Gastrocnemius recession: calf-lengthening surgery for a tight calf

What is a tight calf (equinus)?

Equinus means that the ankle can’t bend upward (dorsiflex) as far as it should. The calf has two main muscles that join the Achilles tendon: the gastrocnemius, which crosses both the knee and the ankle, and the soleus, which crosses only the ankle. Tightness of the tendon or calf muscles can be present from birth or develop over time, for example after wearing high heels, after a period in a cast or on crutches, or with diabetes.^[1,2] When the ankle can’t bend, the body compensates by flattening the arch, lifting the heel early, walking on the toes, or bending the knee and hip differently, and this puts extra stress on the forefoot.^[1]

A tight calf is associated with plantar fasciitis, calf cramping, Achilles tendinitis, pain in the ball of the foot, flatfoot, midfoot arthritis, pressure sores, bunions, hammertoes, ankle pain and shin splints.^[1] See plantar fasciitis, plantar plate tears and adult-acquired flatfoot.

How a tight calf is evaluated

We measure how far the ankle bends with the knee bent and with the knee straight. If the ankle bends well with the knee bent but not with the knee straight, the gastrocnemius is the tight structure (the Silfverskiöld test); if both are limited, the soleus and Achilles tendon are also tight. This difference tells us which operation, if any, would help.^[1,2] X-rays may be taken, and a neurologic evaluation is sometimes advised if the cause is unclear.^[1] X-ray and ultrasound are available on site at our practice; see foot and ankle imaging.

Non-surgical care

Treatment starts with:

• calf-stretching exercises and physical therapy
• night splints
• heel lifts in your shoes
• custom orthotic devices^[1]

Read more about non-surgical care.

When surgery is considered

A gastrocnemius recession is considered when a tight gastrocnemius is contributing to a problem and non-surgical treatment hasn’t provided enough relief.^[1,3] It is used on its own, for example for stubborn heel pain or pain in the ball of the foot, and it is often added to other operations when a tight calf would otherwise strain the repair, as in flatfoot reconstruction.^[7,1]

How the operation works

In a gastrocnemius recession the surgeon releases the tendon of the gastrocnemius muscle where it joins the calf, so the muscle-tendon unit can lengthen while the soleus and the Achilles tendon stay in place. It can be done through a small incision (open) or with an endoscope. Lengthening the Achilles tendon itself is a different operation, used when both the gastrocnemius and the soleus are tight.^[6,3,2]

What do the results show?

• Ankle motion and function. A systematic review of 23 studies found improved ankle dorsiflexion, function scores and pain scores after gastrocnemius recession. Calf strength was measured in only a few studies and did not return to normal in any of them, and the average complication rate was 14%. Most of the studies were low-level, with follow-up of one to three years.^[4] The operation may change how the knee, ankle and subtalar joint work together during walking.^[4]
• Stubborn plantar fasciitis. A systematic review of seven studies found a consistent reduction in pain, about 76% at 12 months in the four studies that measured it, with no major complications, though the study designs were of low quality.^[3] A meta-analysis of five randomized trials (150 patients) found significant improvements in function, pain and ankle motion, and advantages over plantar fascia release for recovery.^[5]
• Endoscopic technique. In a review of 11 studies (697 feet), ankle motion improved from about −2° to 11°, plantarflexion weakness occurred in about 3.5%, sural nerve injury in about 3%, and wound complications in about 1%, with an overall complication rate of 7.5%.^[6]

Recovery

Recovery depends on the technique and on whether it was combined with another operation. Advocates describe a quicker recovery after gastrocnemius recession than after some other operations for heel pain,^[3] and physical therapy focuses on calf motion and strength. When it is done together with other procedures, the plan follows the larger operation. Your surgeon will give you a timetable. See recovery after foot and ankle surgery and preparing for foot and ankle surgery.

Risks

Risks include weakness of the calf, which may not fully return to normal; irritation or injury of the sural nerve, causing numbness or tingling on the outer foot; wound-healing problems; over-lengthening; scarring; recurrence of the tightness; and the general risks of surgery, including infection and blood clots.^[4,6,3] Counseling before surgery covers these risks.^[6]

Questions to ask before deciding

• Is my tightness in the gastrocnemius alone, or in the soleus and Achilles tendon too?
• Have I tried enough stretching, night splints and heel lifts?
• Will this be my only operation, or is it part of a larger plan?
• How will my calf strength be affected, and when can I walk, drive and return to sport?

When to seek care