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Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study
Journal Pre-proof Patient Reported Outcomes and Ankle Plantarflexor Muscle Performance Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Case-Control Study Frank E. DiLiberto, Deborah A. Nawoczenski, Josh Tome, Benedict F. DiGiovanni
PII:
S1268-7731(19)30172-9
DOI:
https://doi.org/10.1016/j.fas.2019.10.001
Reference:
FAS 1373
To appear in:
Foot and Ankle Surgery
Received Date:
20 May 2019
Revised Date:
4 July 2019
Accepted Date:
5 October 2019
Please cite this article as: DiLiberto FE, Nawoczenski DA, Tome J, DiGiovanni BF, Patient Reported Outcomes and Ankle Plantarflexor Muscle Performance Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Case-Control Study, Foot and Ankle Surgery (2019), doi: https://doi.org/10.1016/j.fas.2019.10.001
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
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Title: Patient Reported Outcomes and Ankle Plantarflexor Muscle Performance Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Case-Control Study
Authors Frank E. DiLiberto, PT, PhD.a Deborah A. Nawoczenski, PT, PhD.b Josh Tome, MS.c Benedict F. DiGiovanni MD.d a
School of Nursing, University of Rochester. 255 Crittenden Blvd, Rochester, NY 14642, USA. Adjunct Professor, Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester. 601 Elmwood Avenue, Rochester, NY 14642. USA. Email: [email protected] c Research Biomechanist, School of Health Science and Human Performance, Movement Analysis Laboratory, Ithaca College. 953 Danby Road, Ithaca, NY 14850, USA. Email: [email protected] d Professor, Department of Orthopaedics; Director of Sub-Internship and Medical Student Education; Director of Musculoskeletal Curriculum, University of Rochester School of Medicine and Medical Center. 601 Elmwood Avenue, Rochester, NY 14642. USA. Email: [email protected]
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Corresponding Author (Permanent Address) Frank E. DiLiberto, PT, PhD. Assistant Professor, Department of Physical Therapy, College of Health Professions, Rosalind Franklin University of Medicine & Science. 3333 Green Bay Road, North Chicago, IL 60064. Email: [email protected]
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Highlights
Prospective data on gastrocnemius recession for Achilles tendinopathy are limited
Improved patient reported outcomes were sustained through two year follow up
Ankle power during walking was preserved postoperatively
Ankle power during stair ascent and work during heel rise declined postoperatively
Findings can inform patient selection, expected outcomes, and rehabilitation
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Abstract
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Background: Prospective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance. Methods: Patients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n=8) and a healthy control group (n=8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected. Results:
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Improvements in pain and self-reported function were observed (six months and two years).
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Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment
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(p ≤ .02). Conclusions: Study findings regarding long-term improvements in patient pain, self-
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reported function and sport participation, and early preservation of ankle function during
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walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.
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Keywords: Achilles tendinopathy; Gastrocnemius recession; Biomechanics; Ankle power
1. Introduction
Approximately six percent of patients who seek orthopaedic care are diagnosed with Achilles tendinopathy (AT) [1]. The cumulative effect of tendon micro trauma from repetitive
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overloading results in patient pain and decreased function [2-6]. The association between recalcitrant AT and an isolated gastrocnemius contracture suggests that chronicity is propagated by the gastrocnemius muscle as opposed to the entire posterior compartment [7, 8]. For this reason, the application of a gastrocnemius recession has emerged as a treatment option for patients with recalcitrant AT.
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Prospective studies regarding gastrocnemius recession for patients with AT are limited. Enthusiasm for this procedure has been driven by promising findings of primarily retrospective and / or uncontrolled investigations. While different surgical approaches and evaluation instruments were utilized, studies have demonstrated improved pain, ankle dorsiflexion, and patient reported function following gastrocnemius recession for recalcitrant AT [9-12]. More recent retrospective studies further substantiate these benefits [13-16]. In comparison to alternate
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operative approaches for chronic AT, the combination of positive outcomes, low complication
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rates, and a relatively short recovery time provide support for the use of gastrocnemius recession. However, prospective, controlled studies are lacking, and it is unclear if the initial benefits are
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maintained.
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Despite patient reported improvements following gastrocnemius recession, additional study findings suggest patients may have reduced muscle function following treatment. In a
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retrospective study, patients with recalcitrant AT 18 months following gastrocnemius recession reported difficulty with higher level activities (i.e. running, jumping) and had lower ankle
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plantarflexion power and endurance in comparison to healthy controls [17]. However, theoretically, the torque producing capability of the plantarflexors is preserved following gastrocnemius recession [18]. Without prospective data, it is unclear if the reported postoperative deficits in ankle muscle performance stemmed from chronic AT, the gastrocnemius recession
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procedure and postoperative care, or some combination. The majority of evidence to substantiate the application of gastrocnemius recession is
retrospective in nature and lacking comparative normative data. A biomechanically rigorous prospective study, which also includes validated patient reported outcomes, would aid in determining if patient and muscle function is reduced, preserved, or improved following
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treatment. A study to this effect would be expected to improve patient selection, inform rehabilitation paradigms, and better allow clinicians to communicate anticipated outcomes. Therefore, the purpose of this prospective case-control study was to evaluate changes in plantarflexor muscle function and patient reported outcomes in people before and after gastrocnemius recession for recalcitrant AT, and in comparison to a healthy matched control group. We hypothesized that 1) patients would report improved pain and function six months
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following gastrocnemius recession, 2) patients would demonstrate ankle muscle performance
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similar to preoperative values but lower than control values at six months following
gastrocnemius recession, and 3) that improvements in pain and function would be maintained or
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improved at two-year follow-up.
