are treated successfully [10–14]. Further non-surgical treatments include platelet-rich plasma injection and extracorporeal shockwave therapy [15–18]. Surgical management may be indicated in patients that experience progressive symptoms despite these measures. There are various surgical techniques used to lengthen the gastrocnemius–Achilles tendon complex. These include the Strayer procedure, Baumann procedure, Vulpius procedure and proximal medial gastrocnemius release [19, 20]. Surgical procedures involving direct treatment of the pathologic portion of the tendon can carry risk of wound problems due to the poor blood supply to the tendon and cutaneous tissues [21].
An isolated gastrocnemius release is a surgical treatment option for refractory Achilles tendinopathy. Gastrocnemius release has already become a commonly used procedure to treat several foot conditions, including forefoot overload, plantar fasciitis and flat foot reconstruction [22–24]. The majority of evidence to substantiate the use of gastrocnemius release in Achilles tendinopathy is retrospective in nature and lacking in comparative normative data [18].
The aim of this systematic review is to evaluate the use of isolated gastrocnemius release in the treatment of Achilles tendinopathy. The primary outcome is the change in patient-reported pain outcomes. Secondary outcomes include the change in patient-reported foot and ankle function, ankle range of motion and strength, patient satisfaction and the rate of surgical complications.
Methods
Eligibility Criteria
Randomised controlled trials, cohort studies, case–control and case series of patients treated with isolated gastrocnemius release for insertional and non-insertional Achilles tendinopathy were eligible. Studies where gastrocnemius release was performed for another indication or in conjunction with another procedure were excluded. Patient-reported outcomes for pain were required. There was no restriction on the method used to diagnose a gastrocnemius contracture which included clinical assessment, ultrasound scan and magnetic resonance imaging. There was no restriction on patient age, surgical technique for gastrocnemius release or duration of follow-up. Studies in secondary or tertiary care were eligible. Only published studies in English language were included and there was no restriction on the date of publication.
Searches
MEDLINE and EMBASE electronic bibliographic databases were searched. Searches were performed on 01.01.2023 and repeated on 02.05.2023. The complete electronic search strategies are detailed in Table 1. Search strategies were developed by a hospital librarian with training in systematic review methodology. Checking of reference lists of obtained articles was undertaken to supplement electronic searching. Two authors screened abstracts of studies retrieved using the search strategy independently to identify studies that potentially met the inclusion criteria. The full text of these studies was then independently assessed for eligibility by two authors. Disagreement was resolved through consensus with third author involvement when necessary. Study selection was unblinded.
Table 1.
MEDLINE and EMBASE electronic search strategies
| Database: Medline via Pubmed | |
|---|---|
| Date: 02/05/23 | |
| Strategy | |
| #1 | gastrocnemius recession.ab. |
| #2 | gastrocnemius recession.m_titl. |
| #3 | gastrocnemius release.ab. |
| #4 | gastrocnemius release.m_titl. |
| #5 | Contracture/su [Surgery] |
| #6 | Tenotomy/ |
| #7 | 1 or 2 or 3 or 4 or 5 or 6 |
| #8 | achilles tendin*.ab. |
| #9 | "achilles tendin*".m_titl. |
| #10 | achilles tendon.ab |
| #11 | achilles tendon.m_titl |
| #12 | Achilles Tendon/ |
| #13 | Tendinopathy/ |
| #14 | 8 or 9 or 10 or 11 or 12 or 13 |
| #15 | 7 and 14 |
| Database: Embase | |
|---|---|
| Date: 02/05/23 | |
| Strategy | |
| #1 | gastrocnemius recession.ab. |
| #2 | Gastrocnemius recession.m_titl. |
| #3 | gastrocnemius release.ab. |
| #4 | Gastrocnemius Release.m_titl. |
| #5 | contracture/su [Surgery] |
| #6 | tenotomy/ |
| #7 | 1 or 2 or 3 or 4 or 5 or 6 |
| #8 | achilles tendin*.ab. |
| #9 | "achilles tendin*".m_titl. |
| #10 | achilles tendon.ab. |
| #11 | achilles tendon.m_titl. |
| #12 | achilles tendon/ |
| #13 | tendinopathy.mp. |
| #14 | 8 or 9 or 10 or 11 or 12 or 13 |
| #15 | 7 and 14 |
Data Extraction
Two authors independently extracted data using an electronic data extraction form. Disagreement was resolved through consensus with a third author involvement where necessary. Data extraction was unblinded. Extracted information included study title, authors, year of publication, country of origin, study design, start date, end date, study setting, patient demographics, outcomes, and follow-up duration (Table 2).
