Surgeons do what they do….surgery!

Did you ever hear the one about the scorpion and the frog?

A scorpion and a frog meet on the bank of a stream and the scorpion asks the frog to carry him across on its back. The frog asks, “How do I know you won’t sting me?” The scorpion says, “Because if I do, I will die too.”

The frog is satisfied, and they set out, but in midstream, the scorpion stings the frog. The frog feels the onset of paralysis and starts to sink, knowing they both will drown, but has just enough time to gasp “Why?”

Replies the scorpion: “Its my nature…”

I just read the latest published work regarding the isolated gastrocnemius contracture and as so many works indicate over and over, the isolated gastrocnemius contracture (calf contracture) and the damage it produces in the foot and ankle is the real deal.^1-27  I have known this my entire career, and I have always been the biggest proponent of everyday calf stretching. And now I see my colleagues finally catching on, but only on a limited basis at this point. My problem, knowing how effective, yet how ignored calf stretching is, is how we are shaping up to treat this problem as we discover it.

“…the isolated gastrocnemius contracture (calf contracture) and the damage it produces in the foot and ankle is the real deal.”^1-27

In their article “Isolated Gastrocnemius Recession for Achilles Tendinopathy: Strength and Functional Outcomes”Nawoczenski, et al., showed the clinical efficacy treating chronic Achilles tendinitis by just making the gastrocnemius longer, surgically as the trend goes. More importantly they start to answer a much needed question: what happens to muscle strength and function following the ever more popular calf lengthening procedure (Strayer or gastrocnemius recession)?  The evidence in a nutshell is there is on average some residual calf weakness, noted especially in the upper level of function such as sports participation. Then again we docs pretty much knew that, it is just good to see it in print.

“…why aren’t we looking at better non-operative treatments instead of going straight to surgery?”

Here is the real question: why aren’t we looking at better non-operative treatments instead of going pretty much straight to surgery?  The quick answer is because we are surgeons, and we do surgery (it’s a scorpion thing). Unfortunately this seems to be the default trend that we surgeons are currently taking in the care of the foot and ankle when it comes to the isolated gastrocnemius contracture. To reiterate an important point, at the exact same time we orthopedic surgeons are also discovering that the isolated gastrocnemius contracture is the cause of the majority of acquired non-traumatic foot and ankle pathology.

Rock solid and compelling evidence already exists that non-operative efforts to “lengthen” the gastrocnemius, AKA focused daily calf stretching, works!^{2,3,10,15,19,24,26,27} Yet we continue to say that “non-operative” treatment fails and we move to surgery too fast in my opinion. To quote this very study which has the typical, recurring non-operative vetting or exclusion:

“We reviewed the medical records of individuals who sought professional outpatient consultation from foot and ankle orthopaedic surgeons at the University of Rochester Medical Center for recalcitrant Achilles tendinopathy (of at least six months’ duration)…”

This is typical failure of non-operative treatment wordsmith. What does this even mean? What non-operative treatments were undertaken? While good non-operative treatment has been reported many times, no doubt we somehow overlook it.

Let me get right to the point: non-operative treatment for the isolated gastrocnemius contracture [stretching] and the resulting pathology it causes is very effective, which has been shown time and time again in the orthopaedic literature.^{2,3,10,15,19,24,26,27}. However, for some reason (maybe because we are surgeons), we have summarily determined that “non-operative treatment” fails at some point and that point is after six months. I do not disagree with six months, but I completely disagree with the definition of what constitutes non-operative treatment.

In my opinion there are only two forms of non-operative treatments: those that make the symptoms better, but don’t treat the actual problem, and the ONE that actually addresses the underlying problem.

In the pain improving pile you have orthotics, general PT, rest or pain avoidance, steroid shots, immobilization, ice, ESWT, PRP injections, NSAIDS, surgery specifically on the foot, and the list goes on. While these might make you feel better, they do not fix the problem – the isolated gastrocnemius contracture. I feel the push back and anger already.

To fix the real underlying mechanical problem, which is the isolated gastrocnemius contracture, the isolated gastrocnemius contracture must be addressed by getting longer one way or another. Fix that and the foot will fix itself in time the right way! Why not stretch every day for six months, which almost always works. Only then, if this fails then you have failed non-operative treatment. Then and only then can you have your gastrocnemius surgically lengthened.