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2. Material and methods
This was a prospective case-control study of patients with recalcitrant AT (n=8) and a
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healthy control group (n=8). Sample size was determined from an a priori power analysis of the minimal clinically important difference (8% change) and expected variability in Foot and Ankle
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Ability Measure Activity of Daily Living (FAAM ADL) scores in people following gastrocnemius recession for AT (paired t-test: d = 1, α = 0.05, 1- β = 0.8; required per group n = 7) [17, 19]. Patients with unilateral recalcitrant AT who were candidates for an isolated gastrocnemius recession were recruited on a rolling basis from the Foot and Ankle Division of
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the Department of Orthopaedics at (blinded for review). The healthy matched control group was recruited from the local community. Study procedures were approved by (blinded for review) and all participants provided written informed consent. Data were collected at (blinded for review). AT group participant inclusion criteria were as follows: 1) greater than 18 years old, 2)
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clinical diagnosis of unilateral insertional or noninsertional AT, 3) unresponsive to at least six months of nonoperative care, 4) isolated gastrocnemius contracture (positive Silfverskiold test), [20] and 5) deemed appropriate for an isolated gastrocnemius recession by the orthopaedic surgeon. Control participants were matched (age, gender, body mass index) to the AT group and were required to be without current foot / ankle pain or surgical history (Table 1). All
disease to the leg (i.e. neurologic injury, stroke, Diabetes Mellitus).
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2.1 Operative and postoperative procedures
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participants were excluded if they had prior Achilles or plantar fascia surgery or other surgery or
AT group participants received an isolated gastrocnemius recession (Strayer procedure)
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[7, 21, 22] from a fellowship trained foot and ankle orthopaedic surgeon. Briefly, following a
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posterior medial approach, the gastrocnemius fascia was sectioned at the musculotendinous junction without disruption to the soleus. The gastrocnemius tendon and muscle were allowed to
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retract before the tendon was sutured to the underlying soleus fascia. AT group participants were followed in the orthopaedic clinic. Following one week of
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limited weight bearing wearing a short leg plaster splint, patients were weightbearing as tolerated in a high walking boot and began range of motion and calf stretching exercises for the next two weeks. The walking boot was discontinued after 3 weeks. Patients then began a home strengthening program (i.e. elastic resistance exercises, heel rises) and low impact activities (i.e.
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walking). Activity restriction was lifted at week eight. Formal physical therapy, once per week, was utilized during the following four weeks for patient-specific functional and strength training. Return to full activity was expected by 8 to 12 weeks. 2.2 Patient reported outcomes
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The visual analog scale (10 cm line) was used to record patient worst pain level [23]. The validated FAAM ADL and Sport subscales were used to record patient perceived function [19]. FAAM items are scored on a 0-4 scale and an overall percent score is generated for each subscale where higher scores correspond to higher levels of function. If a participant selects ‘non applicable’ to more than one item, an overall self-rating of ADL or Sport performance is an alternative metric to examine [19]. These outcomes were recorded preoperatively, and at six
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months and two years postoperatively. At two years postoperatively, patients were asked to
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complete a satisfaction questionnaire. 2.3 Instrumented procedures and outcomes
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An electromagnetic tacking system (Flock of Bird MiniBird hardware; Ascension
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Technology Corporation, Burlington, VT; 100 Hz) and force plate (4060-NC; Bertec Corporation, Columbus, OH; 1000 Hz) were used to record foot and ankle kinematics and
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kinetics [24]. MotionMonitor™ software (Innovative Sport Training, Chicago, IL) was used to synchronize these data. We have previously detailed our validated modeling approach
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(references blinded for review). Briefly, sensors were affixed to the skin overlying the first metatarsal, calcaneus, and tibia of each subject. Subject-specific models were developed through digitization procedures. Segment to segment displacements were calculated using an Euler rotation sequence of Z, X’, Y’’ [25]. Data from a standing subtalar neutral position were used as
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a zero reference point for segmental rotations [26]. AT group data were collected preoperatively and six months postoperatively. Control
group data were collected once. Five activities were performed during each instrumented data collection session: 1) seated active ankle sagittal plane range of motion with the knee in full extension, 2) walking, 3) ascending a standard step (17 cm), 4) ascending a high step (34 cm),
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and 5) repeated single limb heel rise. The six-month follow-up time point was selected to evaluate the immediate effect of the gastrocnemius recession and postoperative rehabilitation. Within and between subject comparisons of ankle power during walking and stair ascent were made possible via specific procedures. Since ankle power changes with gait speed [27], self-selected walking speeds (range: 0.76 - 1.11 m/s2) were maintained consistent at +/- 5% across all activities and across time points. Control group walking speeds were matched to AT
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group speeds. The distance from the center of the force plate to the step was normalized to 75%
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of leg length for each stair ascent task [25]. Data were normalized across stance phase (0-100%) [25]. Ankle plantarflexion power was calculated as the product of the ankle moment and
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calcaneus to tibia angular velocity (τω). Peak power, normalized to mass, and averaged across 3
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trials for each subject during each task, was the primary outcome measure. Participants performed repeated single limb heel raises to complete the heel raise work
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test. The activity concluded when the participant was unable to continue due to fatigue. Plantarflexor muscle endurance (total work) was calculated as the sum of work across all
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completed heel raises as F(t)Δd(t) where ‘F’ is the peak positive ground reaction force during the ascent phase of the heel rise and ‘d’ is the linear distance of the heel from the floor. A limb symmetry index (LSI), (AT group: involved/uninvolved x 100 or Control group: nondominant/dominant x 100) was used to further quantify heel raise endurance. An LSI greater
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than 90% has been used as the marker of full recovery in people with Achilles tendon pathology [17, 28].
