- Mr. DS is a 51-year-old man who experiences plantar heel pain that worsens with prolonged standing and first thing in the morning. He has tried various non-operative treatments for 6 months with limited improvement. - Gastrocnemius contracture can be associated with plantar heel pain and is assessed using the Silfverskiöld test. Surgical lengthening of the gastrocnemius via the percutaneous medial gastrocnemius recession technique may help recalcitrant plantar fasciitis cases. - A prospective study found that 88% of patients reported significant or full improvement after gastrocnemius lengthening surgery for recalcitrant plantar fasciitis, with no

1. Heel pain
Mr Derek Park
Consultant Orthopaedic Surgeon (Foot & Ankle)
NHS: Barnet & Chase Farm Hospital (Royal Free
London NHS Foundation Trust)

2. Plantar heel pain
• Background
• Illustrative case
• Differential diagnosis
• Treatment options
• Evidence
• Current management
concepts

3. Mr DS
• 51 yr old, commercial
manager, triathlon enthusiast
• 6m Hx plantar heel pain
• worse 1st thing in the
morning, prolonged standing
• no radiculopathy, no
neuropathy (DM/Alcohol)
• tried: insoles, night splints,
calf stretches 3 months

4. Plantar heel pain
• Common condition
• Affects 1:10 adults
• Often self-limiting
• Recalcitrant cases can
be challenging

5. Anatomy
PF is closely connected to the paratenon of
Achilles tendon, through the periosteum of the
heel. Hence it is functionally & structurally
continuous with TA

6. Anatomy
• Type I collagen
• Supports medial longitudinal
arch & aids propulsion,
dissipates forces + stresses
during gait and loading
• Visco-elastic property
• Ruffini & Pacinian corpuscles
= mechanoreceptors
• Hyaluronan (HA) = proximally

7. Anatomy

8. Biomechanics

9. Biomechanics

10. Where is the pain

11. Differential diagnosis
• Nerve
• sciatica; tarsal tunnel syndrome, FBLPN (N to ADQ)
• Soft tissue
• fibromatosis, bursitis, bruise, fat-pad atrophy
• Bone
• stress fracture, infection, tumour, Paget’s

12. History
• Plantar heel pain
• No trauma
• Pain on 1st steps
• Warms up
• Returns with prolonged
WB

13. Examination
heel compression for stress fx Tinel’s test for tarsal tunnel or ADQ

14. Enthesopathy
• Associated with inflammatory
arthropathy
• Heel spurs often found
• Medical management of
inflammation

15. Mr DS
• 51 yr old, commercial
manager, triathlon enthusiast
• 6m Hx plantar heel pain
• worse 1st thing in the
morning, prolonged standing
• no radiculopathy, no
neuropathy (DM/Alcohol)
• tried: insoles, night splints,
calf stretches 3 months

16. Investigation

17. Night splint

18. Medial arch foot orthoses
1. Martin et al J Orthop Sports Phys Ther. 2014
2. Crawford & Thomson Cochrane review 2000, 2003

19. Treatment
• Steroid injection
• risk fat atrophy
• risk of rupture
• Ultrasound guided
• Judicious use
• ESWT

20. Treatment
• AOFAS position statement:
• Don’t perform surgery for PF
before trying 6 months of
nonoperative Rx (97% will
resolve with 6 months of
consistent, nonoperative Rx)
• Surgery is reserved as a last
resort:
• Open or endoscopic plantar
fascia release + release
FBLPN +/- tarsal tunnel
release

21. Mr DS

22. Evidence
• Marginal gains only
• steroid injection - short term & small degree
• orthoses - prolonged standing
• limited evidence that stretching & heel pads are
better than custom-made orthoses
• ESWT +ve but small effect
1. Crawford & Thomson Cochrane 2000, 2003
2. Thomson & Crawford BMC 2005

23. Treatment
• GP - Physio - stretches - US - insoles - NSAIDS -
taping - GP - MSK Triage - Acupuncture -
Orthopaedic F&A surgeon
• Ortho F&A clinic - more physio - gastroc/PF
stretches - imaging - review - desperate measures
- pain clinic - CBT ….