1. Abbassian A, Kohls-Gatzoulis J, Solan MC. Proximal Medial Gastrocnemius Release in the Treatment of Recalcitrant Plantar Fasciitis. Foot & Ankle International. 2012;1:14-19.
2. Amis J. Letters to the Editor. Foot & Ankle International. 2001;22:524
3. Amis J. The Gastrocnemius: A New Paradigm for the Human Foot and Ankle. Foot Ankle Clinics. 2014;19:637-647.
4. Aronow MS, Diaz-Doran V, Sullivan RJ, Adams DJ. The Effect of Triceps Surae Contracture Force on Plantar Foot Pressure Distribution. Foot & Ankle International. 2006;1:43-52.
5. Barske HL, DiGiovanni BF, Douglass M, Nawoczenski DA. Current Concepts Review: Isolated Gastrocnemius Contracture and Gastrocnemius Recession. Foot & Ankle International.2012;33:915-921.
6. Bolívar YA, Munuera PV, Padillo JP. Relationship Between Tightness of the Posterior Muscles of the Lower Limb and Plantar Fasciitis. Foot & Ankle International. 2013;1:42-48.
7. DiGiovanni BF, Moore AM, Zlotnicki JP, Pinney SJ. Preferred Management of Recalcitrant Plantar Fasciitis Among Orthopaedic Foot and Ankle Surgeons. Foot & Ankle International. 2012;6:507-512.
8. DiGiovanni CW, Kuo R, Tejwani N, Price R, HansenJr. ST, Cziernecki J, Sangeorzan BJ. Isolated Gastrocnemius Tightness. The Journal of Bone & Joint Surgery. 2002;6:962-970.
9. DiGiovanni CW, Langer P. The Role of Isolated Gastrocnemius and Combined Achilles Contractures in the Flatfoot. Foot & Ankle Clinics. 2007;2:363-379.
10. Garrett T, Neibert PJ. The Effectiveness of a Gastrocnemius/Soleus Stretching Program as a Therapeutic Treatment of Plantar Fasciitis. J Sport Rehabil. 2013.
11. Gentchos CE, Bohay DR, Anderson JG. Gastrocnemius Recession as Treatment for Refractory Achilles Tendinopathy: A Case Report. Foot & Ankle International. 2008;6:620-623.
12. Greenhagen RM, Johnson AR, Bevilacqua NJ. Gastrocnemius recession or tendo-achilles lengthening for equinus deformity in the diabetic foot? Clin Podiatr Med Surg. 2012;3:413-424.
13. Gurdezi S, and Kohls-Gatzoulis J, Solan, MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. Foot & Ankle International. 2013;10:1364-1369.
14. Hamilton PD, Brown M, Ferguson N, Adebibe M, Maggs J, Solan M. Surgical Anatomy of the Proximal Release of the Gastrocnemius: A Cadaveric Study. Foot & Ankle International. 2009;12:1202-1206.
15. de Jonge S, de Vos RJ, Van Schie HTM, Verhaar JAN, Weir A, Tol JL. One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy. Br J Sports Med. 2010;9:673-677.
16. Kiewiet NJ, Holthusen SM, Bohay DR, Anderson JG. Gastrocnemius Recession for Chronic Noninsertional Achilles Tendinopathy. Foot & Ankle International. 2013;4:481-485.
17. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius Recession to Treat Isolated Foot Pain. Foot & Ankle International. 2010;1:19-23.
18. Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: Plantar fasciotomy versus gastrocnemius recession. Int Orthop. 2013.
19. Norregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports. 2007;2:133-138.
20. Nutt, J. Diseases and Deformities of the foot, E.B.Treat & Co. 1913. Google Digital Copy, books.google.com/books?id=UWgQAAAAYAAJ.
21. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011;1:5-8.
22. Patel A, Rao S, Nawoczenski D, Flemister AS, DiGiovanni B, and Baumhauer JF. Midfoot arthritis. J Am Acad Orthop Surg.2010;18:417-425.
23. Pinney ST, Hansen ST, Sangeorzan BJ. The Effect on Ankle Dorsiflexion of Gastrocnemius Recession. Foot & Ankle International. 2002;23:26-29.
24. Porter D, Barrill E, Oneacre K, May BD. The Effects of Duration and Frequency of Achilles Tendon Stretching on Dorsiflexion and Outcome in Painful Heel Syndrome: A Randomized, Blinded, Control Study. Foot & Ankle International. 2002;7:619-624.
25. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk Factors for Plantar Fasciitis: A Matched Case-Control Study. The Journal of Bone & Joint Surgery. 2003;5:872-877.
26. Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy – a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004;5:286-295.
27. Verrall G., Schofield, S., Brustad, T. Chronic Achilles Tendinopathy Treated With Ecentric Stretching Program. Foot & Ankle International. 2011;32:843-849.
28. Young R, Nix S, Wholohan A, Bradhurst R, Reed L. Interventions for increasing ankle joint dorsiflexion: a systematic review and meta-analysis. Journal of Foot and Ankle Research. 2013;6:1-10.