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A Closer Look At The Gastroc Recession For Recalcitrant Plantar Fasciitis
Exhorting his surgical colleagues to stop cutting the plantar fascia due to complications of plantar fasciotomy, this author says the gastrocnemius recession can improve function and lead to good results for patients with chronic heel pain.
Please stop cutting the plantar fascia. Plantar fasciotomy, whether it be partial or complete, has been rightfully put in the category of outdated procedures along with the likes of the closing base wedge osteotomy, the Austin bunionectomy, the extended posterior medial clubfoot release and others.
The evidence is in and it is clear. Please stop cutting the plantar fascia.
The plantar fascia consists of three sections. The central band is the thickest and strongest of the three, extending from the proximal attachment at the medial tubercle of the calcaneal tuberosity distally into the metatarsal heads. The central band is divided into superficial and deep fibers that have different distal attachments. The deep fibers become medial and lateral slips that insert into the base of the proximal phalanx and hallucal sesamoids, forming flexor tendon sheaths. The superficial bands have longitudinal fibers that attach to the skin and transverse fibers uniting with the deep transverse metatarsal ligament.
The thin medial band also proximally runs from the medial tubercle of the calcaneal tuberosity running superficial to the abductor hallucis muscle belly. The medial band is continuous with the central band laterally and dorsal fascia medially.
Proximally, the lateral band begins at the lateral tubercle of the calcaneal tuberosity and runs to the fifth metatarsal base overlying the abductor digiti minimi muscle, forming a strong band of tissue along the plantar lateral aspect of the foot. The lateral band is continuous with the central band medially and the dorsal fascia laterally. The anatomical makeup of the plantar fascia is why it is critical to foot function.
What The Research Reveals About The Biomechanics Of The Plantar Fascia
The classic article from Hicks in 1954 illuminated the importance of the plantar fascia by demonstrating that dorsiflexion of the digits engaged the “windlass” mechanism by tensioning the plantar fascia and thereby raising the arch.1 Conversely, severing the plantar fascia all but eliminated this effect, weakening the arch-raising function of the plantar fascia.Griffin and colleagues postulated that the plantar fascia evolved to increase speed and conserve energy (as much as 15 percent) during bipedal gait.2
Thordarson and colleagues further developed Hicks’ concepts with a cadaveric study proving the plantar fascia is the primary arch augmenter in the sagittal plane and, with increasing load, also augments the arch in the transverse plane.3 The authors concluded, “The plantar fascia clearly has an important dynamic function ... dividing this structure should be tempered by this data.” Equally important, the study demonstrated the Achilles as the primary arch deformer in both the sagittal and transverse planes.3 The interplay between the plantar fascia and gastrocsoleus complex becomes important when considering alternative approaches to plantar fasciotomies.
Johnson and Christensen were able to specifically identify the level of arch deformation with increasing loads applied to the gastrocsoleal complex. With increasing loads to the Achilles, the authors demonstrated in cadaveric study that the function of the peroneus longus is dampened, specifically the eversion of the medial column of the foot into the central column of the foot.4 Unlocking of the midtarsal joint results in dorsiflexion of the first metatarsal and medial cuneiform, and plantarflexion of the navicular and talus. The end result is a sag or breach at the naviculocuneiform joint. This creates abnormal forces acting upon the foot, leading the authors to conclude, “In clinical practice, the early destructive influence of equinus is often not appreciated. Instead, we are usually faced with the end result of equinus effects … .”4
Amis went farther to expand upon this deleterious effect of equinus on the foot in his 2016 article titled “The Split-Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle.”5 With high speed photography, Amis demonstrated that when equinus is present, an abnormal fourth rocker occurs during late midstance at the naviculocuneiform joint as Johnson and Christensen had found previously.4,5
In 2014, Chen and coworkers used finite element analysis to establish that the plantar fascia experiences peak tension at pre-swing, increasing arch stability to prepare for push-off with the stress concentrated near the medial calcaneal tubercle as the gastrocsoleal complex tension increases.6 The authors went on to postulate that reduction of Achilles tendon load would decrease plantar fascia load.
How Equinus Factors Into Plantar Fasciitis
The literature continues to define the role of equinus in plantar fasciitis overwhelmingly. The robust evidence stretches back over a century. In 1913, Nutt advocated the hypothesis that as the body passes over the planted foot, a tight gastrocnemius applies a “strain on plantar supportive tissues” and a “lowering of the dome” (flattening of the arch).7
Patel and DiGiovanni proved equinus is present in 83 percent of patients with acute plantar fasciitis and 82 percent of patients with chronic plantar fasciitis.8
Chueng and colleagues established a linear relationship in tension between the plantar fascia and Achilles tendon.9 As tension increases on the Achilles tendon due to tightness, there is a corresponding increase in tension in the plantar fascia. The increase in tension on the plantar fascia due to equinus was up to twice that of the body weight. Interestingly enough, increased body weight is often associated with plantar fasciitis yet the Achilles tendon has significantly more influence on the plantar fascia. The authors concluded lengthening of the Achilles tendon resulted in plantar fascia stress relief.