24. Mr DS

25. Assessment
• Ideal one-stop service: diagnosis, imaging,
treatment
• Determine gastrocnemius tightness: Silfverskiöld
test

26. Gastrocnemius contracture
• Restricted ankle dorsiflexion associated with
• chronic TA tendinopathy
• plantar heel pain
• acquired flat foot deformity
• midfoot OA
• metatarsalgia 1. Digiovanni et al 2002 JBJSAm

27. Treatment
TA stretching, technique important

28. Gastroc lengthening

29. Gastroc lengthening
Classic Strayer lengthening

30. PMGR
International meeting of the French Foot societies, Toulouse 2006

31. The role of gastrocnemius
contracture
• Association between
isolated gastrocnemius
contracture and
forefoot/hindfoot problems -
DiGiovanni JBJS 2002, Patel &
DiGiovanni FAI 2011
• Spectrum midfoot/arch
collapse - J Anderson, D Bohay
et al

32. Tibial nerve
Semimembranosus
Short saphenous vein
Midline
Medial Sural Cutaneous nerve
Common
Peroneal
nerve
Lateral Sural
Cutaneous
nerve
Anatomy
Hamilton et al. FAI 2009
Medial approach is free from nervous structures

33. Anatomy
Hamilton et al. FAI 2009
Medial head x-sectional area 2.4x Lateral

34. Technique

35. Technique
Fossa is medial
2.5 cm incision
Prone
Left Leg

36. Technique
Surgeon’s view
Prone
Right Leg

37. Technique
Surgeon’s view

38. Technique
Surgeon’s view

39. Technique

40. Calf Lengthening
PMGR
Level 4.5

41. PMGR
• Heel pain clinic
• Gastrocnemius contracture and its role in
plantar fasciitis and Achilles tendinopathy
• Specific indications
• Stress ongoing management with eccentric
stretching +/- ESWT

42. • Prospective consecutive series of 21 heels (17
patients) with recalcitrant plantar fasciitis
• Symptom duration 12 months to 6 years
• Positive Silfverskiöld’s test
• Confirmed with imaging (MRI, USS or bone scan)
• Average 24 months follow up (8-36 months)
• Outcome measure: 5 pt Likert scale, calf weakness,
satisfaction
Results - PMGR in
recalcitrant plantar
fasciitis
Abbassian et al. FAI Jan 2012

43. 0
2
5
7
9
11
Worse No change Some improvement Significant
improvement
Pain Free
5 point Likert scale
88% recommend surgery
No weakness
1 minor wound complication
Abbassian et al. FAI Jan
2012

44. Mr DS
• Steroid injection
• ESWT
• Moderate improvement
30-40%
• Next steps…

45. Personal approach
• Clinical assessment - include XRs,
USS to define pathology and PF
thickness, r/o other pathology
• 6 months physio (lower limb team)
• If gastroc tight - stretch - PMGR
• If not - ESWT
• Consider steroid, PRP, ABT, HA,
dry needling, acupuncture, topaz
• Defer surgery

46. Summary
• Aim for logical approach,
step-wise management,
and one-stop model
• Think of tight calves
• Consider non-operative
measures always
• Evidence

47. References
1. Hicks JH. The mechanics of the foot. II. The plantar aponeurosis and the arch. J Anat. 1954
Jan;88(1):25-30
2. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to
clinical practiceJ Athl Train. 2004 Jan;39(1):77-82
3. Shaw HM, Vázquez OT, McGonagle D, Bydder G, Santer RM, Benjamin M. Development of
the human Achilles tendon enthesis organ. J Anat. 2008 Dec;213(6):718-24
4. Pavan PG, Stecco C, Darwish S, Natali AN, De Caro R. Investigation of the mechanical
properties of the plantar aponeurosis. Surg Radiol Anat. 2011 Dec;33(10):905-11
5. Stecco C, Corradin M, Macchi V, Morra A, Porzionato A, Biz C, De Caro R. Plantar fascia
anatomy and its relationship with Achilles tendon and paratenon. J Anat. 2013 Dec;223(6):665-
76
6. Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, McDonough CM.
Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014 Nov;44(11):A1-33