2.4 Statistical analysis Study data were analyzed with SPSS (version 24, Chicago, IL). Data were examined for normality with the Shapiro-Wilk test, which guided the conduction of parametric or non-
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parametric tests. The a priori alpha level was 0.05. We were unable to contact one patient at two year follow up. Missing data in pain and FAAM ADL scores were addressed via a mean imputation method with random variability that was based on the present distribution [29, 30]. A Friedman’s analysis of variance (ANOVA) with Bonferroni corrected Dunn’s post hoc tests was conducted on pain scores. A repeated measures ANOVA with Bonferroni corrected pairwise comparisons was conducted to evaluate FAAM ADL scores. Some patients selected ‘non
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applicable’ for more than one item on the FAAM Sport subscale at the postoperative time points.
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Therefore, we conducted a Friedman’s ANOVA with Bonferroni corrected Dunn’s post hoc tests to evaluate patients overall self-rating of sport performance and qualitatively assessed the mode
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of select FAAM Sport items. Descriptive statistics were generated to evaluate patient
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satisfaction. Peak dorsiflexion active range of motion was evaluated with a paired t-test. Three separate 2 x 3 (group x activity) mixed ANOVAs with least significant difference comparisons
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were conducted to examine differences in ankle power across time and between groups. For the heel rise activity, appropriate t-tests were used to evaluate between limb within group differences
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in total work and in LSI across time and between groups. A descriptive analysis was conducted to examine between group differences in total work values during heel rise. 3. Results
3.1 Patient reported outcomes
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Pain and FAAM ADL scores significantly improved from preoperative scores (Figure 1
and 2). Patients overall self-rating of sport performance on the FAAM Sport subscale significantly improved to a mean of 92% postoperatively (Figure 3). The most common response to items pertaining to running, jumping and the ability to participate in sport activity at six months postoperatively was ‘extreme difficulty’ (score of 1 out of 4). At two years
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postoperatively, the most common response to these items improved to ‘slight difficulty’ (score of 3 out of 4). At two year follow up, all patients reported they were either completely satisfied or satisfied with minor reservations in regards to the gastrocnemius recession procedure and postoperative care. Each patient also reported between 75-100% pain reduction. Interestingly, patient perceived time to achieve the maximal result after surgery ranged between 2 - 4 months
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to greater than 12 months.
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3.2 Instrumented outcomes
Peak ankle dorsiflexion motion increased between the preoperative and six-month
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postoperative time points [Mean (SD) 95% confidence interval: Pre 12.2 (8.3) 5.3 – 19.1 vs. Post
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15.9 (9.4) 8.1 – 23.7 degrees; p < .01].
In all analyses of ankle power, there were significant linear trends indicating a
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progressive increase of ankle power from walking to standard step to high step ascent. Interactions in two of the analyses (AT postoperative vs AT preoperative and vs controls)
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indicated the rate of change was different between groups. Ankle power during walking and stair ascent was similar between the control and AT group preoperatively (group effect: F = .01; p = 0.94). Postoperative AT group ankle power during walking remained similar to preoperative values and to the control group. However, in comparison to preoperative values, AT group ankle
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power significantly declined during standard and high step ascent six months postoperatively (Figure 4). Postoperative AT group ankle power was also significantly lower than control group ankle power during high step ascent (Figure 4). Between limb within group (side-to-side) comparisons in total work during repeated heel rise testing were not significant (Figure 5). However, control group total work was 30-33% greater
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than AT preoperative group limbs and the AT postoperative group uninvolved limb. These differences were due to more heel rise repetitions and a greater average heel height in the control group. Control group total work was also approximately 54% greater than the AT postoperative group involved limb. AT group LSI significantly decreased between the preoperative and postoperative time points but were not different at either time point from the control group
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(preoperative p = .88; postoperative mean difference 17.1% p = .22) (Figure 6).
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4. Discussion
To our knowledge, this is the first study to prospectively evaluate a compendium of
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meaningful and validated outcomes in people with recalcitrant AT following an isolated
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gastrocnemius recession. Study findings illustrate marked improvements in pain and activities of daily living following treatment, which are noted at early follow-up and maintained at two years.
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Additionally, our findings suggest that reduced ankle plantarflexor muscle performance at six months postoperatively is most likely associated with operative treatment and postoperative care,
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as opposed to chronic AT. Importantly, patients reported improved participation in sport activities two years postoperatively, suggesting ankle plantarflexor muscle performance gradually returns or patients develop adequate compensatory strategies over a two-year time span.
