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FAS 1035 No. of Pages 5

Foot and Ankle Surgery xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Gastrocnemius recession leads to medial shift of gait line, impairment

of muscle strength and improved dorsal extension in forefoot overload
syndrome
Hagen Schmal, MDa,c , Markus Walther, MDb , Anja Hirschmller, MDa , Nina Bunert, MDa ,
Norbert P. Sdkamp, MDa , Alexander T. Mehlhorn, MDa,b,*
a
Department of Orthopedic and Trauma Surgery, University Medical Center, Hugstetterstrae 55, 79106, Freiburg, Germany
b
Center of Foot and Ankle Surgery, Schn Klinik Mnchen Harlaching, Harlachingerstrae 51, 81547, Munich, Germany
c
Department of Orthopedics and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Sdr.
Boulevard 29, 500, Odense C, Denmark

A R T I C L E I N F O A B S T R A C T

Article history: Background: Gastrocnemius recession (GR) has been introduced for treatment of forefoot overload
Received 18 October 2016 syndrome (FOS). We questioned if GR leads to an altered forefoot load and weakness of plantarexors in
Received in revised form 29 January 2017 those patients.
Accepted 2 March 2017
Methods: 26 patients suffering from FOS and gastrocnemius tightness underwent GR. A strength power
Available online xxx
analysis of plantar exors and a pedobarography was performed. Clinical outcome was measured by Foot
Function Index (FFI).
Keywords:
Results: Plantarexors are impaired about 40% six weeks and around 10% 24 weeks following GR
Gastrocnemius tightness
Gastrocnemius recession
compared to the contralateral side. Patients experienced a pain relief and an improvement of ankle
Forefoot overload syndrome dorsiexion from 2 to 15 . An increased contact time of the heel (15%) and a shift of metatarsal plantar
Muscle strength pressure from lateral to medial could be demonstrated.
Conclusions: This study suggests that GR leads to pain reduction by an increase in heel contact time and a
shift of gait line to medial in patients with a FOS. Despite, a temporary impairment of muscle strength has
to be considered.
2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction FOS in adults [35]. Despite, it is still unclear how GR alters

Gastrocnemius tightness is considered to alter plantar pressure
distribution leading to excessive strain throughout the foot. During
gait an isolated contract gastrocnemius muscle decreases the
dorsiexion of the ankle if the knee is extended. It is suggested that
under this condition the area of plantar load bearing is reduced
leading to a pathologic pattern of plantar pressure [1]. Forefoot
overload syndrome (FOS) describes metatarsalgia without any
structural abnormality and is strongly associated with gastrocne-
mius tightness. It is considered that isolated gastrocnemius
contracture shifts weightbearing plantar pressure from the hind-
foot to the midfoot and forefoot [2].
There is evidence to support the use of gastrocnemius
recession (GR) for the treatment of isolated foot pain due to
* Corresponding author at: Center of Foot and Ankle Surgery, Schn Klinik
Mnchen Harlaching, Harlachingerstrae 51, 81547, Munich, Germany.
E-mail address: amehlhorn@schoen-kliniken.de (A.T. Mehlhorn).
plantar pressure distribution in order to positively inuence this
disease. Beside the benecial effects GR is suggested to weaken
ankle plantar exors [3]. Nawoczenski et al. found in side-to-side
strength comparisons following unilateral gastrocnemius reces-
sion a good function for activities of daily living, but a weaker
function for power and endurance sports [6]. Gait analysis
revealed that gastrocnemius recession did not alter gait
kinematics/kinetics at a 3-month follow-up [7]. In contrast, it
was shown in a rabbit model, that the gastrosoleus muscle
complex undergoes atrophy and fatty inltration after gastroc-
nemius recession leading to a partial loss of function [8]. Since
direct positive and negative effects related to GR are unclear, the
purpose of this study was to elucidate if gastrocnemius recession
alters forefoot load and plantar contact time in patients with FOS.
Time course and extent of plantar exor weakness was assessed
in isokinetic, concentric and eccentric mode. Finally, it was
hypothesized that patients suffering from FOS nally benet by
GR.

http://dx.doi.org/10.1016/j.fas.2017.03.014
1268-7731/ 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: H. Schmal, et al., Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength
and improved dorsal extension in forefoot overload syndrome, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.014
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2. Methods
2.1. Patients
After approval by the ethical committee of the Albert-Ludwigs-
University Freiburg (No. 188/13) and informed consent
n = 26 patients (20 females, 6 males) were included in the study.
