Surgical management of recalcitrant plantar fasciitis has largely been limited to plantar fasciotomy. A potential alternative is effective, relatively safe, and reliable gastrocnemius recession, which addresses the effect of gastrocnemius muscle contracture on these patients.
By Joseph G. Wilson, DPM, T. Craig Wirt, DPM, PhD, Jonathan L. Hook, DPM, MHA
Plantar fasciitis is the most common cause of plantar heel pain, with more than 1 million people seeking medical treatment for this complaint each year in the United States alone.¹ Inflammation of the plantar fascia and pain associated with it can be debilitating.
Anatomically, the plantar fascia is a broad aponeurosis that originates in the medial calcaneal tuberosity and extends distally to the level of the metatarsophalangeal joints, with a lateral band reaching the base of the fifth metatarsal. This deep fascial band supports the longitudinal arch of the foot and provides biomechanical stability throughout the gait cycle.¹
The precise etiology of plantar fasciitis is unknown but is thought to be multifactorial. Various studies point to risk factors such as sports or physical exercise, high body-mass index (BMI), age, prolonged standing, pes planus, increased subtalar joint pronation, and decreased ankle-joint dorsiflexion.1-3
Does posterior leg-muscle tightness play a role in plantar fasciitis?
- There is a proven strong correlation between gastrocnemius contracture and plantar fasciitis, suggesting that the treatment of fasciitis should address this underlying association.
- Patients whose plantar fasciitis is associated with contracture of the gastrocnemius muscle often benefit from targeted physical therapy to stretch the posterior leg-muscle group.
- Studies show that patients respond well to gastrocnemius recession when plantar fasciitis is unresponsive to conservative therapies.
One of the most commonly cited causes of plantar fasciitis is decreased ankle-joint dorsiflexion resulting from tight calf musculature, whether isolated gastrocnemius contracture or combined gastrocnemius–soleus tightness.1,4 Differentiation of isolated gastrocnemius contracture and gastrocnemius–soleus tightness is made clinically, using the Silfverskiöld test.4,5 (Based on the knowledge that the gastrocnemius muscle originates in the posterior surface of the femoral condyles, the test compares the findings of hip and knee extension, in which the muscle is taut, and hip and knee flexion, in which the muscle relaxes. Consistent loss of ankle dorsiflexion, even with flexion of the knee, is a sign of isolated gastrocnemius contracture.1,5)
Plantar fasciitis is defined as chronic or recalcitrant, or both, when 6 to 12 months of conservative treatment yield little or no improvement.4,6 It is estimated that 10% of patients with acute plantar fasciitis progress to chronic symptoms.4
Several studies have demonstrated strong correlation between gastrocnemius contracture and plantar fasciitis, suggesting that treatment regimens for plantar fasciitis should address this important underlying association:
■ Patel and DiGiovanni, in a prospective study, looked at the percentage of patients with diagnosed plantar fasciitis who also had an isolated gastrocnemius contracture.4 Of 254 patients, 84% (n = 211) had limited ankle dorsiflexion. More specifically, 57% (n = 145) had an isolated gastrocnemius contracture; 26% (n = 66) had contracture of the gastrocnemius–soleus complex; and 17% (n = 43) did not have any limitation in dorsiflexion.4 Diagnosis was based on a modified Silfverskiöld test, in which 1) isolated gastrocnemius contracture was defined as ankle dorsiflexion <5° upon knee extension that resolved when the knee was flexed to 90° and 2) contracture of the gastrocnemius–soleus complex was defined as <10° of ankle dorsiflexion regardless of the position of the knee.
■ Labovitz and colleagues, in a prospective cohort study of 210 feet, found a similar association between plantar fasciitis and tight gastrocnemius musculature.7 In a control group of 107 patients without plantar fasciitis, 51.4% (n = 55) had gastrocnemius contracture or gastrocnemius-soleus equinus, or both, compared to the plantar fasciitis group (n = 103), in which 96.1% (n = 99) had associated contracture or equinus.
■ Nakale and co-workers more recently examined the relationship between gastrocnemius contracture and plantar fasciitis in a cross-sectional prospective study.8 The researchers looked at 223 patients across 3 groups—those who had:
- a clinical diagnosis of plantar fasciitis (Group 1)
- foot and ankle pathology other than plantar fasciitis (Group 2)
- no foot and ankle pathology (Group 3).