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Patients and clinicians can expect improved motion and sustained improvements in pain,
as well as daily and sport function following treatment. Our patients experienced improvements in pain and function which exceeded the clinically meaningful change in both VAS pain and FAAM ADL scores [19, 31]. Additionally, active ankle dorsiflexion motion improved to approximately 16 degrees following treatment; within normal motion expectations. These
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findings are similar to previous investigations and suggest adequate tendon loading was achieved following gastrocnemius recession [9, 10, 13]. Further, while patient sport function is limited at 6 months (76%), patients rated their ability to participate in sport at 92% two years postoperatively. These outcomes likely reflect why all of our patients were satisfied with minor reservations or completely satisfied at two-year follow-up. It is interesting to note that these positive outcomes were observed without incorporating adjunct operative techniques, suggesting
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the gastrocnemius recession can be successful when used in isolation. Our findings serve to
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strengthen the growing evidence for the use of gastrocnemius recession in patients with
not return until one to two years postoperatively.
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recalcitrant AT, with the important and new additive knowledge that near full sport activity may
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Awareness regarding the reduction of ankle plantarflexion power and endurance six months after gastrocnemius recession is important for patient selection and postoperative
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rehabilitation. With the exception of greater total work during heel rise in the control group (≈ 30%), AT preoperative versus control group differences in ankle muscle performance were not
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detected. This suggests altered patient function during chronic AT is largely driven by pain. However, with pain reduced at six months postoperatively, patients demonstrated a reduction of push off power during standard and high step ascent in comparison to preoperative values (Figures 1 and 4). Additionally, during repeated heel rise testing, early changes in plantarflexor
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muscle endurance were also observed (≈ 20% reduction in LSI) (Figure 6). While plantarflexion power was preserved during walking, muscle function declines during higher level activity for a period of time following gastrocnemius recession and postoperative rehabilitation. Accordingly, under the current operative and postoperative paradigm, a gastrocnemius recession may not be appropriate for patients who desire an early return to sports involving higher level power and
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endurance. However, it is not clear if the observed reductions in power and endurance could be mitigated with an earlier and more substantial rehabilitation program. Our findings provide rationale to emphasize, not only strength, but plantarflexion power and endurance during postoperative rehabilitation. Longer term prospective biomechanical studies are needed to determine if ankle plantarflexor muscle performance can approximate normal levels following gastrocnemius
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recession. At six months postoperatively, AT group ankle powers during high step ascent were
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lower than the control group (Figure 4). The control group also demonstrated greater total work during the heel raise work test (≈ 54%) (Figure 5). While the AT postoperative group LSI was
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not significantly different from our control group, they remained 17% below the control group
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and 10% below the normative LSI metric of 90% [28]. The patients of a previous, similar, retrospective case-control study who were evaluated 18 months following gastrocnemius
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recession for recalcitrant AT also demonstrated lower ankle power and endurance in comparison to controls [17]. In contrast, Molund et al. [15] retrospectively reported between limb
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similarities on 5/6 functional tests (i.e. heel rise, vertical jump) in people with AT 1-4 years following gastrocnemius recession. Since half of the tests involved multiple muscle groups, compensatory strategies may have contributed to their findings. Further study is needed to determine if anticipated improvements in sport performance by two years, as evidenced in our
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current study, represent improved ankle muscle performance or alternate compensatory strategies. Presently, our current study findings can aid surgeon to patient communication regarding expected outcomes and assist in the selection of gastrocnemius recession candidates. Limitations of our prospective study include the relatively short-term follow up of muscle performance measures. It is important to note that the six-month follow-up time point may not
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represent full recovery of ankle plantarflexor muscle function. Future studies with longer term follow-up may help clarify long term ankle muscle performance expectations. The strengths of our investigation include the prospective design, inclusion of a healthy matched control group, isolated application of the gastrocnemius recession, standardized postoperative procedures, and the use of a validated biomechanical model and patient reported outcome measures. Based on these strengths we offer the following conclusions. Patients can
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expect early and sustained improvements in pain and daily function following an isolated
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gastrocnemius recession for AT. Allied health should consider new strategies to mitigate
anticipated short-term deficits in ankle plantarflexor muscle performance. Physicians should
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counsel patients on the expected one to two year return to sport time frame.
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Funding
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Declaration of Interest
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This work was supported by the University of Rochester Department of Orthopaedics Louis A. Goldstein Scholarship Award. This funding source did not have a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Dr. DiGiovanni reports board or committee member from American Board of Orthopaedic Surgery, Inc., board or committee member from American Orthopaedic Foot and Ankle Society, and editorial or governing board from FootEducation.com (please see his COI form). These interests are outside of the submitted work.
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Data Statement We are not specifying any data sets. Data will be made available upon request. Acknowledgements: none
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References [1] Waldecker U, Hofmann G, Drewitz S. Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders. Foot Ankle Surg. 2012;18:119-23. https://doi.org/10.1016/j.fas.2011.04.007 [2] Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. J Bone Joint Surg Am. 2013;95:1620-8.
of
https://doi.org/10.2106/JBJS.L.01004
ro
[3] James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med. 1978;6:40-50. https://doi.org/10.1177/036354657800600202
-p
[4] Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic
re
science and clinical management. Br J Sports Med. 2002;36:239-49.
[5] Li HY, Hua YH. Achilles Tendinopathy: Current Concepts about the Basic Science and
lP
Clinical Treatments. Biomed Res Int. 2016;2016:6492597.
