Gastrocnemius Recession Review: Should You Get This Invasive Surgery?
POSTED ON 1/23/2018 IN Foot and Ankle BY Christopher Centeno
I have a list of surgeries that I classify as something like "They did what to you?" One of those is called gastrocnemius recession, a procedure that is increasingly being used to treat heel pain. Recently, a podiatrist read one of my other posts on the procedure and wrote in the comments that he disagreed. Hence, I thought it was time to delve deeper into the procedure and discuss some of his and my concerns.
What Is Gastrocnemius Recession?
Your gastrocnemius is the calf muscle that attaches your knee joint to your ankle. The muscle can get tight for all sorts of reasons, and this tension can lead to pain in the heel. This can happen either at the back of the heel where the Achilles tendon attaches to the heel bone (calcaneus) or where the heel bone meets the ground (plantar fascia). Some surgeons believe that if physical therapy or a steroid injection doesn't take care of this pain, then you need a gastrocnemius recession surgery to lengthen the calf muscle and take the pressure off of this area. I've blogged before on more of the details of the gastrocnemius recession procedure. My analysis back then was that this procedure was some seriously invasive overkill. Why? Treating plantar fasciitis or Achilles tendon heel pain is very easy with orthobiologics. Generally, both of these problems respond well to platelet rich plasma (PRP). This is a procedure where the physician's office takes blood and concentrates the platelets and then reinjects these into the area using precise ultrasound guidance. While I've never had a patient who had these problems and who failed to respond to PRP, what does the research say?
PRP Research on Achilles Tendinopathy
The Achilles tendon attaches the calf to the heel bone, so extra pulling and a tight calf can lead to the tendon getting beat up, a condition known as tendinopathy. A 2014 research study by Filardo showed nice results from injecting PRP, and the follow-up on these patients was up to four years. A larger study in 2015 by Geulfi also reported excellent results with only a PRP injection and without any surgery. There's also another similar 2012 study. A 2010 study which tried to compare PRP injections with saline didn't show a difference, but the study used a very weak PRP preparation. Contrast that to a more recent 2015 study where objective changes in tendon strength were observed via biopsies after PRP injections into Achilles' versus control tendons.
PRP Injection for Heel Pain Due to Plantar Fasciitis
How does a PRP injection (instead of invasive surgery) do with heel pain due to plantar fasciitis? This condition is caused when the tough fascia at the bottom of the foot becomes overloaded and painful at the heel. Pretty well. A 2014 study compared a PRP shot to a steroid injection and found that PRP was better at treating plantar fasciitis. Multiple case series have also been published showing that this procedure is effective, like this one in 2015 and this one in 2014. Finally, a different study in 2014 showed that both dextrose prolotherapy and PRP were effective.
So Where Are We at This Point?
The research showing that PRP can successfully treat heel pain without an invasive surgery is pretty robust at this point. So now let's take a look at the comment the podiatrist posted about my blog criticizing the gastrocnemius recession procedure: "As chairman of the education and scientific affairs committee for the largest academic of foot and ankle surgeons in the world, the American College of Foot and Ankle Surgeons, I encourage everyone to research both approaches to management of common problems ie achilles tendonopathy and plantar fasciosis. I advocate for evidence based approaches on behalf of all patients. In the course of my career, I have had the opportunity to treat over 75 thousand patients, thousands of them have been affected by plantar heel pain and various tendon issues. I personally perform regenerative techniques in addition to be uniquely qualified as an orthopaedic fellowship trained podiatric foot and ankle surgeon. Do your research. When structural problems and structural alignment issues exist, a shot of growth factors will not fix that aspect of the issue. It's like putting a new tire on a car without doing an alignment, it will likely break down again. I have trained with the world's leading experts in orthopaedic foot and ankle surgery in Europe and the USA through three fellowships and can tell you that surgery is strongly supported by the evidence including gastroc recession for plantar fasciitis. I advocate you do your own research before embarking on this procedure. With that said, there are no bridges burned by trying a regenerative technique, but keep in mind, the description of these surgeries as being dangerous etc should be carefully scrutinized. I have lectured worldwide on these topics at orthopedic meetings. These techniques are used by tens of thousands of surgeons internationally for a reason. Read the literature on both approaches and decide what works for you personally. Michael Dujela, DPM" So let's take the comment apart to see what the issues raised are regarding gastrocnemius recession. The crux is that Dr. Dujela believes that the research that supports this invasive procedure is dramatically better than the research that would support an injection-based approach, like PRP, and the latter couldn't really work because it doesn't change the structure. Going backward first, we do know based on the Achilles tendon research above that a PRP injection does improve the tendon structure without surgery. So that's one for PRP. Now to Dr. Dujela's point that the research base for gastrocnemius recession is vast and well situated. Is that true? Not really.
The Research Base on Gastrocnemius Recession to Treat Heel Pain Is Not Fantastic
As of today, there are only nine published studies listed in the US Library of Medicine on gastrocnemius recession to treat plantar fasciitis. If we dig into these studies, we see that they aren't any better and in many ways are far worse than the research published on PRP to treat heel pain. In fact, most only have a three-month follow-up after the procedure, which isn't enough to tell what happened to these patients. In particular, there are no randomized controlled trials or studies where biopsies were performed or even studies comparing the surgery to any other treatment, like PRP. Hence, while Dr. Dujela professes to be about evidence-based medicine (EBM), he doesn't have much evidence for his medicine. The upshot? I've seen countless surgeons profess to be ardent supporters of EBM, despite the fact that their own surgeries have no high-level evidence that they're effective, and many times there's research showing that they don't work. In the case of gastrocnemius recession to treat heel pain, surgeons aren't performing these procedures because there's a stellar evidence base showing the procedure works compared to proper conservative therapy like PRP or large randomized controlled trials—I suspect they're getting done because insurance companies are still paying for these invasive surgeries. We can only hope that changes!
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