In total, 101 (45.3%) of patients had isolated gastrocnemius tightness: specifically, 36 of 45 (80%) in Group 1; 53 of 117 (45.3%) in Group 2; and 12 of 61 (19.7%) in Group 3. The difference in the prevalence of isolated gastrocnemius contracture among the groups was statistically significant (P <.001). In Group 1, the prevalence of gastrocnemius contracture was 78.9% in acute plantar fasciitis and 80.6% in chronic plantar fasciitis.
Ninety percent of patients respond positively to conservative treatment of plantar fasciitis, commonly consisting of posterior muscle and plantar fascia-specific stretching; orthotics interventions, including foot orthoses and night splints; pharmacotherapy, including nonsteroidal anti-inflammatory drugs, oral methylprednisolone (e.g., Medrol Dosepak), and corticosteroid injections; and physical therapy modalities, including extracorporeal shock wave therapy, ultrasound, cryotherapy, and taping.2,3,6,9 Determining whether a patient has associated contracture of the gastrocnemius muscle is essential because these patients often benefit from a more-targeted physical therapy regimen to stretch the posterior leg-muscle group.4,8
Operative treatment for recalcitrant plantar fasciitis
Often, surgical intervention for plantar fasciitis is indicated when 6 to 12 months of conservative treatment fail. Procedures include:
Plantar fascial release. In patients with recalcitrant plantar fasciitis, a common surgical procedure includes either partial or total release of the plantar fascia from its origin at the calcaneal tuberosity, using either an endoscopic or open technique, plus nerve decompression.2,4,6 However, several experts have postulated that surgical release destabilizes the static supportive forces of the longitudinal arch1,3,4; moreover, surgical plantar fascial release can increase midfoot and forefoot pressure during stance phase and has been shown to cause collapse of the arch over time.1,8 In reporting the results of a study that looked at the function of the plantar fascia during the gait cycle, researchers cautioned that procedures that include release of part or all of the plantar fascia compromise efficient propulsion during gait, due to the role of the plantar fascia in transmitting force from the Achilles tendon to the forefoot.10
Gastrocnemius recession. Several researchers have examined the advantages of gastrocnemius recession—ie, releasing the proximal medial head of the gastrocnemius muscle—compared to the traditional approach of direct surgical release of the plantar fascia:
■ Abbassian and co-workers were the first to look at the effectiveness of gastrocnemius recession for the treatment of recalcitrant plantar fasciitis (defined as >1 year without improvement in symptoms with non-operative treatment).3 Of 17 patients (21 heels) evaluated over a 3-year follow-up, total or significant pain relief was reported in 17 (81%) heels. Fifty-eight percent (n = 10) of patients noted improvement 1 or 2 weeks after surgery; the remaining 42% noted improvement over 3 to 6 months. Subjective calf weakness was reported in 1 patient; 1 case of wound dehiscence occurred and resolved over 2 weeks. Fifteen patients (88%) were satisfied with the outcome of the procedure and said they would recommend it to others who require treatment of plantar fasciitis.3
■ Monteagudo and colleagues, in their retrospective study, reviewed the charts of 60 patients with chronic plantar fasciitis, which they defined as pain and other symptoms persisting >9 months despite conservative treatment.9 Patients were divided into 2 treatment groups:
- 30 received surgical treatment, entailing isolated, proximal medial gastrocnemius release (PMGR)
- 30 underwent partial proximal fasciotomy (PPF)—ie, traditional plantar fascial release.
Based on pain scores using a visual analogue scale (0, no pain, to 10, maximum pain), patients in the PMGR group experienced an average improvement from 8.2 preoperatively to 1.8 at 6 months and then to 0.9 at 12 months postoperatively, compared to scores in the PPF group, in which the average score was 8.1 preoperatively and, postoperatively, 4.5 at 6 months and 3.1 at 12 months. Patient satisfaction scores reached 95% in the PMGR group; patients in that group were back to work and prior sports activities in, on average, 3 weeks. In the PPF group, the satisfaction rate was 60%; patients returned to work and sports after a significantly longer interval—on average, 10 weeks.
Complications in the PPF group were painful scars (5 patients), neuropraxia (1), and superficial infection with wound dehiscence (1). In the PMGR group, 1 postoperative complication, a calf hematoma that resolved spontaneously, was reported.9
These findings suggest that patients in the PMGR group, compared to those who received a PPF, had, on average, a higher patient satisfaction score, quicker recovery, and faster return to work and prior activities, and had a lower rate of complications.
