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Gastrocnemius Recession or Tendo-Achilles Lengthening Acceptable for Adult Acquired Flatfoot Deformity Surgery

Key findings

  • Massachusetts General Hospital FARIL researchers conducted a best-evidence synthesis of 10 studies, evaluating the effects of including gastrocnemius recession or tendo-Achilles lengthening in the surgical treatment of adult acquired flatfoot deformity
  • There was evidence of improvement in ankle range of motion and plantar flexion power after gastrocnemius recession
  • Both gastrocnemius recession and tendo-Achilles lengthening were associated with improvement in radiographic outcomes after surgical correction of adult acquired flatfoot deformity
  • All studies were retrospective and judged as level IV evidence, but arguably gastrocnemius recession or tendo-Achilles lengthening should continue to play a role in the surgical treatment of adult acquired flatfoot deformity unless proven otherwise
  • Additional high-level prospective research is needed to better explore this issue

Prolonged contracture of the gastrocnemius–soleus complex can impact foot and ankle function and is believed to be capable of causing or exacerbating adult acquired flatfoot deformity (AAFD). It seems intuitively correct that incorporating gastrocnemius recession (GR) or tendo-Achilles lengthening (TAL) into AAFD correction surgery would be worthwhile.

Song Ho Chang, MD, PhD, a former research fellow at the Massachusetts General Hospital Foot & Ankle Research and Innovation Laboratory (FARIL), now at the University of Tokyo in Japan; Christopher W. DiGiovanni, MD, chief of the Foot and Ankle Center at Mass General; Daniel Guss, MD, MBA, orthopaedic foot and ankle surgeon; and colleagues recently conducted a systematic review of this question. In The Journal of Foot & Ankle Surgery, they report support for including GR or TAL in AAFD correction.

Review Methods and Studies

Two reviewers independently searched five electronic databases for peer-reviewed, English-language clinical studies evaluating the effects of GR or TAL for AAFD correction surgery on ankle range of motion, plantar flexion strength and radiographic outcomes.

They identified 10 studies that covered 79 GRs and 111 TALs in conjunction with multiple additional forms of AAFD correction. The weighted average patient follow-up was 18 months for GR and 27 months for TAL.

All studies included were retrospective and were judged level IV evidence. Because of the poor level of evidence and heterogeneity of outcomes, best evidence synthesis was performed instead of meta-analysis.

Ankle Range of Motion

Only one prospective study, including 18 patients, reported on the ankle range of motion. In this study, the ankle dorsiflexion with the knee extended improved, on average, from −9.3° to 3.7° one year after GR.

Plantar Flexion Power

Another prospective study evaluated 24 patients following GR and found no loss of plantar flexion power with the knee in flexion compared with the contralateral side one year after surgery.

Conversely, other retrospective case series showed:

  • About 10% reduction in triceps surae strength after distal GR and 25% loss of plantar flexion power after TAL
  • Decrease in plantar flexor power in 20% of patients after GR
  • Sensation of falling forward when descending stairs after TAL; this symptom persisted in 7% of patients an average of 6.6 years after surgery

In an additional study, GR was less likely than TAL to be linked to loss of plantar flexion.

Radiographic Outcomes

Three studies of GR and five studies of TAL assessed radiographic outcomes.

Two GR studies and one TAL study showed postoperative improvement of the anteroposterior talocalcaneal angle. The TAL study compared a TAL group with a non-TAL group and found improvement of the anteroposterior talocalcaneal angle with TAL (10.8° vs 5.8° respectively); this implies TAL may contribute to realigning the calcaneus to the medial column in AAFD surgery.

Three GR studies and four TAL studies reported improvement of the lateral tarsometatarsal angle. The mean improvement in postoperative lateral TMT angle was not significant between the comparative groups (13.7° vs. 12.8° among the TAL and non-TAL group, respectively); this implies that, at the very least, TAL does not hinder medial arch reconstruction after AAFD.


All studies reported complications. Those directly related to GR or TAL were:

  • GR—Seven patients (9%): neuritis of sural nerve (n=2); decrease in plantar flexory power (n=2); stiffness (n=3)
  • TAL—11 patients (10%): neuritis of sural nerve (n=9); Achilles tendon rupture (n=2)

Implications for Surgeons

Lacking data from high-level clinical studies, it is difficult to separate the impact of addressing a contracted gastrocnemius–soleus complex from the overall AAFD correction. Nevertheless, it can be argued from these findings that GR or TAL should continue to play a role in the surgical treatment of AAFD unless proven otherwise.

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