[6] Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, et al.
ur na
Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018;48:A1-A38. https://doi.org/10.2519/jospt.2018.0302 [7] Barske HL, DiGiovanni BF, Douglass M, Nawoczenski DA. Current concepts review: isolated gastrocnemius contracture and gastrocnemius recession. Foot Ankle Int. 2012;33:915-
Jo
21. https://doi.org/10.3113/FAI.2012.0915 [8] DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen STJ, Cziernecki J, et al. Isolated gastrocnemius tightness. J Bone Joint Surg Am. 2002;84-A:962-70.
15
[9] Duthon VB, Lubbeke A, Duc SR, Stern R, Assal M. Noninsertional achilles tendinopathy treated with gastrocnemius lengthening. Foot Ankle Int. 2011;32:375-9. https://doi.org/10.3113/FAI.2011.0375 [10] Gurdezi S, Kohls-Gatzoulis J, Solan MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. Foot Ankle Int. 2013;34:1364-9. https://doi.org/10.1177/1071100713488763
ro
noninsertional Achilles tendinopathy. Foot Ankle Int. 2013;34:481-5.
of
[11] Kiewiet NJ, Holthusen SM, Bohay DR, Anderson JG. Gastrocnemius recession for chronic
https://doi.org/10.1177/1071100713477620
-p
[12] Laborde JM, Weiler L. Achilles tendon pain treated with gastrocnemius-soleus recession.
re
Orthopedics. 2011;34:289-91. https://doi.org/10.3928/01477447-20110228-16 [13] Nawoczenski DA, Barske H, Tome J, Dawson LK, Zlotnicki JP, DiGiovanni BF. Isolated
lP
gastrocnemius recession for achilles tendinopathy: strength and functional outcomes. J Bone Joint Surg Am. 2015;97:99-105. https://doi.org/10.2106/JBJS.M.01424
ur na
[14] Tallerico VK, Greenhagen RM, Lowery C. Isolated Gastrocnemius Recession for Treatment of Insertional Achilles Tendinopathy: A Pilot Study. Foot Ankle Spec. 2015;8:260-5. https://doi.org/10.1177/1938640014557077 [15] Molund M, Lapinskas SR, Nilsen FA, Hvaal KH. Clinical and Functional Outcomes of
Jo
Gastrocnemius Recession for Chronic Achilles Tendinopathy. Foot Ankle Int. 2016;37:1091-7. [16] Smith KS, Jones C, Pinter Z, Shah A. Isolated Gastrocnemius Recession for the Treatment of Achilles Tendinopathy. Foot Ankle Spec. 2017;11:49-53. https://doi.org/10.1177/1938640017704942
16
[17] Nawoczenski DA, DiLiberto FE, Cantor MS, Tome JM, DiGiovanni BF. Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy. Foot Ankle Int. 2016;37:766-75. https://doi.org/10.1177/1071100716638128 [18] Delp SL, Statler K, Carroll NC. Preserving plantar flexion strength after surgical treatment for contracture of the triceps surae: a computer simulation study. J Orthop Res. 1995;13:96-104. [19] Martin RL, Irgang JJ, Burdett RG, Conti SF, VanSwearington JM. Evidence of validity for
of
the foot and ankle ability measure (FAAM). Foot Ankle Int. 2005;26:968-83.
ro
[20] Silfverskiold N. Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand. 1924;56:315-30.
re
(strayer procedure). Foot Ankle Int. 2004;25:247-50.
-p
[21] Pinney SJ, Sangeorzan BJ, Hansen ST. Surgical anatomy of the gastrocnemius recession
[22] Strayer LM. Recession of the gastrocnemius; an operation to relieve spastic contracture of
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the calf muscles. J Bone Joint Surg Am 1950;32-A:671-6.
[23] Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976;2:175-84.
ur na
https://doi.org/10.1016/0304-3959(76)90113-5
[24] Milne AD, Chess DG, Johnson JA, Ring GJW. Accuracy of an electromagnetic tracking device: a study of the optimal range and metal interference. J Biomech. 1996;29:791-3. [25] Rao S, Baumhauer JF, Tome J, Nawoczenski DA. Comparison of in vivo segmental foot
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motion during walking and step descent in patients with midfoot arthritis and matched asymptomatic control subjects. J Biomech. 2009;42:1054-60. https://doi.org/10.1016/j.jbiomech.2009.02.006 [26] Houck J, Tome J, Nawoczenski DA. Subtalar neutral position as an offset for a kinematic model of the foot during walking. Gait Posture. 2008;28:29-37.
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[27] Farris DJ, G.S. S. The mechanics and energetics of human walking and running: a joint level perspective. J R Soc Interface. 2012;9:110-8. https://doi.org/10.1098/rsif.2011.0182 [28] Silbernagel KG, Nilsson-Helander K, Thomee R, Eriksson BI, Karlsson J. A new measurement of heel-rise endurance with the ability to detect functional deficits in patients with Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc. 2010;18:258-64. https://doi.org/10.1007/s00167-009-0889-7
of
[29] Graham JW. Missing data analysis: making it work in the real world. Annu Rev Psychol.
ro
2009;60:549-76. https://doi.org/10.1146/annurev.psych.58.110405.085530
[30] Schafer JL, Graham JW. Missing Data: Our View of the State of the Art. Psychol Methods.
-p
2002;7:147-77.
re
[31] Kelly AM. The minimum clinically significant difference in visual analogue scale pain
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ur na
lP
score does not differ with severity of pain. Emerg Med J. 2001;18:205-7.
