Proximal Medial Gastrocnemius Release in the Treatment of Recalcitrant Plantar Fasciitis

Transcription

1 FOOT & ANKLE INTERNATIONAL DOI: /FAI Proximal Medial Gastrocnemius Release in the Treatment of Recalcitrant Plantar Fasciitis Ali Abbassian, FRCS; Julie Kohls-Gatzoulis, FRCS; Matthew C. Solan, FRCS Surrey and London, UK ABSTRACT Background: Isolated gastrocnemius contracture has been implicated as the cause of a number of foot and ankle conditions. Plantar fasciitis (PF) is one such condition that can be secondary to altered foot biomechanics as a result of gastrocnemius contracture. In this paper, we report our results with an isolated release of the proximal medial head of gastrocnemius for recalcitrant PF. Methods: We prospectively followed a consecutive series of 21 heels in 17 patients following a Proximal Medial Gastrocnemius Release (PMGR). PF was diagnosed clinically and confirmed radiologically in all cases. To be included, at least 1 year of conservative treatment must have been tried and an isolated gastrocnemius contracture confirmed clinically using Silfverskiold s test preoperatively. Outcome measures included a 5-point Likert scale as well as subjective and objective calf weakness assessments. Final followup was on average 24 (range, 8 to 36) months after the surgery. Results: Seventeen of the 21 heels (81%) reported total or significant pain relief following the surgery and none reported worsening of their symptoms. The majority did not have subjective or objective evidence of calf weakness. There were no major complications and only one case that suffered a minor complication. Conclusion: We believe a PMGR is a simple way of treating a patient with PF who has failed to respond to conservative management. In our series, the results were favorable, the recovery fast and the morbidity low. Level of Evidence: IV, Retrospective Case Series No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding Author: Ali Abbassian, MBBS, FRCS(Tr&Orth) Royal National Orthopaedic Hospital Brockley Hill Stanmore Middlesex HA7 4LP United Kingdom aabbassian@gmail.com For pricing and availability of reprints, reprints@datatrace.com or call x232. Key Words: Plantar Fasciitis, Heel Pain; Gastrocnemius INTRODUCTION Plantar fasciitis (PF) is a debilitating condition that has sparked a number of debates in the literature, with regards to its etiology and management. It is generally accepted as a self-limited condition where a significant proportion of patients improve with little or no intervention. Recently, isolated contractures of the gastrocnemius and a reduction in the dorsiflexion range of the ankle have been implicated in its etiology. 5,12 Assessment of the contracture is done clinically using the Silfverskiold test. There are many non-surgical options that include stretching, orthotics, casting, 23 corticosteroid injection, 11 or botulinum toxin 3 injections as well as shock wave therapy. 22 Surgical release of the plantar fascia may have implications for foot biomechanics, 6 can have a prolonged rehabilitation period and is therefore best avoided when possible. We perform a small day case procedure to release the proximal aponeurosis of the medial head of the gastrocnemius, when conservative therapy fails and when isolated gastrocnemius contracture is confirmed clinically using the Silfverskiold s test. The purpose of this study was to report our results in a cohort of patients who underwent a Proximal Medial Gastrocnemius Release (PMGR) in a 3-year period. To our knowledge, this is the first report of a series of patients with recalcitrant PF treated with a proximal gastrocnemius lengthening procedure, although in a recent report 10 a more distal recession procedure has been successful in controlling symptoms of PF. In this series the lengthening was undertaken at the musculotendinous junction. PATIENTS AND METHODS Seventeen patients (21 heels) who were managed surgically by a PMGR were followed over a 3-year period. The diagnosis of PF was initially made clinically when patients 14

2 Foot & Ankle International/Vol. 33, No. 1/January 2012 GASTROCNEMIUS RELEASE IN PF TREATMENT 15 described typical symptoms and demonstrated tenderness at the proximal insertion of the plantar fascia. Other causes of heel pain were excluded. Those with dysethsesia or hypoesthesia of the plantar foot; or clinical signs suggestive of Baxter s nerve or tarsal tunnel syndrome were excluded. The patients were offered surgery after at least one year of conservative treatment. This had normally started in the primary care sector prior to referral for an orthopaedic consultation. Treatment included orthotics, physiotherapy and in some cases steroid injections. In addition to their previous physiotherapy, all patients underwent at least a further 3-month period of eccentric stretching (as popularized by Alfredson) 1 under the supervision of our unit s physiotherapists before surgical release was performed. Surgery was only performed in patients with a positive Silfverskiold s test despite a prolonged period of eccentric stretching. All patients had a