The Use of Ultrasound toIsolate the Gastrocnemius-

Soleus Junction Prior toGastrocnemius Recession

Eugene P. Toomey, MD*, Nicholas R. Seibert, MD

KEYWORDS

� Gastrocnemius recession � Strayer � Ultrasound � Achilles tendon

KEY POINTS

� Gastrocnemius recession has become a popular procedure to release isolated gastrocne-mius tightness.

� Using visual anatomic landmarks alone to plan the incision can be deceiving.

� The use of ultrasound preoperatively has been highly reproducible in isolating thegastrocnemius-soleus junction in the authors’ practice. This provides confidence for inci-sion placement, a smaller incision, and isolated release of the gastrocnemius fascia whileleaving the underlying soleus undisturbed.

INTRODUCTION

Release of the gastrocnemius aponeurosis has become a popular procedure to treatmany common pathologies of the foot. Investigators have advocated the procedurefor forefoot overload, plantar fasciitis, flatfoot reconstruction, and foot pain relatedto, or in conjunction with, a tight gastrocnemius.1–4 A tight gastrocnemius is bestdefined as an ankle achieving less than 0� of dorsiflexion with a Silverskiold testwhen the knee is straight.5

Gastrocnemius recession is a much more popular procedure than either open orpercutaneous release of the Achilles tendon, because it is unlikely to lead to over-lengthening of the Achilles or a calcaneal gait.6

The most common way of performing a gastrocnemius recession is through amedial approach to the gastrocnemius fascia just before it becomes confluent withthe underlying soleus fascia. The sural nerve and lesser saphenous vein are protected

Disclosures: None.Orthopedic Physician Associates, Swedish Orthopedic Institute, 601 Broadway, Seattle, WA98122, USA* Corresponding author.E-mail address: e.toomey@proliancesurgeons.com

Foot Ankle Clin N Am 19 (2014) 739–743http://dx.doi.org/10.1016/j.fcl.2014.08.008 foot.theclinics.com1083-7515/14/$ – see front matter � 2014 Elsevier Inc. All rights reserved.

Toomey & Seibert740

and the interval between the gastrocnemius fascia and soleus fascia is identified. Thegastrocnemius fascia is then cut and the underlying soleus fascia is left undisturbed.The gastrocnemius is then allowed to retract and is either sutured to the underlyingsoleus muscle or simply left in the lengthened position.1,4,7

To achieve a good outcome without weakness or overlengthening, the literature isreasonably clear that only the gastrocnemius fascia should be lengthened and the so-leus left alone. If the Silverskiold test demonstrates contracture of the gastrocnemiusand soleus, then it is appropriate to do a lengthening of both muscles with either a Vul-pius procedure or Achilles tendon lengthening.Unfortunately, few calf muscles are the same, and because of these anatomic or

cosmetic differences, the incision may be off by several centimeters (Fig. 1). Aneven bigger problem is dividing the fascia and finding underlying soleus muscle ratherthan fascia and essentially doing a form of Achilles lengthening.8

The authors have concluded that some method of predicting the exact location ofthe gastrocnemius junction is desirable.

PROCEDURE

The authors have begun localizing the junction of the gastrocnemius and soleus with aportable ultrasound machine (SonoSite, Bothell, Washington) and have found that thisis a very reproducible method for localizing the gastrocnemius-soleus junction, allow-ing for accurate incision placement.The ultrasound evaluation is done with the patient supine and the leg externally

rotated. This is done this in a preoperative holding area with the machine used forpopliteal nerve blocks.Conductive gel is placed over the site and the flat wand of the SonoSite machine is

placed over the medial head of the gastrocnemius (Fig. 2). The wand is then moveddistally, until the junction is identified and centered on the screen (Fig. 3). The centerscreen position corresponds to the line on the wand and the skin is then marked forincision placement (Fig. 4).

DISCUSSION

Isolated gastrocnemius contracture has been demonstrated to be a component ofmultiple foot pathologies. It is readily defined by the Silverskiold test. Many

Fig. 1. The gastrocnemius-soleus complex comes in many shapes and sizes. Some junctionsare easy to identify and others are not.

Fig. 2. Ultrasound image demonstrating gastrocnemius muscle belly (white arrow) andgastrocnemius-soleus junction (black arrow).

Fig. 3. The wand is moved distally to center the junction (black arrow) on the screen. Thewhite arrow indicates the confluence of the 2 muscles and the beginning of the Achillestendon.

Fig. 4. The centering line on the screen (lower) corresponds to the arrow on the wand (up-per). The site is marked with indelible marker for later incision placement.

Isolating the Gastrocnemius-Soleus Junction 741

Toomey & Seibert742

investigators have advocated the Strayer procedure, which divides the gastrocnemiusfascia from the underlying soleus fascia.9

Maskill and colleagues1 showed an improvement in visual analog scale pain scorefrom 8/10 preoperatively to 2/10 postoperatively; 93% of patients were satisfied withthe results. Strength was not measured.Sammarco and colleagues10 approached the tendon with a central incision and per-

formed a Vulpius procedure (gastrocnemius-soleus lengthening). Strength was testedwith stair climbing in 40 patients; 9 patients had noticeable weakness, and 1 had mod-erate weakness. Peak torque tested at 6 months was 62.6% of the opposite limb andreached an average of 74% of the opposite limb by 18 months.11–25

Rush and colleagues7 performed a retrospective review of 126 cases of isolatedgastrocnemius recession. Total complication rate was 6%. They found all patientscould do a single limb heal rise on the operative side at 6 months.