Table 2.
Characteristics of the ten studies included in the systematic review
| Study | Design | Country | Duration of study (start–end) | Mean age (years) | Gender | Number of patients | Duration of symptoms | Duration of follow-up | Method of tendinopathy diagnosis | Surgical procedure | Prior treatments |
|---|---|---|---|---|---|---|---|---|---|---|---|
| DiLiberto et al. [27] | Prospective case–control study | United States of America | Not given |
Tendinopathy group: 51 Healthy matched control group: 32 |
80% male |
Tendinopathy group: 8 (5 insertional, 3 non-insertional) Control group: 8 |
20.3 months | 2 years | Clinical assessment | Strayer procedure | Not given |
| Nawoczenski et al. [28] | Cohort study | United States of America | 2008–2010 | 52.8 |
Tendinopathy group: 8 Male 6 Female |
Tendinopathy group: 14 Control group: 10 |
Minimum 6 months | 19.2 months | Clinical assessment | Strayer procedure | Nonsteroidal anti-inflammatory drugs, heel lifts, physical therapy |
| Molund et al. [29] | Case Series | Norway | 2007–2014 | 45.5 | Not given | 30 (all non-insertional) | 39 months | 37.5 months | Clinical assessment, ultrasound scan or magnetic resonance imaging | Strayer procedure (open or endoscopic) | Eccentric stretching protocol, 5 patients had previous surgery |
| Holtmann et al. [32] | Case series | Switzerland | 2001–2010 | 43 | Not given | 15 | Minimum 6 months | Minimum 6 months | Clinical assessment | Strayer procedure | Nonsteroidal anti-inflammatory drugs, orthotics, stretching program, weight reduction |
| Maffuli et al. [34] | Case series | United Kingdom | 2008–2009 | 46 |
7 Male 11 Female |
18 | 16 months | 54 months | Clinical assessment and ultrasound scan | Release of the gastrocnemius medial head | Shockwave, steroid injection |
| Gurdezi et al. [30] | Case series | United Kingdom | 2-year period | 45 |
4 Male 5 Female |
9 (4 insertional, 5 non-insertional) | Ranged from 6 months to 15 years | 2.5 years | Clinical assessment | Release of the gastrocnemius medial head | Conservative modalities such as physiotherapy |
| Kiewiet et al. [31] | Case series | United States of America | 2004–2009 | 49.9 | Not given | 8 | Minimum 6 months | 34.6 months | Not given | Strayer procedure | Activity modification, immobilisation, stretching programs, physical therapy |
| Duthon et al. [33] | Case Series | Switzerland | 2003–2007 | 42 |
11 Male 3 Female |
14 | Minimum 1 year | Minimum 1 year | Clinical assessment | Strayer procedure | Immobilisation, eccentric exercise, extracorporeal shock wave therapy, sclerosing injections, nonsteroidal anti-inflammatory drugs |
| Tallerico et al. [35] | Case series | United States of America | 2010–2012 | 59 | Not given | 11 (all insertional) | 6.2 months | 13.8 months | Clinical assessment | Strayer procedure (open or endoscopic) | Not given |
| Smith et al. [6] | Case Series | United States of America | 2013–2015 | 53.2 |
5 Male 20 Female |
25 (5 non-insertional, 16 insertional, 4 both) | Minimum 3 months | 13.1 months | Clinical assessment | Strayer procedure | Casting or walking boot immobilisation with a heel wedge, anti-inflammatory drugs, home stretching programs, physical therapy |
Risk of Bias Assessment
Two authors independently assessed the risk of bias in included studies. Disagreement was resolved through consensus with a third author involvement where necessary. Risk of bias was assessed at a study level using the Methodological Index for Non-randomised Studies (MINORS) assessment scale for non-randomized studies and is summarized in Table 3 [25]. Risk of bias assessment was unblinded. The quality of evidence at an outcome level was assessed using the GRADE criteria [26].
Table 3.