They had an average age of 37  13 years (Age  SD) and presented
with a forefoot overload syndrome (FOS) which was characterized
by a diffuse pain below the metatarsals 24 while walking. The
radiographs of all feet showed a harmonic metatarsal arch according
to Maestro [9] without any instabilities of the metatarsophalangeal
joints. A Morton neuroma was excluded by clinical examination and
MRI of all feet. All patients showed an isolated contracture of
gastrocnemius muscle in clinical examination using Silfverskild-
test [10]. The indication for surgery implied a failed conservative
therapy for at least 6 month including NSAIDs, orthotics and a
stretching program. Exclusion criteria of the study were a previous
surgery to the same and contralateral limb, osteoarthritis or
systematic diseases including diabetes or rheumatologic conditions
and spastic contracture secondary to neurological diseases and
trauma related to the ipsi- and contralateral extremity (n = 10).
Patients with a FOS of both sides (n = 5) were excluded from study in
order to be able to compare the treated to a healthy foot.
2.2. Surgical proceduregastrocnemius recession
All patients underwent a gastrocnemius recession following a
modied Strayer technique. With the patient supine and narco-
tized a dorsomedial skin incision (2.53.5 cm) was made. The fascia
was incised and the gastrocnemius muscle was identied and
separated from the soleus muscle by blunt dissection. The sural
nerve was identied and protected throughout the procedure. The
gastrocnemius tendon was cut transversally under direct vision at
the musculo-tendinous junction. After the dissection, a dorsiex-
ion test with extended knee joint was made. The gastrocnemius
was not sutured onto the soleus tendon. Fascia and skin were
closed as standard procedure requires.
Postoperative care included a lower leg splints for two weeks.
Afterwards pain-adapted weight-bearing was recommended. The
patients were instructed to wear the splint at night. A standard
protocol for analgesia and thrombosis prophylaxis was followed in
all patients.
2.3. Clinical assessmentFoot Function Index
The German Foot Function Index (FFI) was used to measure
function and pain pre- and 6 month postoperatively. The FFI is a
reliable and valid questionnaire for self-assessment of pain and
disability in patients with foot complaints [11]. In contrast to the
English version, the German FFI is not limited to rheumatoid arthritis
related limitations but evaluated for general foot and ankle disorders.
2.4. Dorsiexionrange of motion (ROM)
Dorsiexion ROM was measured in full knee extension pre- and
6 months postoperatively using a goniometer. To prevent excessive
dorsiexion due to pathological motion the examiner put the
subtalar joint in a neutral position. Following the correct examina-
tion technique the visual goniometer is a reliable and reproducible
method [12].
2.5. Gait analysispedobarography
The plantar pressure distribution was measured on a 1.2  10 m
walkway with integrated pressure plate (Emed-M, 38 cm  42 cm,
Please cite this article in press as: H. Schmal, et al., Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength
and improved dorsal extension in forefoot overload syndrome, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.014
4 sensors/cm2, 50 Hz, Novel GmbH, Munich Germany). The
patients were given (according to the midgait protocol [13]) an
unlimited number of trial attempts. Evaluation was performed by
taking the average of ve accurate measurements [13,14]. Based on
masks of plantar pressure distribution (Novel Automask, Novel
GmbH, Munich, Germany) peak pressure and contact time of the
heel, midfoot, forefoot, medial and lateral midfoot and metatarsal
IV were analysed preoperatively and 6 months postoperativeley.
2.6. Strength measurementsCon-Trex Multi-Joint-System
Peak torque of plantar exors of the ankle joint was measured
on the Con-Trex Multi-Joint-System (CMV AG, Dbendorf,
Switzerland) separately for right and left leg before and
6 weeks/6months after operation. Patients lay on the Con-Trex
in supine position, xed with 60 exion of the knee and hip joint.
The foot was strapped into the attachment with Velcro fastenings
in Neutral Subtalar Position [15]. Before taking the measurement,
the maximum range of motion of the injured side (maximal
30/0/20) was determined and selected for measurements on both
sides [16]. Furthermore, patients were given a stop button for
safety reasons.
The dynamic concentric and eccentric testing included
5 repetitions of bidirectional plantar exion and dorsiexion at
60 /s. The means comprised the 3 repetitions with the highest
peak torques. Isometric strength was measured at an angle of 0 for
a period of 5 s.
2.7. Statistics
Data from the case report forms were entered into a preformed
database (GraphPad Prism1, Statistical software package, Version
5.03, USA).