plain foot and ankle radiograph to exclude structural or degenerative changes. Furthermore all patients had radiological diagnosis of PF by either MRI bone scan or NSS. PF was diagnosed with an increase in tracer uptake at the proximal insertion of plantar fascia on bone scan, thickening of the plantar fascia on MRI or on ultrasound or a change in the signal characteristic of the proximal fascia at its insertion on MRI. The Silfverskiold s test was performed with the examiner holding the subtalar joint in neutral alignment with one hand, while exerting a dorsiflexing moment about the ankle joint with the other. The test was considered positive if the ankle could not be made plantigrade when the knee was extended but would dorsiflex to or beyond plantigrade alignment with the knee flexed. The lateral border of the foot and the subcutaneous border of fibula were used as references when measuring the range of ankle movements (Figure 1). At final followup patients rated the change in the level of their pain on a 5-point Likert scale (Table 1); this is a patient-reported outcome satisfaction scale and, although commonly used, has not been validated. There are, however, no validated outcome tools available for PF. The patients were also asked if they felt weaker on the released side (subjective). Calf power was assessed objectively, by asking Table 1: Likert Scale for Postoperative Success Impact on Symptoms Number of Heels Made worse 0 No Change 2 Some improvement 2 Significant improvement 8 Pain free 9 the patients to perform 20 consecutive single stance heel rises on the released side. The power was considered full if this was achieved. Postoperative complaints or complications were also noted. Additionally, they were also asked whether they would recommend this treatment to a family member. Seventeen patients (21 heels) were included in the study. The male-to-female ratio was 3:14 and the average age was 52 (range, 31 to 70) years. The symptom duration prior to surgical release ranged from 12 months to 6 years (average, 3.8 years) but with a mode of 5 years. One patient with a bilateral release and one with a unilateral release had their surgery under a general anesthetic; the remaining 15 patients (19 heels) had their surgery under local anesthetic infiltration and sedation. Final followup was at an average of 24 (range, 8 to 36) months post-op. Surgical technique Unless otherwise indicated, the procedure was performed as a day case; under local anesthetic (1% Lidocaine and epinephrine); with the patient positioned prone; and without a tourniquet. The medial dimple of the popliteal fossa was located and the incision was marked 1 cm distal and lateral (central) to it (Figure 2). It is important to keep the incision lateral to avoid injury to the branches of saphenous nerve or vein. A 3-cm incision was made through the skin and the subcutaneous fat. The incision was then deepened through the deep fascia Fig. 1: The Silfverskiold test. On the left, with the knee extended, the ankle cannot be made plantigrade. With the knee flexed (right) the ankle is made plantigrade. The lateral border of the foot and the fibula are marked on the skin for ease of reference.

3 16 ABBASSIAN ET AL. Foot & Ankle International/Vol. 33, No. 1/January 2012 absorbable sutures (Figure 3). A small adhesive dressing was applied. Release of the contracture was confirmed clinically by repeating the Silvferskiold test. Patients did not require a cast or a brace and were encouraged to continue with their eccentric calf stretches. RESULTS Fig. 2: In this figure the incision for a PMGR is marked (solid balck line) and shown on the left leg of the patient. The dotted circle marks the medial dimple of the popliteal fossa. to expose the underlying aponeurosis of the medial head of the gastrocnemius. The aponeurosis was then divided with scissors, ensuring a semi- circumferential release to the anterior aspect of the medial head. The skin was closed using None of the patients reported worsening of their symptoms after release. Seventeen of the 21 heels (81%) reported total or significant pain relief (Table 1). Of the 17 heels that had markedly improved, ten (58%) had noticed this improvement within 1 to 2 weeks of their surgery. The remaining seven reported a slow but progressive improvement over a 3- to 6-month period. In two cases, symptoms were improved by 50% but further improvement occurred after an ultrasound guided corticosteroid injection. In the remainder no further intervention was necessary. When considering subjective reports of calf weakness, only one patient who had had a bilateral release reported A B C D E F Fig. 3: A proximal medial gastrocnemius release. A, The skin and subcutaneous tissues have been incised. B, The deep fascia over the medial head is being incised. C, The plane between the deep fascia and the medial head is dissected and developed bluntly. D and E, The apponeurosis of the medial gastrocnemius is identified (D) and is being cut with scissors (E). F, The final release performed and figure demonstrating the resultant gap in the apponeurosis.