Risk of bias assessment using the minors criteria for studies included in the systematic review
| Study | A clearly stated aim | Inclusion of consecutive patients | Prospective collection of data | Endpoints appropriate to the aim of the study | Unbiased assessment of the study endpoint | Follow-up period appropriate to the aim of the study | Loss to follow-up less than 5% | Prospective calculation of the study size | An adequate control group | Contemporary groups | Baseline equivalence of groups | Adequate statistical analyses |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DiLiberto et al. [27] | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | 0 | 2 | 2 | 2 |
| Nawoczenski et al. [28] | 2 | 2 | 2 | 2 | 0 | 2 | 2 | 0 | 0 | 2 | 2 | 2 |
| Molund et al. [29] | 2 | 2 | 0 | 1 | 0 | 2 | 0 | – | – | – | – | – |
| Holtmann et al. [32] | 2 | 2 | 1 | 1 | 0 | 1 | 2 | – | – | – | – | – |
| Maffuli et al. [34] | 2 | 2 | 2 | 2 | 0 | 2 | 0 | – | – | – | – | – |
| Gurdezi et al. [30] | 2 | 2 | 0 | 2 | 0 | 2 | 0 | – | – | – | – | – |
| Kiewiet et al. [31] | 2 | 2 | 0 | 2 | 0 | 2 | 0 | – | – | – | – | – |
| Duthon et al. [33] | 2 | 2 | 2 | 2 | 0 | 1 | 0 | – | – | – | – | – |
| Tallerico et al. [35] | 2 | 2 | 0 | 2 | 0 | 2 | 2 | – | – | – | – | – |
| Smith et al. [6] | 2 | 2 | 0 | 2 | 0 | 2 | 2 | – | – | – | – | – |
The Methodological Index for Non-randomised Studies (MINORS) criteria comprises a 12-item checklist, each item given a score of 0 (not reported), 1 (inadequately reported), or 2 (adequately reported). Each study is scored against a maximum of 16 points for noncomparative studies and 24 points for comparative studies
Results of Individual Studies
Nine hundred and eighty-six studies were identified using the search strategy and after screening abstracts the full text of 15 studies was accessed to assess for eligibility. Five articles were excluded at this stage for the following reasons: gastrocnemius release was performed for another indication (n = 1), gastrocnemius release was performed in conjunction with another procedure (n = 1) and the article was a case report (n = 3). Therefore, 10 studies met the criteria for inclusion in the systematic review (Fig. 1).
Fig. 1.
PRISMA flow diagram for search strategy and study selection
Results
Patient-Reported Pain Outcomes
The quality of evidence assessed using the GRADE score was low (2 GRADE points) for all outcomes.
All studies reported an improvement in patient-reported pain outcomes after surgery (Table 4). A significant improvement in mean visual analogue scale (VAS) score was reported for both insertional and non-insertional tendinopathy patients in several studies [6, 27–31]. DiLiberto et al. report an improvement in mean VAS score from 7 to 0 in patients undergoing a Strayer procedure [27]. The time to achieve maximal pain relief ranged from 2 months to over 12 months, and the improvement was maintained at 2-year follow-up [27]. A significant improvement in VAS scores was replicated in a number of the other studies for both insertional and non-insertional tendinopathy patients, with follow-up ranging from 19 months to 37.5 months [6, 28–31].
Table 4.
Summary of outcomes for included studies in the systematic review
| Study | Outcomes | Surgical complications | |||
|---|---|---|---|---|---|
| Outcome measure | Pre-treatment (mean) | Post-treatment (mean) | Statistical significance | ||
| DiLiberto et al. [27] | Visual analogue scale | 7 |
2 (6 months) 0 (24 months) |
p = 0.01 | None reported |
| Foot and Ankle Ability Measure Activity of Daily Living subscale scores (higher scores higher level of function) | 70% |
90% (6 months) 100% (24 months) |
p = 0.1 p < 0.1 |
||
| Foot and Ankle Ability Measure sport participation self-rating scores (higher scores higher level of function) | 30% |
80% (6 months) 92% (24 months) |
p < 0.1 | ||
| Ankle power during functional activity (W/kg) | Walk 1.5 |
1.5 (6 months) 1.5 (control) |
|||
| Ascending a standard step 2.5 |
2 (6 months) 2.5 (control) |
p = 0.02 | |||
| Ascending a high step 4 |
3 (6 months) 4 (control) |
p = 0.01 | |||