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Figure Legends
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Figure 1. Achilles tendinopathy (AT) group pain scores. Data are given as means ± 95% CI. Friedman’s ANOVA: χ2 = 15.2; p < .01. Dunn’s post hoc tests: AT Pre vs AT 2 yr Post *p <
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.01. Pre = preoperative; mo = months; Post = postoperative; yr = year.
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Figure 2. Achilles tendinopathy (AT) group Foot and Ankle Ability Measure Activity of Daily Living subscale scores. Data are given as means ± 95% CI. Repeated measures
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ANOVA: F = 30.1; ήp2 = .81; p < .01. Pairwise comparisons: AT Pre vs AT 6 mo Post *p = .01; AT Pre vs AT 2 yr Post *p < .01. Pre = preoperative; mo = months; Post = postoperative;
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yr = year.
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Figure 3. Achilles tendinopathy (AT) group Foot and Ankle Ability Measure sport participation self-rating scores. Data are given as means ± 95% CI. Friedman’s ANOVA: χ2
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= 14.0; p < .01. Dunn’s post hoc tests: AT Pre vs AT 2 yr Post *p < .01. Pre = preoperative;
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mo = months; Post = postoperative; yr = year.
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Figure 4. Ankle power during functional activity. Data are given as means ± 95% CI. AT Pre vs AT Post mixed ANOVA: group F = 11.3; ήp2 = .62; p = .01; activity F = 94.2; ήp2 = .93; p < .01; interaction F = 11.9; ήp2 = .63; p < .01. Pairwise comparisons: Standard step *p = .02;
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High step *p = .01. AT Post vs Control mixed ANOVA: group F = 3.9; ήp2 = .22; p = .07; activity F = 169.6; ήp2 = .92; p < .01; interaction F = 5.6; ήp2 = .28; p = .01. Pairwise comparisons: High step *p = .02. AT = Achilles tendinopathy; Pre = preoperative; mo =
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months; Post = postoperative.
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Figure 5. Total work during the heel raise work test. Data are given as means ± 95% CI.
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Between limb within group (side-to-side) paired t-tests: all p ≥ .09. AT = Achilles
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tendinopathy; Pre = preoperative; mo = months; Post = postoperative.
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Figure 6. Limb symmetry index during the heel raise work test. Data are given as means ±
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95% CI. Paired t-test: AT Pre vs AT 6 mo Post *p = .02. AT = Achilles tendinopathy; Pre =
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preoperative; mo = months; Post = postoperative.
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Tables Table 1. Subject characteristics. Means and standard deviations (SD) of the matching variables of age, gender, and body mass index (BMI) are displayed along with additional patient cohort
Control (n = 8)
Mean (SD)
Mean (SD)
Gender (male : female)
80%
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Involved Limb (left : right)
30.9 (3.2)
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Limb Dominance (left : right)
55.7 (10.2)
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51.5 (10.2)
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AT (n = 8)
Age (years)
BMI (Kg/m2)
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information.
0:8
80%
31.9 (5.8) 2:6
4:4
Type of AT (insertional : non-insertional)
5:3
Duration of AT (months)
20.3 (6.1)
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AT = Achilles tendinopathy; Limb dominance was determined by asking participants which foot they use to kick a ball.
PII:
S1268-7731(19)30172-9
DOI:
https://doi.org/10.1016/j.fas.2019.10.001
Reference:
FAS 1373
To appear in:
Foot and Ankle Surgery
Received Date:
20 May 2019
Revised Date:
4 July 2019
Accepted Date:
5 October 2019
Please cite this article as: DiLiberto FE, Nawoczenski DA, Tome J, DiGiovanni BF, Patient Reported Outcomes and Ankle Plantarflexor Muscle Performance Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Case-Control Study, Foot and Ankle Surgery (2019), doi: https://doi.org/10.1016/j.fas.2019.10.001
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
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Title: Patient Reported Outcomes and Ankle Plantarflexor Muscle Performance Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Case-Control Study
Authors Frank E. DiLiberto, PT, PhD.a Deborah A. Nawoczenski, PT, PhD.b Josh Tome, MS.c Benedict F. DiGiovanni MD.d a
School of Nursing, University of Rochester. 255 Crittenden Blvd, Rochester, NY 14642, USA. Adjunct Professor, Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester. 601 Elmwood Avenue, Rochester, NY 14642. USA. Email: [email protected] c Research Biomechanist, School of Health Science and Human Performance, Movement Analysis Laboratory, Ithaca College. 953 Danby Road, Ithaca, NY 14850, USA. Email: [email protected] d Professor, Department of Orthopaedics; Director of Sub-Internship and Medical Student Education; Director of Musculoskeletal Curriculum, University of Rochester School of Medicine and Medical Center. 601 Elmwood Avenue, Rochester, NY 14642. USA. Email: [email protected]
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Corresponding Author (Permanent Address) Frank E. DiLiberto, PT, PhD. Assistant Professor, Department of Physical Therapy, College of Health Professions, Rosalind Franklin University of Medicine & Science. 3333 Green Bay Road, North Chicago, IL 60064. Email: [email protected]
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Highlights
Prospective data on gastrocnemius recession for Achilles tendinopathy are limited
Improved patient reported outcomes were sustained through two year follow up
Ankle power during walking was preserved postoperatively
Ankle power during stair ascent and work during heel rise declined postoperatively
Findings can inform patient selection, expected outcomes, and rehabilitation
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Abstract
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Background: Prospective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance. Methods: Patients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n=8) and a healthy control group (n=8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected. Results:
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Improvements in pain and self-reported function were observed (six months and two years).
