Orthopedics

The Cutting Edge 

Achilles Tendon Pain Treated With Gastrocnemius-Soleus Recession

J. Monroe Laborde, MD, MS; Luke Weiler, MS

Abstract

The Achilles tendon is the largest and strongest tendon in the body.1 Loads up to 10× body weight are applied during activities such as jumping and are increased by malalignment of the foot and ankle.1 The Achilles tendon is the most common location of posterior ankle pain.2

Achilles tendon pain is thought to result from multiple factors including obesity, tendon overuse, and repetitive stress, causing microscopic tears and degeneration of the tendon.3-6 Gastrocnemius-soleus tightness is common in patients with Achilles tendon pain.7-9 Some authors have felt that this tightness is a major contributing cause of Achilles tendon pain and have recommended gastrocnemius recession as treatment.5,10-12 Biomechanical stress is increased at the Achilles tendon insertion, the most common location of Achilles tendon pain in this study (Figure). Swelling and tenderness usually accompany Achilles tendon pain. Blood supply and healing potential is decreased 2 to 6 cm from the insertion, another location of Achilles tendon pain.1

Conservative treatment consists of rest, stretching, and anti-inflammatory medications.2-4,6,9,13,14 Surgery is an acceptable choice for patients who fail to respond to conservative treatment.2-4,9,13,14 Recommended surgeries include longitudinal division, excision of adhesions and intratendinous lesions, removal of bony prominences, reattachment of the Achilles tendon to the calcaneus, and transfer of the flexor hallicis longus to the calcaneus.3,5,9,14 If the Achilles tendon is reattached, a recovery time of >6 months may be required.

Gastrocnemius-soleus recession was also sometimes added to other procedures.15 Costa et al6 used Z-plasty of the Achilles tendon to correct the abnormal loading of the tendon and consequent trauma and to prevent recurrence of pain. The best surgical approach is controversial because the results of different approaches are generally similar.3,4,13

Wound complications of distal Achilles surgery such as delayed healing, skin necrosis, and infection have been reported in most studies.3,4,6,9,14,16 Many fewer wound complications are reported after gastrocnemius-soleus recession.17

Habbu et al12 presented a paper at the 2010 American Academy of Orthopedic Surgeons Annual Meeting on using gastrocnemius recession for pain relief for various foot problems, including Achilles tendinitis, with good results. Gentchos et al5 presented 1 case of Achilles tendon pain relieved by gastrocnemius recession.

This article, to the author’s knowledge, is the first that evaluates a series of patients with Achilles tendon pain treated with gastrocnemius-soleus recession alone. Gastrocnemius-soleus recession was performed not only to relieve Achilles tendon pain with a lower risk of wound problems, but also to potentially prevent foot ulcers and Charcot arthropathy in diabetics and other neuropathic patients.18,19

Between August 2005 and March 2010, 24 patients with Achilles tendon pain (4 bilateral), who failed nonoperative treatment, agreed to undergo gastrocnemius-soleus recession (28 procedures). None of the patients were competitive athletes. There were 8 men and 16 women.

A midline vertical incision was made just distal to the gastrocnemius muscle. The sural nerve and lessor saphenous vein were avoided and gently retracted. The gastrocnemius tendon and soleus fascia were cut transversely and the soleus muscle was stretched by dorsiflexing the ankle. The incision was closed with a #3-0 absorbable suture subcutaneously and with staples in the skin.

Patients were allowed to bear full weight immediately in a cam walking boot. At 2 weeks, the wounds were checked for problems, stitches were removed, and range of motion exercises began. At 1 month, the boot was removed and unlimited walking was allowed. At 6 weeks, bilateral simultaneous toe raising calf strengthening exercises were started; at 10 weeks unilateral, exercises began.

Long-term follow-up was by phone (12/18) if the patient would not return for examination. Patients were asked to rate their pain from 0 to 10, with 0 being no pain and 10…

The improvement in Achilles tendon pain and lack of wound complications with gastrocnemius-soleus recession compares favorably with other surgical treatments.