| Total work during the heel raise work test (J/kg) | Operated limb 25 | Operated limb 20 (6 months) | p > 0.09 | ||
| Non-operated limb 25 | Non-operated limb 25 (6 months) | ||||
| Control dominant side 30 | |||||
| Control non-dominant side 30 | |||||
| Limb symmetry index during the heel raise work test | 100% |
80% (6 months) 100% (control) |
p = 0.02 | ||
| Peak ankle dorsiflexion motion (degrees) | 12.2 (SD 8.3) (CI 5.3–19.1) | 15.9 (SD 9.4) (CI 8.1–23.7) | |||
| Overall satisfaction | All patients reported completely satisfied or satisfied with minor reservations | ||||
| Nawoczenski et al. [28] | Visual analogue scale | 6.8 ± 1.8 | p1.6 ± 2.3 | p < 0.05 | None reported |
| Foot and Ankle Ability Measure (FAAM) Activities of Daily Living subscale |
Operated: 90.0 ± 8.4 Control: 98.3 ± 3.6 |
p = 0.01 | |||
| Foot and Ankle Ability Measure (FAAM) Sports subscale |
Operated: 70.6 ± 22.4 Control: 94.6 ± 10.9 |
p = 0.01 | |||
| Peak ankle plantarflexion power (W/kg) | |||||
| Walking |
Operated: 1.1 Control: 1.6 |
p = 0.02 | |||
| Standard step activity |
Operated: 2.1 Control: 2.6 |
p = 0.02 | |||
| High step activity |
Operated: 2.8 Control: 3.7 |
p = 0.04 | |||
| Endurance/Heel Raise Work Test (J) |
Operated limb: 1141 Non-operated limb: 1583 Control: 2303 |
p = 0.01 p = <0.01 |
|||
| Molund et al. [29] | Visual analogue scale | 7.5 | 0.7 | Wound infection (1/30) (3%) | |
| Victorian Institute of Sports Assessment–Achilles (VISA-A) | 39.5 (subgroup of patients with preoperative data) |
91.9 (subgroup of patients with preoperative data) 91.4 (all patients) |
Sural nerve injury (1/30) (3%) | ||
| Vertical jump–countermovement jump (jump height in cm) |
Operated limb: 4.3 Non-operated limb: 5.5 |
||||
| Hopping (plyometric quotient [flight time/contact time]) |
Operated limb: 0.37 Non-operated limb: 0.42 |
||||
| Drop countermovement jump (jump height in cm) |
Operated limb: 3.2 Non-operated limb: 5.5 |
||||
| Concentric toe raise (power in W) |
Operated limb: 279 Non-operated limb: 268 |
||||
| Eccentric concentric toe raise (power in W) |
Operated limb: 299 Non-operated limb: 319 |
||||
| Toe raise endurance (work in J) 1451, 1921 |
Operated limb: 1451 Non-operated limb: 1921 |
||||
| Overall satisfaction | 28/30 patients were satisfied with their results after surgery and would have chosen the same treatment again | ||||
| Holtmann et al. [32] | Dorsiflexion range of movement (degrees) | 1.7 ± 3.6 | 15.7 ± 7.1 | p < 0.001 | Wound infection (3/64) (5%) |
|
Foot Function Index Total Foot Function Index Function subscale |
65.4 ± 26.5 66.5 ± 26.9 |
33.4 ± 19.5 33.4 ± 19.1 |
p < 0.001 | Sural nerve injury (7/64) (11%) | |
| Foot Function Index Pain subscale | 65.3 ± 28.3 | 33.0 ± 20.6 | Allergy to suture material (1/64) (2%) | ||
| Strength Testing (Janda method, mean out of 5) | 4 (85% of maximal muscle strength) | ||||
| Patient Satisfaction | 11 patients were satisfied would have undergone the surgery again | Scar revision surgery (1/64) (2%) | |||
| Maffuli et al. [34] | Boyden classification system | 15 patients rated good or excellent | None reported | ||
| Victorian Institute of Sport Assessment–Achilles (VISA-A) | 52.3 | 75 | p = 0.04 | ||
| Maximum calf circumference (cm) | Operated limb: 36.4 ± 5.2 |
Operated limb: 36.7 ± 6.7 cm Non-operated limb: 39.9 ± 4.2 |
p = 0.01 | ||
| Peak torque (N) | Operated limb 218.5 ± 109.3 | Operated limb 259.2 ± 123 N | p = 0.01 | ||
| Gurdezi et al. [30] | Visual analogue scale | Non-insertional 7.8 Insertional 9 |
Non-insertional 0.4 Insertional 5.6 |
p < 0.05 p = 0.05 |
Deep vein thrombosis (1/9) (11%) |
| Victorian Institute of Sport Assessment–Achilles (VISA-A) | Non-insertional 34.8 Insertional 51.8 |
Non-insertional 94 Insertional 73.6 |
p < 0.05 p = 0.05 |
Hypertrophic scarring (1/9) (11%) | |
| American Orthopaedic Foot & Ankle Society ankle-hindfoot score |
Non-insertional 61.8 (36–75) Insertional 63.2 (49–69) |
Non-insertional 91.2 (63–100) Insertional 78.2 (60–98) |
p < 0.05 p = 0.05 |
||
| Overall satisfaction (0–10) |
Non-insertional 9.6 Insertional 5.3 |
||||
| Kiewiet et al. [31] |