■ Ficke and colleagues conducted a smaller study of 17 overweight and obese patients (total cases, 18; average BMI, 34.7* [range, 26.6 to 57.8]) who underwent gastrocnemius recession. The study population included 3 patients with diabetic peripheral neuropathy, 4 with Achilles tendinitis , and 3 active smokers. The researchers observed significant improvement in the self-administered Foot Function Index, on average (from 66.4, preoperatively, to 26.5, postoperatively) and pain (on a visual analogue scale, a score of 8 preoperatively and 2 at final evaluation).6 Average time to return to work and preoperative activities was 8 weeks.
Complications included 1 case of sural neuritis, which resolved spontaneously, and 1 case of calcaneal stress fracture, which resolved with treatment with a walking boot and weight-bearing restrictions.6
Findings of this study suggest that, despite high BMI and other comorbidities, patients respond well to gastrocnemius recession for treatment of plantar fasciitis that is unresponsive to conservative therapies.
* Calculated as weight in kilograms divided by height in meters squared.
Recalcitrant plantar fasciitis can be a challenging pathology to treat; traditionally, surgical management has largely been limited to plantar fasciotomy. Of concern is that researchers have reported a number of complications of plantar fasciotomy, including persistent pain, medial arch collapse, incisional pain, and complex regional pain syndrome; furthermore, the satisfaction rate with traditional plantar fascial release is only about 60%.4
Gastrocnemius recession is an effective, relatively safe, and reliable procedure that addresses the often underappreciated effect of gastrocnemius muscle contracture on patients with recalcitrant plantar fasciitis. Studies have shown that this procedure offers significant improvement in pain, quality of life, activity level, and speed of recovery, and causes minimal complications. It is crucial, therefore, that practitioners carefully evaluate plantar fasciitis patients for associated gastrocnemius contracture and tailor nonoperative and operative treatments accordingly.
Dr. Wilson is a second-year podiatric resident at Mercy Hospital and Medical Center, Chicago, Illinois, where Dr. Wirt is chief podiatric resident and Dr. Hook is affiliated with the podiatric residency program. Dr. Hook also is in podiatric practice, specializing in foot, rearfoot reconstruction, and ankle surgery, at Midland Orthopedic Associates in Chicago.
Disclosures: None reported.
- Solan MC, Carne A, Davies MS. Gastrocnemius shortening and heel pain. Foot Ankle Clin. 2014;19(4):719-738.
- Bolívar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis.Foot Ankle Int. 2013;34(1):42-48.
- 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.
- Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius.Foot Ankle Int. 2011;32(1):5-8.
- Silfverskiöld N. Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions.Acta Chir Scand.1924;56:315-330.
- Ficke B, Elattar O, Naranje SM, et al. Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients.Foot Ankle Surg.2017. pii: S1268-7731(17)30111-X.
- Labovitz JM, Yu J, Kim C. The role of hamstring tightness in plantar fasciitis.Foot Ankle Spec. 2011;4(3):141-144.
- Nakale NT, Strydom A, Saragas NP, Ferrao PNF. Association between plantar fasciitis and isolated gastrocnemius tightness.Foot Ankle Int. 2018;39(3):271-277.
- Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession.Int Orthop. 2013;37(9):1845-1850.
- Erdemir A, Hamel AJ, Fauth AR, et al. Dynamic loading of the plantar aponeurosis in walking.J Bone Joint Surg. 2004;86(3):546-552.
The experts and research point to shorter mountain bike crank arms benefitting many riders.
Martin found that the max power output of the test subjects only varied by about 4% from the smallest crank length to the largest crank length.. Buchanan has raced both road bikes and mountain bikes, and has been fitting riders to bikes for 20 years.. While some argue longer cranks provide riders with better leverage, Buchanan doesn’t believe it’s that simple.. Besides agreeing with the results of the studies I read, Buchanan also provided a practical benefit to using shorter cranks on mountain bikes: they reduce pedal strikes.. Barrett, who is 5’4″, uses 165mm cranks on her mountain bike.. In the road bike world, there are several different cranks sizes available to riders.. The variety of road cranks on the market today stems from road riders being pickier about bike fit because they don’t move around on a road bike the way riders do on mountain bikes.. However, Barrett notes that the mountain bike industry is starting to trend downward in crank length.. Will riders see more MTB crank sizes become available in the future?. Best of all, I no longer feel pain in my knees or hips after hard rides.. After experiencing the difference between the two crank sizes, I believe shorter cranks definitely benefit shorter riders like myself.. 175mm cranks might be right for some riders, but they are not right for all riders.