4 Foot & Ankle International/Vol. 33, No. 1/January 2012 GASTROCNEMIUS RELEASE IN PF TREATMENT 17 calf weakness following surgery. This was a 70-year-old female who had reported improvements in her heel pain initially but reported progressive calf pain, weakness, and sensory symptoms. Further investigation revealed a coexisting diagnosis of spinal stenosis. She was, however, able to perform the 20 heel rise test on both sides. No other patient complained of a subjective awareness of calf weakness following his or her surgery. Sixteen of the released calves were able to perform 20 single stance heel rises. Two patients refused to perform any due to hip and forefoot osteoarthritis, respectively. Three patients failed to reach the 20-heel rise threshold. Fifteen patients (88%) would recommend this operation to a close family member. The two patients who would not included the female mentioned above who had a coexisting diagnosis of spinal stenosis with a bilateral release and another patient who had not improved with this technique. There were no major complications. One minor complication occurred, which was a case of persistent drainage from the wound that resolved spontaneously over a 2-week period. DISCUSSION Plantar fasciitis is very common. In one North American study, 1% of all orthopaedic referrals were because of plantar heel pain. This amounted to 1 million medical visits per year in a 5-year period. 16 Despite this, the exact etiology of the condition is still subject to debate. A high body mass index (BMI) and participating in activities or occupations that involve prolonged weightbearing are generally accepted as risk factors. In a more recent study, however, reduced ankle dorsiflexion was associated with a much greater risk of developing the condition than either BMI or activity type, with an odds ratio of 23.3 (95% CI, 4.3 to 124.4) for loss of ankle dorsiflexion compared to 5.6 (95% CI, 1.9 to 16.6) for BMI. 15 Isolated contracture of the gastrocnemius has been implicated in plantar fasciitis by other investigators. 5 Assessment of gastrocnemius contracture is done with a clinical exam. It is subject to high levels of intra- and interobserver variability. Attempts at introducing standardized methods have at best resulted in cumbersome tools suitable only for research purposes. 5,7 The range of dorsiflexion before a contracture is diagnosed is variable. Some authors consider the test positive if the ankle cannot be dorsiflexed beyond 10 degrees of dorsiflexion with the knee extended and subtalar joint in neutral. 5 We diagnosed a contracture if the ankle could not be made plantigrade. In this series all patients who presented with recalcitrant plantar fasciitis had clinical evidence of isolated contracture of their gastrocnemius. When all conservative measures fail and surgery is contemplated, local release of the plantar fascia has traditionally been performed. Some have combined this with a release of the first branch of the lateral plantar nerve. 20 Success rates as high as 90% have been reported in the literature, 18,20 but there are risks of plantar fascia rupture, plantar nerve injury and a high incidence of wound complications and lateral column pain. The postoperative rehabilitation is prolonged and may take up to 4 weeks before full weightbearing is possible. It is not surprising therefore that in one study of 47 heels undergoing a plantar fascia release; only 48% were satisfied. 4 The plantar fascia is important for effective propulsion during the gait cycle. A recent cadaveric study 6 concluded that: the plantar aponeurosis plays an important role in transmitting Achilles tendon forces to the forefoot in the latter part of the stance phase of walking. Surgical procedures that require the release of this structure may disturb this mechanism and thus compromise efficient propulsion. We therefore prefer a lengthening procedure, in cases where gastrocnemius contracture is still present despite physiotherapy, before any local surgery is contemplated. There are a number of techniques described for lengthening the gastroc-soleus complex. These procedures can be broadly divided in two groups. The first group results in the lengthening of both the gastrocnemius and soleus muscles, while the other focuses on the gastrocnemius alone. In the context of an isolated contracture, the former group may result in weakness of the calf musculature. Aronow and colleagues demonstrated that similar effects on plantar pressure could be expected when the gastrocnemius alone was loaded as compared to the triceps surae. 2 They concluded that patients with isolated gastrocnemius contractures might obtain similar clinical benefits with potentially less morbidity after gastrocnemius aponeurosis lengthening as compared to Achilles tendon lengthening. Gastrocnemius lengthening can be performed in several ways: The Baumann procedure consists of an intramuscular lengthening (recession) of the gastrocnemius in the deep interval between the soleus and gastrocnemius muscles and isolates the lengthening site to the gastrocnemius, by releasing its deep aponeurosis. 9 The Strayer procedure 21 has also been shown to achieve good correction of a gastrocnemius contracture. 