Should You Get Gastrocnemius Recession?

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gastrocnemius recession

What is gastrocnemius recession? This surgery has become popular for quite a few things, including the treatment of a tight calf, Achilles pain, or plantar fasciitis. Let’s dig in.

gastrocnemius muscle

The Gastrocnemius Muscle

The gastrocnemius (aka gastroc or calf muscle) is at the back of the leg and connects the heel to the calf to the knee. Meaning, it’s a two-joint muscle that helps to flex the foot downward and extend the knee if the foot is fixed. Its nerve supply comes from the lower part of the low back (S1 and S2). These nerves tell the muscle what to do and how to contract.

Gastrocnemius Recession

Gastrocnemius recession (aka Strayer Procedure) is a surgery where the doctor cuts the gastroc tendon and lengthens the muscle and tendon (1). The procedure is usually performed to treat chronic tightness in the calf muscle. Since this muscle attaches to the Achilles tendon, chronic Achilles pain can also be treated this way. Finally, the Achilles tendon has fibers that also travel to the plantar fascia at the bottom of the foot. So the procedure has also been used to treat plantar fasciitis.

Open vs Endoscopic Surgery

Open surgery is when the doctor makes a traditional long incision and then cuts the tendon to lengthen it. Endoscopic surgery involves a smaller incision where a scope is inserted and the tendon is cut through that smaller portal. Both procedures seem to work about the same (5).

Gastrocnemius Recession Recovery

Expect the first few days to be painful and to require narcotic pain medications. You’ll be in a boot or similar for several months while the tendon heals properly. You can usually begin touch down weight bearing (touching your foot to the floor) about at 6-12 weeks. After gastrocnemius recession surgery, return to full activity takes on average about 7 months (2).

Does the Procedure Work?

Regrettably, we don’t have gold-standard randomized controlled trials comparing the procedure to a sham operation to show that gastrocnemius recession is effective (1). For use in Achilles tendon pain, lower-level evidence exists showing some efficacy. However, all of the research published supporting use in other problems is problematic.

Complications

In particular, about 9% of patients never return to their pre-surgery level of activity (2).  Complications happen in about 6% of patients who undergo the surgery and can include postoperative infection, non-healing wounds, nerve problems, decreased muscle strength, scar problems, or the inability to walk normally (3). Endoscopic surgery seems to be associated with fewer complications than open surgery in one study and about the same in another (4,5).

Is There a Better Way?

Cutting and then lengthening a tendon is a big surgery. Given that this procedure is increasingly performed to treat a tight calf muscle, Achilles tendinitis, or plantar fasciitis, it’s critical to understand why these problems happen and that there are non-surgical treatment alternatives for all of these issues:

  1. Tight calf-The S1 nerve in the low back tells the calf muscle how tight or loose it should be. When it’s irritated, the calf can become chronically tight. Hence, the first-line treatment for a tight calf is physical therapy and if that fails, a precise x-ray guided epidural injection around that irritated S1 nerve. In most patients, this takes the problem away. There can also be a disc bulge her pressing on the nerve or too much motion at the L5-S1 back level (degenerative or congenital spondylolisthesis) which can lead to the irritated nerve. Obviously the focus here is fixing the back which fixes the calf. This can usually be done non-surgically.
  2. Achilles Tendinitis-This is chronic degeneration of the tendon that attaches the calf muscle to the heel. Platelet-rich plasma injections performed using ultrasound guidance will usually get rid of this problem (6).
  3. Plantar Fasciitis-The plantar fascia is a tight band at the bottom of the foot that extends from the heel forward and supports the arch (7). This fascial band can also become degenerated and again, platelet-rich plasma injections can usually help this problem as well.

As you can see, there are multiple non-surgical ways to deal with the problems that often lead to gastrocnemius recession surgery. In my experience, when treating a tight calf, the Achilles or plantar fascia, oftentimes treating the low back S1 nerve is also required to make the problem resolve. Hence, a gastroc surgery should be your very last option after trying these much less invasive therapies.

The upshot? Gastrocnemius recession is a big surgery that usually doesn’t need to be done as these days there are much less invasive options. If you do need this surgery, make sure you understand the risks and benefits.

