Elsevier

Foot and Ankle Surgery

Volume 24, Issue 6, December 2018, Pages 471-473
Foot and Ankle Surgery

Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients

https://doi.org/10.1016/j.fas.2017.05.008Get rights and content

Highlights

  • Chronic plantar fasciitis can be difficult to treat.

  • Gastrocnemius recession has been considered for treatment of these patients.

  • Gastrocnemius recession is safe and effective in patients with high body mass index.

  • Majority of patients reported decreased pain and improved foot function.

  • Many would recommend the surgery to others based on their experience.

Abstract

Background

Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese.

Methods

We retrospectively reviewed 18 cases (17 patients) of chronic plantar fasciitis in overweight or obese patients who underwent gastrocnemius recession (mean age = 46 years, mean body mass index = 34.7 kg/m2, mean follow-up = 20 months). Data was gathered regarding pre-operative and post-operative pain (visual analog scale, 0–10), Foot Function Index score, and complications.

Results

Mean Foot Function Index score improved from 66.4 (range, 32.3–97.7) preoperatively to 26.5 (range, 0–89.4) postoperatively (p < 0.01). Mean pain score improved from 8.3 (range, 5–10) preoperatively to 2.4 (range, 0–7) at final follow-up (p < 0.01).

Conclusions

Gastrocnemius recession improved foot function and pain symptoms in overweight and obese patients with chronic plantar fasciitis.

Introduction

Plantar fasciitis is one of the most common foot pathologies encountered in the general population. It is considered the most common cause of plantar heel pain, accounting for more than one million visits to physicians yearly in the United States [1]. Despite this, the exact etiology of the condition remains subject to debate. The pathogenesis of plantar fasciitis is considered multifactorial, with the most widely accepted theory being that repetitive microtrauma predisposes to degeneration and micro-tears of the plantar fascia as well as periostitis of the medial calcaneal tubercle [2]. A high body-mass index (BMI) and participation in activities or occupations that involve prolonged weight bearing are generally accepted as risk factors. Riddle et al. suggested that reduced ankle dorsiflexion was associated with a greater risk of developing the condition than either BMI or level of activity while noting that BMI is an independent risk factor for plantar fasciitis [2]. Further, isolated contracture of the gastrocnemius has been implicated in plantar fasciitis by other investigators [3].

The nonoperative treatment of plantar fasciitis includes Achilles stretching, plantar fascia specific stretches, shoe inserts, night splints, casting, steroid injections, anti-inflammatory medications, and extracorporeal shock wave therapy. Nonoperative measures are frequently successful, but a subset of patients fails to improve. Surgical options are often considered after 6–12 months of failed nonoperative treatment. In several recent studies, gastrocnemius contracture has been implicated as a predisposing factor for chronic plantar fasciitis, and gastrocnemius recession has been proposed as a treatment [3], [4], [5], [6], [7], [8], [9], [10]. In this study, we evaluate the effectiveness of gastrocnemius recession in treating chronic plantar fasciitis in overweight and obese patients.

Section snippets

Materials and methods

All procedures were carried out in accordance with the 1964 Declaration of Helsinki, and the study was approved by our Institutional Review Board. We reviewed surgical cases and identified all patients undergoing gastrocnemius recession for plantar fasciitis by a single surgeon at a single institution from June 2011 to August 2014. We identified 49 potential patients. Via chart review we gathered information regarding patient demographics, prior treatments, symptoms, surgical treatment and

Results

The study group consisted of 12 females and 5 males, with a mean age of 46 (range, 26–59) years. 1 patient underwent staged bilateral procedures. 10 cases were left-sided and 8 were right-sided. The mean BMI was 34.7 (range, 26.6–57.8) kg/m2. 4 patients were smokers, 3 were diabetics, and all 3 diabetics had diabetic neuropathy. 4 patients had concurrent Achilles tendinitis (3 insertional, 1 non-insertional). Mean duration of nonoperative treatment before surgery was 17 months (range, 6–36).

Discussion

Chronic plantar fasciitis develops in only a small portion of those afflicted with plantar fasciitis, but it can significantly impact quality of life. Traditionally, plantar fascia release was recommended when non-operative measures failed to successfully treat plantar fasciitis. These protocols involve a prolonged period of non-weight-bearing (up to 4-6 weeks) followed by a long rehabilitation time. Published success rates vary, and there is a risk for lateral column pain, injury to the

Conflict of interest

None.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgement

We would like to acknowledge our colleague SB for his assistance with data collection.

References (16)

There are more references available in the full text version of this article.

Cited by (17)

  • Gastrocnemius Recession in Recalcitrant Plantar Fasciitis: A Systematic Review

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    A minimum period of conservative treatment (6,13,14,18), a minimum number of conservative treatments (16), or a classification as “unresponsive” or a “failure” of conservative treatment (15,17), was required as part of the inclusion criteria. Gastrocnemius tightness was part of the selection criteria in 4 of the included studies (6,13,14,17) (Table 4). The intervention was a medial gastrocnemius release in all 7 studies (Table 4).

  • Association of Ankle Dorsiflexion With Plantar Fasciitis

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    Therefore, for patients with chronic plantar fasciitis who do not respond to nonsurgical treatment, plantar fascia release is most commonly used, and gastrocnemius recession is also used in patients with gastrocnemius contracture. Although the previous studies had some limitations such as their small numbers of subjects, non-homogenous groups, and short follow-up, they reported good clinical outcomes of gastrocnemius recession (17-20). Recently, Molund et al. (21) demonstrated in a randomized controlled trial that gastrocnemius recession combined with postoperative stretching exercises improved foot function, pain, and general health outcomes in patients with chronic plantar heel pain.

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    Addressing tight gastrocnemius by stretches in the absence of a medial arch supports to protect the spring ligament [11,12] may be detrimental and lead to arch collapse. Gastrocnemius lengthening may remove early heel rise and prolonged pressure of the talar head on the spring ligament thus decreasing tensile forces in the plantar fascia [13]. The plantar fascia is synergistic with the spring ligament in absorbing foot forces in cyclical loading [5].

  • Management of Symptomatic Plantar Fasciitis

    2018, Operative Techniques in Orthopaedics
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    Chronic plantar fasciitis maybe also be due to decreased knee or ankle range of motion, secondary to a stiff gastrocnemius. Monteagudo et al in a study comparing plantar fasciotomy to GR, showed a 95% patients satisfaction rate for GR compared to 60% patient satisfaction with plantar fasciotomy.24-26 In another study by Molund et al, 27 62% of patients undergoing GR reported satisfactory outcomes.

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