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Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment
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(p ≤ .02). Conclusions: Study findings regarding long-term improvements in patient pain, self-
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reported function and sport participation, and early preservation of ankle function during
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walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.
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Keywords: Achilles tendinopathy; Gastrocnemius recession; Biomechanics; Ankle power
1. Introduction
Approximately six percent of patients who seek orthopaedic care are diagnosed with Achilles tendinopathy (AT) [1]. The cumulative effect of tendon micro trauma from repetitive
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overloading results in patient pain and decreased function [2-6]. The association between recalcitrant AT and an isolated gastrocnemius contracture suggests that chronicity is propagated by the gastrocnemius muscle as opposed to the entire posterior compartment [7, 8]. For this reason, the application of a gastrocnemius recession has emerged as a treatment option for patients with recalcitrant AT.
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Prospective studies regarding gastrocnemius recession for patients with AT are limited. Enthusiasm for this procedure has been driven by promising findings of primarily retrospective and / or uncontrolled investigations. While different surgical approaches and evaluation instruments were utilized, studies have demonstrated improved pain, ankle dorsiflexion, and patient reported function following gastrocnemius recession for recalcitrant AT [9-12]. More recent retrospective studies further substantiate these benefits [13-16]. In comparison to alternate
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operative approaches for chronic AT, the combination of positive outcomes, low complication
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rates, and a relatively short recovery time provide support for the use of gastrocnemius recession. However, prospective, controlled studies are lacking, and it is unclear if the initial benefits are
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maintained.
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Despite patient reported improvements following gastrocnemius recession, additional study findings suggest patients may have reduced muscle function following treatment. In a
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retrospective study, patients with recalcitrant AT 18 months following gastrocnemius recession reported difficulty with higher level activities (i.e. running, jumping) and had lower ankle
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plantarflexion power and endurance in comparison to healthy controls [17]. However, theoretically, the torque producing capability of the plantarflexors is preserved following gastrocnemius recession [18]. Without prospective data, it is unclear if the reported postoperative deficits in ankle muscle performance stemmed from chronic AT, the gastrocnemius recession
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procedure and postoperative care, or some combination. The majority of evidence to substantiate the application of gastrocnemius recession is
retrospective in nature and lacking comparative normative data. A biomechanically rigorous prospective study, which also includes validated patient reported outcomes, would aid in determining if patient and muscle function is reduced, preserved, or improved following
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treatment. A study to this effect would be expected to improve patient selection, inform rehabilitation paradigms, and better allow clinicians to communicate anticipated outcomes. Therefore, the purpose of this prospective case-control study was to evaluate changes in plantarflexor muscle function and patient reported outcomes in people before and after gastrocnemius recession for recalcitrant AT, and in comparison to a healthy matched control group. We hypothesized that 1) patients would report improved pain and function six months
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following gastrocnemius recession, 2) patients would demonstrate ankle muscle performance
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similar to preoperative values but lower than control values at six months following
gastrocnemius recession, and 3) that improvements in pain and function would be maintained or
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improved at two-year follow-up.
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2. Material and methods
This was a prospective case-control study of patients with recalcitrant AT (n=8) and a
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healthy control group (n=8). Sample size was determined from an a priori power analysis of the minimal clinically important difference (8% change) and expected variability in Foot and Ankle
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Ability Measure Activity of Daily Living (FAAM ADL) scores in people following gastrocnemius recession for AT (paired t-test: d = 1, α = 0.05, 1- β = 0.8; required per group n = 7) [17, 19]. Patients with unilateral recalcitrant AT who were candidates for an isolated gastrocnemius recession were recruited on a rolling basis from the Foot and Ankle Division of
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the Department of Orthopaedics at (blinded for review). The healthy matched control group was recruited from the local community. Study procedures were approved by (blinded for review) and all participants provided written informed consent. Data were collected at (blinded for review). AT group participant inclusion criteria were as follows: 1) greater than 18 years old, 2)
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clinical diagnosis of unilateral insertional or noninsertional AT, 3) unresponsive to at least six months of nonoperative care, 4) isolated gastrocnemius contracture (positive Silfverskiold test), [20] and 5) deemed appropriate for an isolated gastrocnemius recession by the orthopaedic surgeon. Control participants were matched (age, gender, body mass index) to the AT group and were required to be without current foot / ankle pain or surgical history (Table 1). All
disease to the leg (i.e. neurologic injury, stroke, Diabetes Mellitus).
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2.1 Operative and postoperative procedures
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participants were excluded if they had prior Achilles or plantar fascia surgery or other surgery or
AT group participants received an isolated gastrocnemius recession (Strayer procedure)
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[7, 21, 22] from a fellowship trained foot and ankle orthopaedic surgeon. Briefly, following a
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posterior medial approach, the gastrocnemius fascia was sectioned at the musculotendinous junction without disruption to the soleus. The gastrocnemius tendon and muscle were allowed to
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retract before the tendon was sutured to the underlying soleus fascia. AT group participants were followed in the orthopaedic clinic. Following one week of
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limited weight bearing wearing a short leg plaster splint, patients were weightbearing as tolerated in a high walking boot and began range of motion and calf stretching exercises for the next two weeks. The walking boot was discontinued after 3 weeks. Patients then began a home strengthening program (i.e. elastic resistance exercises, heel rises) and low impact activities (i.e.