Visual analogue scale American Orthopaedic Foot & Ankle Society |
7.3 | 1 | p < 0.05 | None reported |
| Ankle-hindfoot score | Mean 94.4 | ||||
| Foot Function Index | 7.0 | ||||
| Heel raises | 98.6% of the maximum repetitions for the nonoperative limb | ||||
| Calf circumference | 101.4% compared to non-operative limb | ||||
| Ankle range of motion from maximum dorsiflexion through maximum plantarflexion | + 1.3 degrees compared to non-operative limb | ||||
| Overall satisfaction | 8 patients reported being satisfied with the outcome and that they would undergo the procedure again given a similar situation | ||||
| Duthon et al. [33] | Dorsiflexion range of movement (degrees) | − 6 | 7 | None reported | |
| Plantarflexion strength | Equal to non-operative limb | ||||
| American Orthopaedic Foot & Ankle Society Ankle-hindfoot score | 71 | 100 | p < 0.001 | ||
| Foot Function Index Total | 39 |
12 (12 months) 12 (24 months) |
|||
| Foot Function Index Pain subscale | 42 |
10 (12 months) 14 (24 months) |
|||
| Foot Function Index Disability subscale | 42 |
13 (12 months) 11 (24 months) |
p < 0.001 p = 0.001 |
||
| Foot Function Index Activity Limitation subscale | 10 |
10 (12 months) 10 (24 months) |
p < 0.001 p = 0.005 |
||
| SF-12 physical component | 36 |
51 (12 months) 51 (24 months) |
p = 0.012 p = 0.109 |
||
| Patient satisfaction (range 7–35, 35 = worst) |
8 (12 months) 9 (24 months) |
p < 0.001 p = 0.005 |
|||
| Tallerico et al. [35] | American Orthopaedic Foot and Ankle Society (AOFAS) score | 94.8 (median) | Recurrence of heel pain and equinus deformity (1/11) (9%) | ||
| Overall satisfaction | 91% of patients had high patient satisfaction | Sural nerve injury (2/11) (18%) | |||
| Smith et al. [6] | Visual analogue scale | Combined 8.9 |
Combined 2.0 (6 weeks) Combined 1.0 (final) |
p < 0.001 | Sural nerve injury (2/25) (8%) |
| Non-insertional 8.6 |
Non-insertional 0.6 (6 weeks) Non-insertional 0 (final) |
||||
| Insertional (no spur) 8.58 |
Insertional (no spur) 2.09 (6 weeks) Insertional (no spur) 2.4 (final) |
Achilles tendon rupture (1/25) (4%) | |||
| Insertional (spur) 9.5 |
Insertional (spur) 2.75 (6 weeks) Insertional (spur) 1.33 (final) |
||||
| Foot Function Index Total | Combined 73.5 | Combined 27.4 (final) | |||
| Non-insertional 72.15 | Non-insertional 8.4 (final) | ||||
| Insertional (no spur) 68.1 | Insertional (no spur) 23.5 (final) | ||||
| Insertional (spur) 81.3 | Insertional (spur) 44.4 (final) | ||||
In addition to VAS, several studies reported an improvement in a variety of other patient-reported pain outcomes measures [32–35]. Holtmann et al. and Duthon et al. reported a decrease in the Foot Function Index (FFI) pain subscale in patients undergoing a Strayer procedure at a follow-up of 6 months and 24 months, respectively [32, 33]. Maffulli et al. reported an improvement in the mean Victorian Institute of Sport Assessment–Achilles (VISA-A) score in patients undergoing a medial head of gastrocnemius release at a follow-up of 54 months [34].
Patient-Reported Foot and Ankle Function Outcomes
All studies reported an improvement in patient-reported foot and ankle function outcomes after surgery. Two papers reported on Foot and Ankle Ability Measure (FAAM) scores [27, 28]. Both studies showed improvements in FAAM scores for both the activities of daily living subscale and sport subscale in patients undergoing a Strayer procedure [27, 28].
An improvement in the mean VISA-A score was reported by three studies [29, 30, 34]. Gurdezi et al. reported an improvement in mean VISA-A score after proximal medial gastrocnemius release in non-insertional tendinopathy patients [30]. Insertional tendinopathy patients experienced a lesser improvement [30]. Their study also looked at American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot scores and reported a greater improvement in in non-insertional tendinopathy [30]. Improvements in AOFAS ankle–hindfoot scores were also demonstrated by Duthon et al. and Kiewiet et al. [31, 33]. Four studies reported an improvement in FFI after surgery [6, 31–33].