Numerical data were analysed by computer software package
for statistical analysis (SPSS statistical program, version 11.5, SPSS
Inc. Chicago, USA). All values are reported as mean  SD of the
mean. Statistical signicance was determined using Wilcoxon
signed-rank test and MannWhitney-U-test for non-parametric
samples at a condence level of 95% (p < 0.05).
3. Results
3.1. Clinical assessmentFoot Function Index
After a follow-up of 24 weeks all 26 patients (26 feet)
completed the FFI. The clinical score improved from preoperatively
38.4 points (SD  26.5) to postoperatively 29.9 points (SD  19.5).
The subscale function noted preoperative 12.9 points (SD  26.9)
compared to postoperative 16.8 points (SD  19.1). The subscale
pain improved signicantly (p = 0.04) from preoperative
25.5 points (SD  28.3) to postoperative 13.1 points (SD  20.6)
(Fig. 1).
3.2. Ankle dorsiexionrange of motion (ROM)
Preoperatively the average ankle dorsiexion in fully extended
knee position was 2 (SD  3.25). After a follow-up of 6 weeks the
average ROM of the ankle joint improved signicantly to 16
(SD  7.4) (p < 0.05) and remained 15 (SD  4.8) (p = 0.01) after a
follow-up period of 24 weeks (Fig. 2).
3.3. Gait analysispedobarography
Comparing the plantar peak pressure before and 6 months after
operation (heel, hallux, rst metatarsal head, and fth metatarsal
head) a shift of plantar peak pressure from the lateral to medial
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Fig. 1. Function and pain was assessed by Foot Function Index (FFI) before and after
gastrocnemius recession (24 weeks). Asterisks indicates statistically signicance
(* = p < 0.05).
Fig. 2. The dorsiexion of the ankle was assessed before and after gastrocnemius
recession (6 and 24 weeks). Asterisks indicates statistically signicance
(* = p < 0.05).
forefoot was observed supported by a signicant increase of
plantar peak pressure below the rst metatarsal head (29  15%;
p = 0.02) and a decrease below the fth metatarsal head (12  12%;
Fig. 3. Peak torque of plantar exors of the ankle joint was measured on the Con-
Trex Multi-Joint-System 6 and 24 weeks following gastrocnemius recession. A
signicant increase of plantar peak pressure below the rst metatarsal head and a
signicant decrease below the fth metatarsal head was assessed following
gastrocnemius recession. Asterisks indicates statistically signicance (* = p < 0.05)
(MH = metatarsal head).
Please cite this article in press as: H. Schmal, et al., Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength
and improved dorsal extension in forefoot overload syndrome, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.014
3
Fig. 4. The contact time (heel, midfoot, forefoot, toes) was measured on the Con-
Trex Multi-Joint-System 6 and 24 weeks following gastrocnemius recession. A
signicant increase of contact time was detected below the heel. Asterisks indicates
statistically signicance (* = p < 0.05).
p = 0.03) following gastrocnemius recession (Fig. 3). Assessment of
the plantar contact time (heel, midfoot, forefoot, toes) showed a
signicant increase of 15  10% below the heel (p  0.04) (Fig. 4)
suggesting a relocation of the physiological plantar weightbearing
from the fore- to the hindfoot.
3.4. Strength measurementsCon-Trex Multi-Joint-System
The means for the intra-individual side-to-side differences in
maximum strength of the plantar exors (concentric, eccentric,
isometric mode) as percentage of the preoperative value following
6 and 24 weeks are shown in Fig. 5. A statistically signicant
strength reduction was identied in plantar exion (p = 0.01) of the
operated limb after 6 weeks in concentric (45%), eccentric (34%)
and isometric mode (34%). After 24 weeks a statistically signicant
strength impairment remained for plantar exion in concentric
(6%, p = 0.02), eccentric (12%, p = 0.03) and isometric mode (16%,
p = 0.01). The improvement of strength between 6 and 24 weeks
was statistically signicant (p = 0.01).
Fig. 5. The means for the intra-individual side-to-side differences in maximum
strength of the plantar exors (concentric, eccentric, isometric mode) as percent of
the non-operated limb following 6 and 24 weeks are shown. Asterisks indicates
statistically signicance (* = p < 0.05).