Amis summed up the role of equinus not only regarding plantar fasciitis but lower limb pathology as well.5 The author stated, “The isolated gastrocnemius contracture must be addressed as the definitive treatment for many if not the majority of non-traumatic acquired foot and ankle pathology. While treating the obvious foot or ankle problem is advisable and can be of great benefit to the patient, it must be considered only as adjunctive and palliative.”
Understanding The Costs Of Cutting The Plantar Fascia
Severing the plantar fascia comes at a consequence that surgeons can no longer ignore.
Gefen noted that with the sequential release of the plantar fascia, there was as much as ten times an increase in arch deformation with a significant increase in loading of the subordinate deep and superficial plantar ligaments by 123 percent and 204 percent respectively.10 Reduced shock absorption occurred as well with an increase in dorsal compression stress by as much as 65 percent on the metatarsals.
Kim and Voloshin noted the plantar fascia carries up to 14 percent of the total load on the foot and releasing the plantar fascia resulted in lowering of the arch with degeneration of the load-bearing capacity of the foot.11 The authors summarize their findings in the following statement: “The plantar fascia plays an important part in load bearing by the foot and its superficial release should be carefully considered.”
Additionally, a study by Cheung and colleagues examined the consequence of the sequential release of the plantar fascia.12 The study found that as little as a 20 percent release of the plantar fascia substantially increased the strain on the spring ligament and with additional cutting of the plantar fascia, the long and short plantar ligaments also experienced a significant abnormal loading. With an increasing percentage of plantar fascia release, the arch was correspondingly flattened and lengthened, transferring increased loads to these subordinate structures. Abnormalities of osseous loading also demonstrated a substantial elevation in pressures transferred to the lesser metatarsals and lateral column with sequential release. The results of this study clearly demonstrate the “why” of the most common complication after plantar fascia release: lateral column pain.
Although there is literature to support the plantar fasciotomy, a 2016 article noted the paucity of recent research regarding an open partial plantar fascial release.13 The study authors concluded, “Overall, the results from open plantar fascia release were generally poor.”
How The Gastrocnemius Recession Can Be Beneficial
The predictable failure of plantar fasciotomies over decades of frustration with recalcitrant plantar fasciitis surgery led pioneering researchers to search for a better way. Understanding the biomechanics of the plantar fascia and gastrocsoleus complex along with the relationship between the two, a clear alternative began to emerge, beginning in 2010.
Maskill and coworkers were the first to describe the use of a gastrocnemius recession for foot pain, including plantar fasciitis (25 of the 34 operated feet).14 They noted that the preoperative visual analogue scale (VAS) pain score averaged 8.1 and postoperatively decreased to 1.9. The study authors also found that 93.1 percent of patients would recommend the procedure and were satisfied with the procedure.
Abbassian and colleagues specifically examined gastrocnemius recession for recalcitrant plantar fasciitis. The study consisted of 21 heels in 17 patients with an average symptom duration of 3.8 years.15 The results showed that 17 heels were pain-free or significantly improved, and 88 percent of the patients would recommend the procedure.
Molund and colleagues in 2014 evaluated gastrocnemius recession for various lower extremity pathologies.16 The subgroup of patients with plantar fasciitis consisted of 18 patients with 14 showing good/excellent results, who would recommend the procedure to another and who would have the procedure again. The VAS averaged 7.0 preoperatively and 1.8 postoperatively. The similarities between the postoperative VAS scores between the Maskill and Molund studies show the consistency of outcomes.14,16
Recently, more supportive literature has emerged. Ficke and coworkers specifically evaluated gastrocnemius recession for chronic refractory plantar fasciitis in obese patients (mean body mass index (BMI) was 35 with a range of 27 to 58).17 The study consisted of 18 feet in 17 patients, who averaged a preoperative VAS score of 8, which reduced to a mean of 2 postoperatively with patients maintaining a mean BMI of 35. Similar to other findings, 76 percent would have the procedure again and 82 percent would recommend the procedure to another. An interesting side note on this study is the mean follow-up was 20 months and although the authors failed to mention BMI changes at final follow-up, we can assume that the changes in symptoms were directly procedure-related and not related to a reduction in BMI. Since weight is an often cited risk factor for plantar fasciitis, one must question the role of obesity when this group of obese patients improved so dramatically after undergoing a gastrocnemius recession without any significant change in BMI.
Amis again pioneered this concept of the role of equinus versus obesity with a statement from his 2014 article.18 As the author said, “It has been postulated that epidemiologic factors, such as obesity, sedentary lifestyle, medical comorbidities, shoe wear, concrete floors, advanced age, female gender, and overuse issues, to name a few, are responsible for a variety of foot and ankle pathology. Although these factors might consistently coexist with a variety of foot and ankle problems and seem to have a causal relationship, it is my assertion that they have little if any direct relationship.”