SUMMARY

Gastrocnemius recession is successful at alleviating pain, has lowmorbidity, and doesnot lead to overlengthening or significant weakness of the gastrocnemius-soleus com-plex. The authors have found that the use of ultrasound to isolate the junction of these2 tendons preoperatively has been useful to do a minimally invasive, true Strayerlengthening.

REFERENCES

1. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolatedfoot pain. Foot Ankle Int 2010;31(1):19–23.

2. Pinney SJ, Hanseon ST, Sangeorzan BJ. The effect on ankle dorsiflexion of thegastrocnemius recession. Foot Ankle Int 2002;23(1):26–9.

3. Digiovanni CW, Kuo R, Tejwani N, et al. Isolated gastrocnemius tightness. J BoneJoint Surg Am 2002;84(6):962–70.

4. Abdulmassih S, Phisitkul P, Femino J, et al. Triceps surae contracture: impli-cations for foot and ankle surgery. J Am Acad Orthop Surg 2013;21(7):398–407.

5. Silverskiold N. Reduction of the uncrossed two-joint muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand 1924;56:149–59.

6. Chilvers M, Malicky ES, Anderson JG, et al. Heel overload associated with hellcord insufficiency. Foot Ankle Int 2007;28(6):687–9.

7. Rush SM, Ford LA, Hamilton GA. Morbidity associated with high gastrocnemiusrecession: retrospective review of 126 cases. J Foot Ankle Surg 2006;45(3):156–60.

8. Vulpius OS, Stoffel A. Tenotomie der end schen der mm:Gastrocnemisu et soleusmittels rutschenlassens nach vulpius. In: Orthopadische operationslehre. Stutt-gart (Germany): Ferdinand Enke; 1913. p. 29–31.

9. Strayer LM Jr. Recession of the gastrocnemius: an operation to relieve spasticcontracture of the calf muscles. J Bone Joint Surg Am 1950;32(3):671–6.

10. Sammarco GJ, Bagwe MR, Sammarco VJ, et al. The effects of unilateral gastro-csoleus recession. Foot Ankle Int 2006;27(7):508–11.

11. Digiovanni CW, Langer P. The role of isolated gastrocnemius and combinedAchilles contractures in the hindfoot. Foot Ankle Clin 2007;12(2):363–79.

12. Orendorf MS, Rohr ES, Sangeorzan BJ, et al. An equinus deformity of the ankleaccounts for only a small amount of the increased forefoot plantar pressure in pa-tients with diabetes. J Bone Joint Surg Br 2006;88(1):65–8.

Isolating the Gastrocnemius-Soleus Junction 743

13. Cummins EJ, Anson BJ. The structure of the calcaneal tendon ( of Achilles) inrelation to orthopedic surgery, with additional observations on the plantarismuscle. Surg Gynecol Obstet 1946;83:107–16.

14. O’Brien M. The anatomy of the Achilles tendon. Foot Ankle Clin 2005;10(2):225–38.

15. Hennessy MS, Molly AP, Sturdee SW. Noninsertional Achilles tendinopathy. FootAnkle Clin 2007;12(4):617–41.

16. Aronow MS, Diaz-Doran V, Sullivan RJ, et al. The effect of the triceps suraecontracture force on plantar foot pressure distribution. Foot Ankle Int 2006;27(1):43–52.

17. Cheung JT, Zhang M, An KN. Effect of Achilles Tendon loading on plantar fasciatendion in the standing foot. Clin Biomech (Bristol, Avon) 2006;21(2):194–203.

18. Thordarson DB, Schmotzer H, Chon J, et al. Dynamic support of the human lon-gitudinal arch: a biomechanical evaluation. Clin Orthop Relat Res 1995;316:165–72.

19. Arangio G, Rogman A, Reed JF III. Hindfoot alignment valgus moment arm in-creases in adult flatfoot with Achilles tendon contracture. Foot Ankle Int 2009;30(11):1078–82.

20. Downey MS, Banks AS. Gastrocnemius recession in the treatment of nonspasticankle equinus: a retrospective study. J Am Podiatr Med Assoc 1989;79(4):159–74.

21. Radford JA, Burns J, Buchbinder R, et al. Does stretching increase ankle dorsi-flexion range of motion? A systematic review. Br J Sports Med 2006;40(10):870–5.

22. Aronow MS. Triceps Surae contractures associated with posterior tibial tendondysfunction. Tech Orthop 2000;15(3):164–73.

23. Saxena A, Gollwitzer H, Widtfeldt A, et al. Endoscopic gastrocnemius recessionas therapy for gastrocnemius equinus. Z Orthop Unfall 2007;145(4):499–504 [inGerman].

24. Chimera NJ, Castro M, Manal K. Function and strength following gastrocnemiusrecession for isolated gastrocnemius contracture. Foot Ankle Int 2010;31(5):377–84.

25. Lamm B, Paley D, Herzenberg J. Gastrocnemisu soleus recession, a simplermore limited approach. J Am Podiatr Med Assoc 2005;95(1):18–25.