The Achilles tendon is the largest and strongest tendon in the body.1 Loads up to 10× body weight are applied during activities such as jumping and are increased by malalignment of the foot and ankle.1 The Achilles tendon is the most common location of posterior ankle pain.2

Achilles tendon pain is thought to result from multiple factors including obesity, tendon overuse, and repetitive stress, causing microscopic tears and degeneration of the tendon.3-6 Gastrocnemius-soleus tightness is common in patients with Achilles tendon pain.7-9 Some authors have felt that this tightness is a major contributing cause of Achilles tendon pain and have recommended gastrocnemius recession as treatment.5,10-12 Biomechanical stress is increased at the Achilles tendon insertion, the most common location of Achilles tendon pain in this study (Figure). Swelling and tenderness usually accompany Achilles tendon pain. Blood supply and healing potential is decreased 2 to 6 cm from the insertion, another location of Achilles tendon pain.1

Figure: Insertional Achilles tendinitis
Figure: Insertional Achilles tendinitis with swelling at the Achilles insertion.

Conservative treatment consists of rest, stretching, and anti-inflammatory medications.2-4,6,9,13,14 Surgery is an acceptable choice for patients who fail to respond to conservative treatment.2-4,9,13,14 Recommended surgeries include longitudinal division, excision of adhesions and intratendinous lesions, removal of bony prominences, reattachment of the Achilles tendon to the calcaneus, and transfer of the flexor hallicis longus to the calcaneus.3,5,9,14 If the Achilles tendon is reattached, a recovery time of >6 months may be required.

Gastrocnemius-soleus recession was also sometimes added to other procedures.15 Costa et al6 used Z-plasty of the Achilles tendon to correct the abnormal loading of the tendon and consequent trauma and to prevent recurrence of pain. The best surgical approach is controversial because the results of different approaches are generally similar.3,4,13

Wound complications of distal Achilles surgery such as delayed healing, skin necrosis, and infection have been reported in most studies.3,4,6,9,14,16 Many fewer wound complications are reported after gastrocnemius-soleus recession.17

Habbu et al12 presented a paper at the 2010 American Academy of Orthopedic Surgeons Annual Meeting on using gastrocnemius recession for pain relief for various foot problems, including Achilles tendinitis, with good results. Gentchos et al5 presented 1 case of Achilles tendon pain relieved by gastrocnemius recession.

This article, to the author’s knowledge, is the first that evaluates a series of patients with Achilles tendon pain treated with gastrocnemius-soleus recession alone. Gastrocnemius-soleus recession was performed not only to relieve Achilles tendon pain with a lower risk of wound problems, but also to potentially prevent foot ulcers and Charcot arthropathy in diabetics and other neuropathic patients.18,19

Materials and Methods

Between August 2005 and March 2010, 24 patients with Achilles tendon pain (4 bilateral), who failed nonoperative treatment, agreed to undergo gastrocnemius-soleus recession (28 procedures). None of the patients were competitive athletes. There were 8 men and 16 women.

A midline vertical incision was made just distal to the gastrocnemius muscle. The sural nerve and lessor saphenous vein were avoided and gently retracted. The gastrocnemius tendon and soleus fascia were cut transversely and the soleus muscle was stretched by dorsiflexing the ankle. The incision was closed with a #3-0 absorbable suture subcutaneously and with staples in the skin.

Patients were allowed to bear full weight immediately in a cam walking boot. At 2 weeks, the wounds were checked for problems, stitches were removed, and range of motion exercises began. At 1 month, the boot was removed and unlimited walking was allowed. At 6 weeks, bilateral simultaneous toe raising calf strengthening exercises were started; at 10 weeks unilateral, exercises began.

Long-term follow-up was by phone (12/18) if the patient would not return for examination. Patients were asked to rate their pain from 0 to 10, with 0 being no pain and 10 being the most severe pain they could imagine. They were also asked if they had any complications, additional surgery, or other treatments, weakness, or functional limitations.

Results

All patients (24/24) had initial relief of Achilles tendon pain (0-1/10) with no wound or other complications (0/24) on their 2- and 6-week postoperative short-term follow-ups. Six (0 bilateral) patients were lost to long-term follow-up. This left 22 procedures (4 bilateral) in 18 patients with longer follow-up. The average long-term follow-up for 18 patients was 22 months (range, 6-60).

There were 5 men and 13 women. Average patient age was 57 years (range, 47-74 years). Most had pain and tenderness at the Achilles insertion (17/18) and 1 in the tendon proximal to the insertion. Most patients had diabetes (11/18). All of the patients had pulses (18/18).