Ankle Range of Motion and Strength
Three studies reported an increase in ankle range of motion with no loss of ankle strength [29, 31, 33]. Kiewiet et al. reported an improvement of 1.3 degrees in ankle range of motion in the operated limb when compared to the non-operative limb [31]. After surgery the operated limb achieved 98.6% of the maximum repetitions and a mean calf circumference of 101.4% compared to non-operative limb [31]. Duthon et al. reported post-surgery plantaflexion strength equal to the non-operative limb [33]. Molund et al. reported similar performance for operated and non-operative limbs on a functional test battery, including vertical jump, hopping, concentric toe-raise power and toe-raise endurance [29].
A further 4 studies reported an increase in ankle range of motion with an associated reduction in ankle strength [27, 28, 32, 34]. DiLiberto et al. reported a decline in ankle power during stair ascent and a reduced total work during a heel raise work test [27]. Nawoczenski et al. reported that when compared to controls, ankle power was reduced for all activities in the surgery group [28]. Holtmann et al. and Maffulli et al. observed similar reductions in ankle strength [32, 34].
Overall Patient Satisfaction
In all studies, patient satisfaction was reported as high post-operatively [6, 27–35]. DeLiberto et al. observed that all patients reported that they were either completely satisfied or satisfied with minor reservations after surgery at 2-year follow-up [27]. Gurdezi et al. reported an overall post-surgery satisfaction of 9.6/10 for non-insertional patients and 5.3/10 for insertional patients [30]. Several other studies reported similarly high levels of overall patient satisfaction [29, 31–34].
Surgical Complications
The most common post-operative complications were sural nerve injuries and wound infections [6, 29, 30, 32, 35]. Molund et al. reported 1 sural nerve injury (3%) and 1 wound infection (3%) in 30 patients [29]. Holtmann et al. reported complications including 3 wound infections (5%), 7 sural nerve injuries (11%), 1 allergy to suture material (2%) and 1 scar revision surgery (2%) in 64 patients [32]. Smith et al. reported 2 sural nerve injuries (8%) and 1 Achilles tendon rupture (4%) in 25 patients. [6]. Gurdezi et al. reported 1 deep vein thrombosis (11%) and 1 patient with hypertrophic scarring (1%) in 9 patients [30]. Tallerico et al. reported 1 recurrence of insertional heel pain and equinus deformity (9%) and 2 sural nerve injuries (18%) in 11 patients [35]. Five studies reported no complications [27, 28, 31, 33, 34].
Discussion
This systematic review evaluates the use of an isolated gastrocnemius release in the treatment of Achilles tendinopathy. The main findings are as follows: (1) gastrocnemius release results in improved patient-reported outcome scores for pain; (2) gastrocnemius release results in improved patient-reported outcome scores for foot and ankle function; (3) gastrocnemius release results in improved ankle range of motion but reduced ankle strength; and (4) patients report a high rate of overall satisfaction after gastrocnemius release. Our findings are consistent with previously published literature. Jarin et al. conclude that gastrocnemius release is an operative treatment option that has shown to be beneficial in the treatment of non-insertional tendinopathy patients in small non-randomised studies [18].
Gastrocnemius release results in reduced ankle strength. Despite this, improvement in patient-reported outcome scores for foot and ankle function and overall satisfaction remain high. Thus, the functional implications of a reduction in ankle strength are unclear. Improvement in pain and foot and ankle function occurs when performing gastrocnemius release using differing surgical techniques including proximal gastrocnemius release and the Strayer procedure.
This systematic review was performed on cohort studies, case–control studies, and case series. Hence there was significant heterogeneity and low quality of evidence for each outcome. Subgroup analysis of insertional and non-insertional tendinopathy patients was not performed because the published data did not allow adequate separation of these groups. A randomised controlled trial represents the optimal study design but may not be feasible due to the patient heterogeneity.
Conclusion
Based on current evidence, we recommend gastrocnemius release as a potential treatment option in refractory Achilles tendinopathy. Gastrocnemius release may offer maintained and clinically meaningful improvements in pain and foot and ankle function with an associated reduction in ankle strength.
Declarations
Conflict of Interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Ethical Standard
This article does not contain any studies with human or animal subjects performed by the any of the authors.