Patients in the active group were more likely (56 %) than patients in the sham group (45 %) to report an improvement in VAS pain scores of 60 % or more from baseline; however, this difference was not statistically significant.. Aetna's policy on the unproven status of ESWT for plantar fasciitis is supported by the conclusions of more than 12 systematic evidence reviews, including those from national and international authorities (including the Cochrane Collaboration (Crawford and Thomson, 2010), BMJ Clinical Evidence (Landorf and Menz, 2007), the Washington State Department of Labor and Industries (2003), the BlueCross BlueShield Association Technology Evaluation Center (2003, 2005), the Institute for Clinical Systems Improvement (2004), the California Technology Assessment Forum (Tice, 2004; CTAF, 2007; CTAF, 2009), the National Institute for Health and Clinical Excellence (2005), BMC Musculoskeletal Disorders (Thomson et al, 2005), the Canadian Agency for Drugs and Technologies in Health (Ho, 2007), and the Galacian Agency for Health Technology Assessment (Ruano-Ravina, 2004)), and from other investigator groups (Cole et al, 2005; Buchbinder, 2004; Burton and Overend, 2005; Boddeker et al, 2004; and Atkins et al, 1999).. These systematic evidence reviews of ESWT for plantar fasciitis have concluded that the effectiveness of this intervention is unknown.. Meta-analysis of the 14 randomized controlled clinical trials of ESWT for plantar fasciitis identified significant variability in the quality of the randomized trials and in the interventions studied.. The authors concluded that this study is the first randomized controlled trial to evaluate the effectiveness of dry needling for plantar heel pain.. There were 28 patients in each treatment group.. The authors concluded that among patients with plantar fasciitis, the use of LED did not result in greater improvement in function or pain compared with sham treatment.. Group 2 reported no pain difference after injections (p > 0.05).. Plantar fasciitis.. Plantar heel pain and fasciitis.
November 20, 2018, 9:29 pm
Cascade Dafo, a manufacturer of pediatric lower-extremity braces and creator of the original DAFO (Dynamic Ankle Foot Orthosis), has added the JumpStart Softback to its Fast Fit line of prefabricated braces.. Since its inception in 1981, JMS Plastics Supply has been committed to partnering with its orthopedic customers for product satisfaction, including plastic materials, covering and cushioning materials, and equipment and supplies.. Cascade Dafo, creator of the original DAFO (Dynamic Ankle Foot Orthosis), has added the Fast Fit Bug to its line of prefabricated shoe inserts.. Firm Support – Unlike soft foam insoles, Tread Labs insoles offer the firm arch support of a custom orthotic.. Firm Support – Unlike soft foam insoles, Tread Labs insoles offer the firm arch support of a custom orthotic.. Since its inception in 1981, JMS Plastics Supply has been committed to partnering with its orthopedic customers for product satisfaction, including plastic materials, covering and cushioning materials, and equipment and supplies.. Cascade Dafo, a manufacturer of pediatric lower-extremity braces and creator of the original DAFO ® (Dynamic Ankle Foot Orthosis), has added the JumpStart ® Softback to its Fast Fit ® line of prefabricated braces.
Ballet is an art form steeped in tradition, but pointe shoes need not be out of step with the times.
However, I’m not the first and I won’t be the last parent who worries about her daughter’s health and safety.. While the inordinate amount of time serious dancers spend in the studio is not likely to change, it should be possible, given the advances in materials science and athletic footwear research and development, to improve the pointe shoes they perform and train in.. The inner sole, or shank, is traditionally made of leather.. Dancers (or their parents) must hand-sew ribbons and elastics to attain a supportive and comfortable fit.. In recent years, pointe shoe manufacturers have attempted to address the health and safety concerns as well as the usage requirements dancers have regarding their shoes.. Most of Bloch’s Stretch Pointes have a split outsole, which provides greater mobility to the fabric and enables the shoe to better hug a dancer’s foot.. Another product design student, Eugene drew inspiration from the materials science and technology that Nike has developed for its athletic footwear to conceive of a pointe shoe for use during training .. His prototype would integrate a basket weave fabric to provide support and flexibility.. The toe box would be lined with memory foam.. Elastic material rather than satin around the heel would eliminate the need for ribbons to keep the shoe on and avoid problems such as Achilles tendonitis.