Hoefnagels and colleagues similarly studied the effect of a gastrocnemius recession for non-responsive plantar fasciitis.19 The study consisted of 75 patients with 32 not responding to conservative care. At a 12-month follow-up, the authors assessed the 32 patients who had a gastrocnemius recession after failing conservative care. Ankle joint dorsiflexion increased 16 degrees, the VAS decreased from 78 to 20 (100-point scale) and the authors noted excellent satisfaction rates postoperatively.
Avila and coworkers demonstrated a reduction in the VAS from 8.1 to 0.8, an increase in American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores from 47 to 91, and patient satisfaction rates of good or excellent of 90 percent.20 Surgical patients on average returned to work at three weeks and sports at five weeks.
The final and most applicable study to the debate of plantar fasciotomy versus gastrocnemius recession for refractory plantar fasciitis is by Monteagudo and colleagues.21 The study consisted of 30 patients in each surgical group. Clinical outcomes included VAS score, AOFAS ankle-hindfoot scores, weightbearing, return to work, eccentric exercise ability and patient satisfaction. The authors concluded: “The results of the present study have made us change our approach to surgical treatment of (chronic plantar fasciitis) with (proximal medical gastrocnemius release) becoming our procedure of choice and fasciotomy only considered in rare cases of gastrocnemius proximal-medial release failure.”
Final Words
The evidence is mounting to the point where the debate is no longer a debate. Surgeons should rarely, if at all, use the plantar fasciotomy procedure. The importance of the plantar fascia for foot function, the consequences of cutting the plantar fascia and the role of equinus in plantar fasciitis are undeniable. For cases of recalcitrant plantar fasciitis, gastrocnemius recession yields outstanding results while improving function.
Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, a Diplomate of the American Board of Podiatric Surgery, and a member of the American Podiatric Medical Association (APMA) Board of Trustees. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis and is the founder of Step by Step Haiti and Foot Aid.
References
1. Hicks JH. The mechanics of the foot: II. The plantar aponeurosis and the arch. J Anat. 1954; 88(Pt 1):25.
2. Griffin NL, Miller CE, Schmitt D, D’Aout K. Understanding the evolution of the windlass mechanism of the human foot from comparative anatomy: Insights, obstacles, and future directions. Am J Phys Anthropol. 2015; 156(1):1-10.
3. Thordarson DB, Schmotzer H, Chon J, Peters J. Dynamic support of the human longitudinal arch: a biomechanical evaluation. Clin Orthop Rel Res. 1995; 316:165-172.
4. Johnson CH, Christensen JC. Biomechanics of the first ray part V: The effect of equinus deformity: A 3-dimensional kinematic study on a cadaver model. J Foot Ankle Surg. 2005; 44(2):114-120.
5. Amis J. The split second effect: the mechanism of how equinus can damage the human foot and ankle. Front Surg. 2016; 3:38.
6. Chen YN, Chang CW, Li CT, et al. Finite element analysis of plantar fascia during walking: a quasi-static simulation. Foot Ankle Int. 2015; 36(1):90-97.
7. Nutt JJ. Diseases and Deformities of the Foot. EB Treat, New York, 1913.
8. Patel, Amar, and Benedict DiGiovanni. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011; 32(1):5-8.
9. Cheung JTM, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech. 2006; 21(2):194-203.
10. Gefen A. Stress analysis of the standing foot following surgical plantar fascia release. J Biomech. 2002; 35(5):629-637.
11. Kim W, Voloshin AS. Role of plantar fascia in the load bearing capacity of the human foot. J Biomech. 1995; 28(9):1025-1033.
12. Cheung JTM, An KN, Zhang M. Consequences of partial and total plantar fascia release: a finite element study. Foot Ankle Int. 2006; 27(2):125-132.
13. MacInnes A, Roberts SC, Kimpton J, Pillai A. Long-term outcome of open plantar fascia release. Foot Ankle Int. 2016; 37(1):17-23.
14. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010; 31(1):19-23.
15. 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.
16. Molund M, Paulsrud O, Ellingsen Husebye E, et al. Results after gastrocnemius recession in 73 patients. Foot Ankle Surg. 2014; 20(4):272-275.
17. Ficke B, Elattar O, Naranje SM, et al. Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients. Foot Ankle Surg. 2017; article in press.
18. Amis J. The gastrocnemius: a new paradigm for the human foot and ankle. Foot Ankle Clin. 2014; 19(4):637-647.
19. Hoefnagels E, Weereheijm L, Louwerens JW, et al. Chronic therapy resistant plantar fasciitis, the effect of lengthening the gastrocnemius muscle. Foot Ankle Surg. 2016; 22(2):58.
20. Avila A, Monteagudo M, Martinez-Albornoz P, Maceira E. Medial gastrocnemius proximal release in chronic plantar fasciitis. Prospective study of 75 cases. Foot Ankle Surg. 2016; 2(22):24-25.
21. Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthoped. 2013; 37(9):1845-1850.