Informed Consent
For this type of study informed consent is not required.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Paavola M, Kannus P, Järvinen TA, Khan K, Józsa L, Järvinen M. Achilles tendinopathy. Journal of Bone and Joint Surgery. American Volume. 2002;84(11):2062–2076. doi: 10.2106/00004623-200211000-00024. [DOI] [PubMed] [Google Scholar]
- 2.de Jonge S, van den Berg C, de Vos RJ, van der Heide HJL, Weir A, Verhaar JAN, et al. Incidence of midportion Achilles tendinopathy in the general population. British Journal of Sports Medicine. 2011;45(13):1026–1028. doi: 10.1136/bjsports-2011-090342. [DOI] [PubMed] [Google Scholar]
- 3.Kvist M. Achilles tendon injuries in athletes. Annales Chirurgiae et Gynaecologiae. 1991;80(2):188–201. [PubMed] [Google Scholar]
- 4.Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. American Journal of Sports Medicine. 1976;4(4):145–150. doi: 10.1177/036354657600400404.5. [DOI] [PubMed] [Google Scholar]
- 5.Noback PC, Freibott CE, Tantigate D, Jang E, Greisberg JK, Wong T, et al. Prevalence of asymptomatic Achilles tendinosis. Foot and Ankle International. 2018;39(10):1205–1209. doi: 10.1177/1071100718778592. [DOI] [PubMed] [Google Scholar]
- 6.Smith KS, Jones C, Pinter Z, Shah A. Isolated gastrocnemius recession for the treatment of Achilles tendinopathy. Foot & Ankle Specialist. 2018;11(1):49–53. doi: 10.1177/1938640017704942. [DOI] [PubMed] [Google Scholar]
- 7.Nakale NT, Strydom A, Saragas NP, Ferrao PNF. Association between plantar fasciitis and isolated gastrocnemius tightness. Foot and Ankle International. 2018;39:271–277. doi: 10.1177/1071100717744175. [DOI] [PubMed] [Google Scholar]
- 8.The SP, Test S. Foot & ankle. International. 2014;35(8):838–838. doi: 10.1177/1071100714535202. [DOI] [PubMed] [Google Scholar]
- 9.DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen ST, Cziernecki J, et al. Isolated gastrocnemius tightness. Journal of Bone and Joint Surgery. American Volume. 2002;84(6):962–970. doi: 10.2106/00004623-200206000-00010. [DOI] [PubMed] [Google Scholar]
- 10.Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998;26(3):360–366. doi: 10.1177/03635465980260030301. [DOI] [PubMed] [Google Scholar]
- 11.Angermann P, Hovgaard D. Chronic Achilles tendinopathy in athletic individuals: Results of nonsurgical treatment. Foot and Ankle International. 1999;20:304–306. doi: 10.1177/107110079902000507. [DOI] [PubMed] [Google Scholar]
- 12.Alfredson H, Lorentzon R. Chronic Achilles tendinosis: Recommendations for treatment and prevention. Sports Medicine (Auckland, N. Z.) 2000;29:135–146. doi: 10.2165/00007256-200029020-00005. [DOI] [PubMed] [Google Scholar]
- 13.Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surgery, Sports Traumatology, Arthroscopy. 2001;9:42–47. doi: 10.1007/s001670000148. [DOI] [PubMed] [Google Scholar]
- 14.Roos EM, Engström M, Lagerquist A, Söderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy—A randomized trial with 1-year follow-up. Scandinavian Journal of Medicine and Science in Sports. 2004;14(5):286–295. doi: 10.1111/j.1600-0838.2004.378.x. [DOI] [PubMed] [Google Scholar]
- 15.Kearney RS, Ji C, Warwick J, Parsons N, Brown J, Harrison P, Young J, Costa ML, ATM Trial Collaborators Effect of platelet-rich plasma injection vs. sham injection on tendon dysfunction in patients with chronic midportion Achilles tendinopathy: A randomized clinical trial. JAMA. 2021;326(2):137–144. doi: 10.1001/jama.2021.6986. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Furia JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. American Journal of Sports Medicine. 2006;34(5):733–740. doi: 10.1177/0363546505281810. [DOI] [PubMed] [Google Scholar]
- 17.Feeney KM. The effectiveness of extracorporeal shockwave therapy for midportion Achilles tendinopathy: A systematic review. Cureus. 2022;14(7):e26960. doi: 10.7759/cureus.26960. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Jarin I, Bäcker HC, Vosseller JT. Meta-analysis of noninsertional Achilles tendinopathy. Foot and Ankle International. 2020;41(6):744–754. doi: 10.1177/1071100720914605. [DOI] [PubMed] [Google Scholar]