__________________________________________

References:

(1) Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, DiGiovanni CW. Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations. Foot Ankle Surg. 2015 Jun;21(2):77-85. doi: 10.1016/j.fas.2015.02.001.

(2)  Tang Qian Ying C, Lai Wei Hong S, Lee BH, Thevendran G. Return to physical activity after gastrocnemius recession. World J Orthop. 2016;7(11):746–751. Published 2016 Nov 18. doi: 10.5312/wjo.v7.i11.746

(3) Rush SM, Ford LA, Hamilton GA. Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases. J Foot Ankle Surg. 2006 May-Jun;45(3):156-60. https://www.ncbi.nlm.nih.gov/pubmed/16651194

(4) Harris RC, Strannigan KL, Piraino J. Comparison of the Complication Incidence in Open Versus Endoscopic Gastrocnemius Recession: A Retrospective Medical Record Review. J Foot Ankle Surg. 2018 Jul – Aug;57(4):747-752. doi: 10.1053/j.jfas.2018.01.009.

(5) Phisitkul, Phinit et al. Outcomes of Open and Endoscopic Gastrocnemius and Gastrosoleus Lengthening: A Comparative Study. Arthroscopy, Volume 31, Issue 6, e19

(6) Liu CJ, Yu KL, Bai JB, Tian DH, Liu GL. Platelet-rich plasma injection for the treatment of chronic Achilles tendinopathy: A meta-analysis. Medicine (Baltimore). 2019;98(16):e15278. doi: 10.1097/MD.0000000000015278

(7) Peerbooms JC, Lodder P, den Oudsten BL, Doorgeest K, Schuller HM, Gosens T. Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A Double-Blind Multicenter Randomized Controlled Trial. Am J Sports Med. 2019 Nov;47(13):3238-3246. doi: 10.1177/0363546519877181.

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5 thoughts on “Should You Get Gastrocnemius Recession?

  1. Steve

    I had this surgery and lost about 50% size and strength in my calf. Is there anyway to fix it?

    1. Regenexx Team

      Hi Steve,
      Unfortunately not if the loss of strength was due to the surgery.

  2. David Peterson

    Dr. Centeno, I appreciate your calling attention to some of the less supported and even questionable treatments in orthopedic medicine. I wish we had more of that in my field as a DC (Doctor of Chiropractic).

    To me, this is a scary surgery! I once had a 70% Achilles tendon tear and followed the orthopedist’s recommendation to wear a boot for 6 months. Even though I thought I was well versed in strains, I made some mistakes and learned some things while going through this process. After the initial stage of healing, I should have regularly performed light ROM exercises of the foot/ankle outside of the boot. My Achilles/calf healed with such a tight “sleeve” of adhesions over the entire area that I struggled for years getting back to normal activity.

    A surgery cutting through the tendon could certainly create a similar situation. Also, the article only mentioned a small percentage losing muscle strength. While my gross calf strength remained roughly the same, I believe I lost some explosiveness. I doubt the researchers measured explosive strength, something important to athletes.

    Several therapies helped my recovery. Periodic adjustments to the back and lower extremities assisted with normal movement. Various myofascial techniques like Hellerwork, SASTM (or you could substitute Graston), and later, Rapid Release Technology, all addressed my adhesions. Laser therapy was quite important, as were specific stretches and exercises.

    Dr. Centeno, you didn’t include chiropractic in your “first-line treatment for a tight calf”. A good DC can not only provide most of the therapies I just listed, but if the cause is neuromuscular (such as an irritated nerve in the back as you mentioned), that is where we shine. A significant percentage of our patients present with radicular symptoms including pain, numbness, tingling, or myospasm (one or more tight muscles where that nerve travels). Most get better. Sure, there can occasionally be lax ligaments allowing for too much motion, and those are likely the cases that don’t respond as well to our care. However, we think aberrant, restricted motion leading to nerve irritation is much more common, and that is what we address.
    Thank you again for the article.

    1. Regenexx Team

      Hi David,
      We refer patients to Chiropractic care regularly.

  3. Kurt Rasmussen

    Cured my own bilat plantar fasciitis by serious stretch of Gastrocnemius and Soleus plus sleeping with Strassbourg Socks, Incidentally the condition was proved to be caused by heavy dieting and too much biking.

Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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