Medial Gastrocnemius Recession

Introduction

Strayer gastrocnemius recession has been widely used to resolve isolated gastrocnemius contracture (IGC) and associated conditions, including Achilles tendonitis, plantar fasciitis, metatarsalgia, hammertoes, and diabetic foot ulcers. However, the Strayer procedure may lead to power and endurance deficits, which may translate to subjective weakness of the operated extremity, especially during strenuous physical activity. ⁷ As an alternative, proximal medial gastrocnemius recession (PMGR), as described by Barouk, has been proposed to release the thick fibrous portion of the medial head of the gastrocnemius muscle lying adjacent to the popliteal fossa.^1,3

Compared with complete gastrocnemius recession, a partial recession, such as PMGR, may reduce the risk of power or endurance deficits while still providing improvement in ankle dorsiflexion, making it an attractive option for patients with IGC. ⁶ Successful long-term clinical results of PMGR for resolving Achilles tendonitis and plantar fasciitis have been reported.^4,8,10 The traditional incision for PMGR is made close to the popliteal flexion crease, adjacent to the major anatomic structures of the popliteal fossa. An anatomic study performed by Kaplan et al ⁵ demonstrated concern for the proximity of this incision to the semimembranosus tendon, small saphenous vein, and popliteal vein and artery. Particularly, the semimembranosus tendon and the posterior neurovascular structures were located within 10 mm of the medial gastrocnemius fascia release site. ⁵ Moreover, PMGR is generally performed while the patient is in the prone position, which may limit its use with other concomitant procedures that requires the patient to be in the supine position. Given the risks associated with the conventional PMGR, the senior author previously proposed a medial gastrocnemius recession (MGR) at a level distal to the PMGR. ⁵ A subsequent cadaveric study by Bull et al ² demonstrated that MGR and the gastrocnemius intramuscular recession (Baumann procedure) are equally effective in significantly increasing passive ankle dorsiflexion. However, the surgical technique for performing MGR in patients has not yet been described in the clinical setting. The MGR technique presented here has evolved from the initial proof-of-concept anatomic study ⁵ and has since been performed in more than 80 clinical cases by the senior author. The MGR technique uses an incision more distal than the PMGR, aiming to release the thick fascia overlying the proximal medial gastrocnemius muscle while avoiding major anatomic structures, and can be performed in the supine position.

Indications

This technique is described based on the senior author’s extensive operative experience and anatomical rationale; however, prospective outcome studies are still needed to validate its clinical equivalence or superiority to established techniques.

Similar to the Strayer procedure, patients with demonstrated IGC and associated pathologies may be indicated for the MGR. This procedure is indicated for patients with isolated gastrocnemius contracture (IGC) and associated conditions such as Achilles tendinopathy, plantar fasciitis, and forefoot disorders (e.g., Morton’s neuroma), provided they exhibit a positive Silfverskiold sign (Figure 1). Particularly, MGR is best utilized in Silfverskiold test–positive patients with IGC and a mild equinus contracture, defined as at least 0 degrees or greater ankle dorsiflexion with the knee extended and increased dorsiflexion with the knee in flexion. The procedure may not be sufficient for patients with severe tightness (ankle dorsiflexion less than neutral with the knee extended) and is not indicated for severe, chronic, neurogenic, or rigid Achilles contractures with a negative Silfverskiold sign. MGR may be preferred over the Strayer procedure in young and active patients with IGC, as it minimizes postsurgical compromise in power and endurance.

Figure 1.

Medial gastrocnemius recession is indicated for patients with isolated gastrocnemius contracture. This 47-year-old man presented with chronic Achilles tendonitis and a positive Silfverskiold test.

Technique

This procedure may be performed with the patient in supine or prone position, depending on the concomitant procedure planned. A tourniquet may be applied on the proximal thigh region to allow for enhanced visualization; however the procedure can be performed with or without the use of a tourniquet based on surgeon preference. A 2-cm longitudinal incision is made 4 to 6 cm distal from the popliteal fossa region, in line with the medial border of the popliteal crease (Figure 2). After the skin incision and soft tissue dissection, the posterior crural fascia is identified and longitudinally divided. Two army-navy retractors are then inserted to retract the divided posterior crural fascia, allowing for direct visualization of the thick white fibers known as the epimysium overlying the proximal medial gastrocnemius muscle. The medial and lateral borders of the epimysium can be easily identified with gentle retraction at this stage, facilitating protection of the neurovascular structures as the surgeon advances laterally toward the center of the leg. While applying dorsiflexion force to the ankle, the epimysium overlying the medial gastrocnemius muscle is sharply incised in a transverse direction (Figure 3). A forceps or an Allis clamp can be used to draw the medial gastrocnemius muscle and epimysium closer to the surgical field to facilitate the release.

