Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations.
BACKGROUND
Gastrocnemius recession is a surgical technique commonly performed on individuals who suffer from symptoms related to the restricted ankle dorsiflexion that results when tight superficial posterior compartment musculature causes an equinus contracture. Numerous variations for muscle-tendon unit release along the length of the calf have been described for this procedure over the past century, although all techniques share at least partial or complete release of the gastrocnemius muscle given its role as the primary plantarflexor of the ankle. There exists strong evidence to support the use of this procedure in pediatric patients suffering from cerebral palsy, and increasingly enthusiastic support-but less science-behind its application in treating adult foot and ankle pathologies perceived to be associated with gastrocnemius tightness. The purpose of this study, therefore, was to evaluate currently available evidence for using gastrocnemius recession in three adult populations for whom it is now commonly employed: Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers.


METHODS
A systematic review of the literature was performed on December 21, 2013 using the PubMed, Scopus, and Cochrane databases along with the search term "(gastrocnemius OR gastrocsoleus) AND (recession OR release OR lengthening)." This search generated 1141 results; 12 articles found in the references of these papers were also screened for inclusion. In total, 18 articles met our inclusion criteria. These articles were reviewed and assigned a classification (I-V) of Level of Evidence, according to the criteria recommended by the Journal of Bone & Joint Surgery. Based on these classifications, a Grade of Recommendation was assigned for each of the indications of interest.


RESULTS
Grade B evidence-based literature ("fair") exists to support the use of gastrocnemius recession for the treatment of isolated foot pain due to midfoot/forefoot overload syndrome in adults. There are some data in support of utilizing gastrocnemius recession to treat midfoot or forefoot ulcers and non-insertional Achilles tendinopathy in adults, but to date this evidence remains Grade Cf. Insufficient evidence (Grade I) is currently available to make any recommendation either for or against this procedure for the treatment of insertional Achilles tendinopathy.


CONCLUSIONS
Scientific literature continues to grow in support of using isolated gastrocnemius recession as an effective treatment strategy for a variety of lower limb pathologies, although it remains clear that higher evidence levels and more carefully controlled investigations will be necessary to more convincingly define the true efficacy and ideal applications of gastrocnemius recession in the adult population.


METHODS
Level IV systematic review.
University of Iowa Carver College of Medicine, Iowa City, IA, USA.
Chris C
CC
Cychosz
Department of Orthopaedics and Rehabilitation, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA. Electronic address: phinit-phisitkul@uiowa.edu.
Phinit
P
Phisitkul
University of Iowa Carver College of Medicine, Iowa City, IA, USA.
Daniel A
DA
Belatti
Orthopaedic Surgery, Dalhousie University, Halifax, Canada.
Mark A
MA
Glazebrook
Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
Christopher W
CW
DiGiovanni
D000125:Achilles Tendon / Q000601:surgery*; D017719:Diabetic Foot / Q000601:surgery*; D004863:Equinus Deformity / Q000601:surgery*; D005534:Foot Diseases / Q000601:surgery*; D006801:Humans; D018482:Muscle, Skeletal / Q000601:surgery*; D052256:Tendinopathy / Q000601:surgery*
Achilles tendinopathy; Equinus; Gastrocnemius; Lengthening; Metatarsalgia; Plantar fasciitis; Recession; Soleus; Systematic review