13 This is a release at the gastrocnemius insertion just proximal to the tendoachilles. It is performed through an open or endoscopic approach and the patient is immobilized in a cast post-operatively. When reviewing the results of a gastrocnemius recession, Rush et al. 17 found complications developed in nine (6%) of 126 patients: six (4%) had scar problems, two (1.3%) had wound dehiscence, two (1.3%) had infection, three (2%) had nerve problems, and one (0.67%) developed complex regional pain syndrome. There was no subjective weakness and no patient complained of a limp, gait disturbance, or persistent decrease in muscle strength. This was a similar finding to our study where there were no subjective complaints of calf weakness without a secondary cause. Additionally, in our study, 16 out of the 19 calves (84%) were able to complete the 20-heel rise-test. These data suggest that calf power was not compromised by isolated gastrocnemius

5 18 ABBASSIAN ET AL. Foot & Ankle International/Vol. 33, No. 1/January 2012 procedures, in contrast to tendoachilles lengthening, which has been shown to result in weakness. The open Strayer procedure may have a poor cosmetic outcome and risks injury to the sural nerve. 14 It also often requires a period of casting and regional or general anesthetic. In a PMGR the incision is in line with the Langer s lines and in the crease behind the knee; the sural nerve is not at risk; and injury to the saphenous nerve is avoided by placing the incision lateral to the medial dimple of the popliteal fossa. The procedure is performed as a day case and under local anesthetic, unless otherwise indicated. Patients are not immobilized and, depending on their pain levels can return to daily activity almost immediately. We encountered no major complications in this series demonstrating the PGMR to be a safe and acceptable alternative to the other lengthening procedures. Gastrocnemius recession at the musculotendinous junction has been performed for PF with good reported success rates 10 where no sural nerve injury or wound problems were reported. There was, however, a short period of immobilization in a pneumatic walking boot after the procedure. In the same study, 93% of the patients said that they would recommend the surgery to a friend. This compares to 88% in our series. This suggests that relief of isolated gastrocnemius contracture will give high satisfaction rates in treating heel pain regardless of the level of lengthening. A direct comparison of the results of the two studies would however not be meaningful due to the small numbers and lack of standardization. In our series the release was performed at the proximal medial head aponeurosis only. When compared to the lateral head, the medial head of the gastrocnemius has a more proximal attachment on the femur and a much larger cross sectional area. 8 Furthermore, it has been shown that the medial head displays more changes on a post-exercise MRI scan compared to its lateral counterpart and may therefore play a greater role in generating plantarflexion power. 19 We have found, intraoperatively, that releasing the medial head alone achieves satisfactory correction of the contracture and so release of both heads is not necessary. A weakness of this study is the lack of a control group. Little is known about the natural history of recalcitrant cases of PF. However, more than half of those who improved with the PMGR in this series did so within 2 weeks of their surgery. This was despite an average of more than 3 years of symptoms. Therefore, we do not believe that these patients improved spontaneously. The other patients displayed a more progressive and slower recovery over months. Two required further conservative therapy to achieve eventual resolution of their symptoms. CONCLUSION Plantar fasciitis is often associated with isolated gastrocnemius contracture. Surgery should be a last resort in the treatment of this condition. In a carefully selected patient with a clinical diagnosis of recalcitrant PF, in the absence of other causes of heel pain and when an isolated contracture is confirmed, we believe a PMGR lengthening procedure is preferred to any local surgery. Our patients recovered from the procedure rapidly and the morbidity was low. REFERENCES 1. Alfredson, H; Pietila, T; Jonsson, P; Lorentzon, R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 26: , Aronow, MS; Diaz-Doran, V; Sullivan, RJ; Adams, DJ: The effect of triceps surae contracture force on plantar foot pressure distribution. 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6 Foot & Ankle International/Vol. 33, No. 1/January 2012 GASTROCNEMIUS RELEASE IN PF TREATMENT Sinnaeve, F; Vandeputte, G: Clinical outcome of surgical intervention for recalcitrant infero-medial heel pain. Acta Orthop Belg. 74: , Strayer, LM, Jr.: Recession of the gastrocnemius; an operation to relieve spastic contracture of the calf muscles. J Bone Joint Surg Am. 32-A: , Thomson, CE; Crawford, F; Murray, GD: The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 6:19, Tisdel, CL; Harper, MC: Chronic plantar heel pain: treatment with a short leg walking cast. Foot Ankle Int. 17:41 42, 1996.