Figure 2.

A 2-cm longitudinal incision is made 4 to 6 cm distal from the popliteal fossa, aligned with the medial border of the popliteal crease or parallel to the posterior border of the medial malleolus. The arrow indicates the medial border of the popliteal crease.

Figure 3.

(A) The epimysium overlying the medial gastrocnemius muscle is identified. (B) The epimysium is transversely incised while applying dorsiflexion force to the ankle. (C) The medial and lateral borders of the epimysium are readily visualized with gentle retraction using Army-Navy retractors. (D) Complete release of the medial gastrocnemius epimysium is confirmed.

Since the location and amount of the epimysium overlying the medial gastrocnemius muscle may differ in each individual, the incision may be extended slightly more proximally when needed. After closure of the soft tissue and skin, a compression dressing with an elastic bandage is applied. Patients may immediately fully weightbear without immobilization. Temporary use of an assistive device is optional, but generally not necessary. Immobilization with a boot or postoperative shoe may be added depending on other concomitant procedures performed. We recommend early ankle range of motion exercises following the procedure.

Complications

After performing more than 80 cases, the senior author has not encountered any neurovascular injury or other major complications. Minor complications include a localized pain or hematoma that resolved with time. We recommend avoiding extending the epimysium release too laterally without complete visualization of the lateral border, as it may get close to the small saphenous vein and medial sural nerve. These structures lie in the central calf, between the medial and lateral gastrocnemius muscles and generally away from the epimysium that we target to release.

Discussion and Conclusion

MGR has multiple advantages over Strayer procedures including a smaller surgical incision, shorter operative time, and potentially decreased weakness. This procedure may be similar to creating a medial gastrocnemius tear that can relieve the inherent gastrocnemius tightness. As in the PMGR, we believe that the MGR technique has a similar role in addressing Achilles tendonitis, plantar fasciitis, and other overload associated forefoot pathologies where the Strayer procedure is indicated. This technique may benefit patients with isolated gastrocnemius contracture who wish to avoid potential weakness after surgery. In a matched-pair cadaveric study, Bull et al ² reported equally significant increases in passive ankle dorsiflexion following both the MGR and Baumann procedures. No sural nerve injuries were observed after complete dissection following the procedure. In their comparative cadaveric study, Rong et al ⁹ found that the Strayer procedure achieved significantly greater increases in ankle dorsiflexion with the knee extended (22.4 degrees) than the Barouk procedure (14.8 degrees) and the Baumann procedure with 1 cut (11.6 degrees) but was similar to the Baumann procedure performed with 2 cuts (11.6 degrees + an additional 7.8 degrees after the second cut). However, the stability of lengthening after the Strayer procedure was the lowest compared with the Barouk and Bauman procedures as noted by greater lengthening at a lower applied load, potentially indicating greater risk of overlengthening. ⁹ Thus, the biomechanical effects of the Strayer procedure vs partial gastrocnemius recession continues to be debated. ⁶ Furthermore, there are currently no biomechanical or clinical studies validating the efficacy of the MGR procedure relative to the PMGR or the Strayer procedure. However, the potential advantages of the suggested MGR are the safety of the approach and the ability to easily perform this procedure with other concomitant foot reconstructive procedures while keeping the patient in supine position. The level of MGR is more distal than the PMGR and more proximal than the Baumann procedure (Figure 4). Although the modified MGR may serve as a viable alternative to PMGR or Strayer procedures based on anatomical and technical advantages, clinical validation through prospective trials is still needed. The MGR is a safe surgical technique for releasing the medial gastrocnemius fascia in patients with IGC and may serve as a viable alternative to PMGR or the Strayer procedure.

Figure 4.

The medial gastrocnemius fascia release is performed at a more distal location (*) compared with the PMGR release site (▲). The PMGR release is situated adjacent to the semimembranosus tendon and major neurovascular structures within the popliteal fossa.