All 18 patients rated their Achilles pain as severe (7-10/10; mean, 9/10) preoperatively. Average pain at follow-up was 1 out of 10 for an average improvement of 8 out of 10. All patients (18/18) had improvement of their pain to mild (0-3/10) and 6 of 18 had no pain on long-term follow-up.

At long term follow-up, none of the patients required additional surgery or other treatments. Two patients reported stiffness, 1 weakness, 1 midfoot pain, 1 occasional calf pain, and 1 reported she was unable to wear high heels. None of the patients with diabetes developed foot ulcers or Charcot arthropathy after gastrocnemius-soleus recession.

Discussion

Most studies of operative treatment of Achilles tendon pain have reported a high rate of satisfactory results.14 After longitudinal tenotomies and debridement, some authors reported frequent recurrence requiring additional surgery (6/14, 9/48), resulting in a low rate of satisfactory results (5/14, 25/48).20,21 Maffulli et al21 reported worse results in nonathletic patients compared to athletic patients. In the present study of nonathletic patients, however, none of the patients required additional surgery for recurrence and all (18/18) had improvement in pain from severe to mild. Tornetta et al22 felt that pain is the dominant factor in comparing foot and ankle surgery outcomes.

Concern exists that gastrocnemius-soleus recession may also cause permanent weakness. Biomechanical studies show the potential for strength improvement with increased range of motion after gastrocnemius-soleus recession.23,24

The clinical study of Chimera et al25 has shown that strength and function 3 months after gastrocnemius recession are usually improved from preoperative level to near normal even without physical therapy. Costa et al6 reported that even Z-plasty of the Achilles tendon did not appear to cause long-term deficit of power or gait.

Costa et al6 also reported 95% (20/21) pain relief, but 21% (4/21) had wound complications and 1 had a pulmonary embolus. Wagner et al15 reported that 14% (7/50) had wound problems after Achilles reattachment. Maffuli et al21 reported 24 of 48 had wound problems including 15 of 48 with wound infections after Achilles tendon debridement. Paavola et al16 reported that 11% (48/432) had distal Achilles surgery complications, of which 6% (29/432) had compromised wound healing. Gastrocnemius-soleus recession was used by Takahashi and Shrestha17 in 230 patients whose average age was 68 years; 98 of 230 patients had diabetes with no wound or tendon problems.

There were no wound complications in the present study. Postoperative reports in this study seemed an acceptable tradeoff for pain relief, especially in high-risk patients. The American Academy of Orthopedic Surgeons evidence-based clinical practice guideline on Achilles tendon rupture recommended by consensus that Achilles tendon surgery be approached more cautiously in patients with diabetes, neuropathy, immunocompromised states, age older than 65 years, tobacco use, sedentary lifestyle, obesity, peripheral vascular disease or dermatologic disorders.26 We believe these recommendations should also be considered when choosing the type of Achilles tendon surgery for Achilles tendinitis. Gastrocnemius-soleus recession should be considered as the initial surgery, especially in high-risk patients, because it has fewer complications and favorable pain improvement compared to other surgeries for Achilles tendon pain. In patients with diabetes, gastrocnemius-soleus recession also has the potential to prevent foot ulcers and other foot problems including Charcot arthropathy.19 If gastrocnemius-soleus recession fails to relieve Achilles tendon pain, distal Achilles surgical procedures with more risk of wound complications could still be performed later. None of the patients in this study required additional surgery.

Conclusion

In this preliminary report, improvement in Achilles tendon pain and lack of wound complications with gastrocnemius-soleus recession compared favorably with other surgical treatments. If these results are confirmed with additional studies, gastrocnemius-soleus recession may become the surgical treatment of choice for Achilles tendon pain in nonathletic, high-risk patients. This would include smokers, the immunosuppressed, and those with venous and arterial disease because of the low complication rate. Gastrocnemius-soleus recession could become the treatment of choice in diabetics because of the low wound complication rate and the potential to prevent foot ulcers.

References

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Authors

Dr Laborde and Mr Weiler are from the Department of Orthopedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.

Dr Laborde and Mr Weiler have no relevant financial relationships to disclose.

Correspondence should be addressed to: J. Monroe Laborde, MD, MS, LSUHSC, 3434 Prytania St, #430, New Orleans, LA 70115 (monroe@laborde.net).

doi: 10.3928/01477447-20110228-16

10.3928/01477447-20110228-16

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