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4 H. Schmal et al. / Foot and Ankle Surgery xxx (2017) xxxxxx
4. Discussion
Contracture of the gastrocnemius muscle complex is consid-
ered to favor several forefoot and rear foot pathologies. Therefore,
the operative treatment of these includes gastrocnemius recession
(GR). Beside plantar fasciitis, non-insertional tendinopathy and
biomechanically induced ulcers, forefoot overload syndrome (FOS)
is treated with GR. However, it is unclear if this procedure reduces
the plantar pressure below the metatarsal heads and if it impairs
muscular strength of ankle plantarexion. In the present study a
cohort of 26 patients suffering from FOS were treated with GR and
clinical benet of this procedure was assessed. The impairment of
plantarexors and plantar peak pressure related to GR was
examined.
It was shown that GR improves the clinical outcome of patients
suffering from FOS. Maskill et al. assessed the pain level of 29
patients suffering from FOS who underwent GR. They improved in
visual analog scale from 8/10 to 2/10 indicating that GR resulted in
pain relief. According to this study we could detect an improve-
ment of the FFI pain scale after GR. Another study showed an
improved AOFAS score from 62.3 to 79.5 in patients with FOS and
other related pathologies suggesting that GR resulted in an
functional improvement [17]. In contrast, we could not show an
increased functional level following GR according to FFI assess-
ment. We believe that a distinct impairment of muscular strength
is subjectively perceived by the patients more than 6 months after
surgery, despite measurements of plantar exor peak torque
resulted in minimal reduction of 10% after GR.
Nawoczenski et al. observed that power and endurance sports
activities were difcult for the subgroup of patients following GR
resulting in a 21% reduced ankle plantar exion peak torque
compared to the healthy contralateral side [6]. Sammarco et al.
reported that peak torque in plantarexion following unilateral GR
improved from an average of 62.6% at 6 months to 82.2% after
18 months compared to the contralateral extremity [17]. These
results go along with the presented study, recognizing a residual
impairment between 6 and 12% on isometric, concentric or
eccentric mode. Thus, it should be considered that GR may be
suitable for normal active patients, but not for high demand
athletes.
GR does weaken plantar exor strength but leads to an
improved ankle dorsiexion. In the present study, dorsiexion
with extended knee improved by 14 and remained unchanged for
at least 24 weeks. Pinney et al. could assess an average increase of
ankle dorsiexion of 18 with knee straight and no change with
knee bent [18]. Similar results obtained Sammarco et al. who
calculated an increase of dorsiexion of 19 with extended knee
[17]. Therefore, we conclude that in gastrocnemius tightness GR is
a reliable method to improve ankle dorsiexion over a period of
more than six months.
GR is used to treat plantar ulcers of diabetic patients due to an
increased biomechanical stress related to neuropathy [1922].
Since plantar ulcers heal following GR it is suggested that GR
reduces plantar peak pressure below all metatarsal heads [22,23].
In the present study a signicant decrease of plantar peak pressure
became apparent below the fth metatarsal heads but not below
the rst ray: below the rst metatarsal head a signicant increase
compared to preoperative measurements was assessed. Since our
patients suffered from anterior metatarsalgia, physiologic propul-
sion over the metatarsal heads is avoided and the gait line is shifted
lateral. Compared to healthy subjects, plantar peak pressure is
reduced under rst ray and is transferred to lateral parts of the
forefoot. Gastrocnemius recession shifts the gait line medially, the
plantar peak pressure under the rst ray increases and below the
fth metatarsal head decreases.
Please cite this article in press as: H. Schmal, et al., Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength
and improved dorsal extension in forefoot overload syndrome, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.014
Gastrocnemius contracture leads to a decreased ankle dorsi-
exion while the knee is extended reducing the contact area and
time below the heel [2]. In the present study a signicant increase
of contact time under the heel was assessed after GR. This is
supported by an increased ankle dorsiexion following GR
compared to preoperative measurements. It is considered that
gastrocnemius contracture shifts weightbearing plantar pressure
from the hindfoot to the midfoot and forefoot; GR seems to undo
such pathologic conditions relocating the contact area back to the
heel.
The present study concludes that GR reduces pain sensation in
patients with FOS which is related to an increased ankle
dorsiexion, a medial shift of plantar peak pressure and an
increased contact time below the heel. Functional impairment is
perceived by the patients following GR which is represented by the
reduced plantar exor strength 24 weeks after GR. Therefore,
indications for GR should be matched to patients demands and
activities, but a long-term assessment of plantar exor strength is
needed for denitive statement.
Conict of interest
Hereby we exclude any nancial and personal relationships
with other people or organisations that could inappropriately
inuence (bias) our work.
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Please cite this article in press as: H. Schmal, et al., Gastrocnemius recession leads to medial shift of gait line, impairment of muscle strength
and improved dorsal extension in forefoot overload syndrome, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.014