- 19.Strayer LM., Jr Recession of the gastrocnemius: An operation to relieve spastic contracture of the calf muscles. Journal of Bone and Joint Surgery. American Volume. 1950;32(3):671–676. [PubMed] [Google Scholar]
- 20.Hsu RY, VanValkenburg S, Tanriover A, DiGiovanni CW. Surgical techniques of gastrocnemius lengthening. Foot and Ankle Clinics. 2014;19(4):745–765. doi: 10.1016/j.fcl.2014.08.007. [DOI] [PubMed] [Google Scholar]
- 21.Theobald P, Benjamin M, Nokes L, Pugh N. Review of the vascularisation of the human Achilles tendon. Injury. 2005;36(11):1267–1272. doi: 10.1016/j.injury.2005.02.012. [DOI] [PubMed] [Google Scholar]
- 22.Cortina RE, Morris BL, Vopat BG. Gastrocnemius recession for metatarsalgia. Foot and Ankle Clinics. 2018;23(1):57–68. doi: 10.1016/j.fcl.2017.09.006. [DOI] [PubMed] [Google Scholar]
- 23.Arshad Z, Aslam A, Razzaq MA, Bhatia M. Gastrocnemius release in the management of chronic plantar fasciitis: A systematic review. Foot and Ankle International. 2022;43(4):568–575. doi: 10.1177/10711007211052290. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Chang SH, Abdelatif NMN, Netto CC, Hagemeijer NC, Guss D, DiGiovanni CW. The effect of gastrocnemius recession and tendo-Achilles lengthening on adult acquired flatfoot deformity surgery: A systematic review. Journal of Foot and Ankle Surgery. 2020;59(6):1248–1253. doi: 10.1053/j.jfas.2020.03.016. [DOI] [PubMed] [Google Scholar]
- 25.Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): Development and validation of a new instrument. ANZ Journal of Surgery. 2003;73(9):712–716. doi: 10.1046/j.1445-2197.2003.02748.x. [DOI] [PubMed] [Google Scholar]
- 26.Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926. doi: 10.1136/bmj.39489.470347.AD. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.DiLiberto FE, Nawoczenski DA, Tome J, DiGiovanni BF. Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study. Foot and Ankle Surgery. 2020;26(7):771–776. doi: 10.1016/j.fas.2019.10.001. [DOI] [PubMed] [Google Scholar]
- 28.Nawoczenski DA, DiLiberto FE, Cantor MS, Tome JM, DiGiovanni BF. Ankle power and endurance outcomes following isolated gastrocnemius recession for Achilles tendinopathy. Foot and Ankle International. 2016;37(7):766–775. doi: 10.1177/1071100716638128. [DOI] [PubMed] [Google Scholar]
- 29.Molund M, Lapinskas SR, Nilsen FA, Hvaal KH. Clinical and functional outcomes of gastrocnemius recession for chronic Achilles tendinopathy. Foot and Ankle International. 2016;37(10):1091–1097. doi: 10.1177/1071100716667445. [DOI] [PubMed] [Google Scholar]
- 30.Gurdezi S, Kohls-Gatzoulis J, Solan MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. Foot and Ankle International. 2013;34(10):1364–1369. doi: 10.1177/1071100713488763. [DOI] [PubMed] [Google Scholar]
- 31.Kiewiet NJ, Holthusen SM, Bohay DR, Anderson JG. Gastrocnemius recession for chronic noninsertional Achilles tendinopathy. Foot and Ankle International. 2013;34(4):481–485. doi: 10.1177/1071100713477620. [DOI] [PubMed] [Google Scholar]
- 32.Holtmann JA, Südkamp NP, Schmal H, Mehlhorn AT. Gastrocnemius recession leads to increased ankle motion and improved patient satisfaction after 2 years of follow-up. Journal of Foot and Ankle Surgery. 2017;56(3):589–593. doi: 10.1053/j.jfas.2017.01.037. [DOI] [PubMed] [Google Scholar]
- 33.Duthon VB, Lübbeke A, Duc SR, Stern R, Assal M. Noninsertional Achilles tendinopathy treated with gastrocnemius lengthening. Foot and Ankle International. 2011;32(4):375–379. doi: 10.3113/FAI.2011.0375. [DOI] [PubMed] [Google Scholar]
- 34.Maffulli N, Del Buono A. Release of the medial head of the gastrocnemius for Achilles tendinopathy in sedentary patients: A retrospective study. International Orthopaedics. 2015;39(1):61–65. doi: 10.1007/s00264-014-2553-1. [DOI] [PubMed] [Google Scholar]
- 35.Tallerico VK, Greenhagen RM, Lowery C. Isolated gastrocnemius recession for treatment of insertional Achilles tendinopathy: A pilot study. Foot & Ankle Specialist. 2015;8(4):260–265. doi: 10.1177/1938640014557077. [DOI] [PubMed] [Google Scholar]