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walking). Activity restriction was lifted at week eight. Formal physical therapy, once per week, was utilized during the following four weeks for patient-specific functional and strength training. Return to full activity was expected by 8 to 12 weeks. 2.2 Patient reported outcomes
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The visual analog scale (10 cm line) was used to record patient worst pain level [23]. The validated FAAM ADL and Sport subscales were used to record patient perceived function [19]. FAAM items are scored on a 0-4 scale and an overall percent score is generated for each subscale where higher scores correspond to higher levels of function. If a participant selects ‘non applicable’ to more than one item, an overall self-rating of ADL or Sport performance is an alternative metric to examine [19]. These outcomes were recorded preoperatively, and at six
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months and two years postoperatively. At two years postoperatively, patients were asked to
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complete a satisfaction questionnaire. 2.3 Instrumented procedures and outcomes
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An electromagnetic tacking system (Flock of Bird MiniBird hardware; Ascension
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Technology Corporation, Burlington, VT; 100 Hz) and force plate (4060-NC; Bertec Corporation, Columbus, OH; 1000 Hz) were used to record foot and ankle kinematics and
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kinetics [24]. MotionMonitor™ software (Innovative Sport Training, Chicago, IL) was used to synchronize these data. We have previously detailed our validated modeling approach
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(references blinded for review). Briefly, sensors were affixed to the skin overlying the first metatarsal, calcaneus, and tibia of each subject. Subject-specific models were developed through digitization procedures. Segment to segment displacements were calculated using an Euler rotation sequence of Z, X’, Y’’ [25]. Data from a standing subtalar neutral position were used as
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a zero reference point for segmental rotations [26]. AT group data were collected preoperatively and six months postoperatively. Control
group data were collected once. Five activities were performed during each instrumented data collection session: 1) seated active ankle sagittal plane range of motion with the knee in full extension, 2) walking, 3) ascending a standard step (17 cm), 4) ascending a high step (34 cm),
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and 5) repeated single limb heel rise. The six-month follow-up time point was selected to evaluate the immediate effect of the gastrocnemius recession and postoperative rehabilitation. Within and between subject comparisons of ankle power during walking and stair ascent were made possible via specific procedures. Since ankle power changes with gait speed [27], self-selected walking speeds (range: 0.76 - 1.11 m/s2) were maintained consistent at +/- 5% across all activities and across time points. Control group walking speeds were matched to AT
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group speeds. The distance from the center of the force plate to the step was normalized to 75%
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of leg length for each stair ascent task [25]. Data were normalized across stance phase (0-100%) [25]. Ankle plantarflexion power was calculated as the product of the ankle moment and
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calcaneus to tibia angular velocity (τω). Peak power, normalized to mass, and averaged across 3
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trials for each subject during each task, was the primary outcome measure. Participants performed repeated single limb heel raises to complete the heel raise work
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test. The activity concluded when the participant was unable to continue due to fatigue. Plantarflexor muscle endurance (total work) was calculated as the sum of work across all
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completed heel raises as F(t)Δd(t) where ‘F’ is the peak positive ground reaction force during the ascent phase of the heel rise and ‘d’ is the linear distance of the heel from the floor. A limb symmetry index (LSI), (AT group: involved/uninvolved x 100 or Control group: nondominant/dominant x 100) was used to further quantify heel raise endurance. An LSI greater
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than 90% has been used as the marker of full recovery in people with Achilles tendon pathology [17, 28].
2.4 Statistical analysis Study data were analyzed with SPSS (version 24, Chicago, IL). Data were examined for normality with the Shapiro-Wilk test, which guided the conduction of parametric or non-
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parametric tests. The a priori alpha level was 0.05. We were unable to contact one patient at two year follow up. Missing data in pain and FAAM ADL scores were addressed via a mean imputation method with random variability that was based on the present distribution [29, 30]. A Friedman’s analysis of variance (ANOVA) with Bonferroni corrected Dunn’s post hoc tests was conducted on pain scores. A repeated measures ANOVA with Bonferroni corrected pairwise comparisons was conducted to evaluate FAAM ADL scores. Some patients selected ‘non
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applicable’ for more than one item on the FAAM Sport subscale at the postoperative time points.
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Therefore, we conducted a Friedman’s ANOVA with Bonferroni corrected Dunn’s post hoc tests to evaluate patients overall self-rating of sport performance and qualitatively assessed the mode
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of select FAAM Sport items. Descriptive statistics were generated to evaluate patient
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satisfaction. Peak dorsiflexion active range of motion was evaluated with a paired t-test. Three separate 2 x 3 (group x activity) mixed ANOVAs with least significant difference comparisons
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were conducted to examine differences in ankle power across time and between groups. For the heel rise activity, appropriate t-tests were used to evaluate between limb within group differences
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in total work and in LSI across time and between groups. A descriptive analysis was conducted to examine between group differences in total work values during heel rise. 3. Results
3.1 Patient reported outcomes
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Pain and FAAM ADL scores significantly improved from preoperative scores (Figure 1
and 2). Patients overall self-rating of sport performance on the FAAM Sport subscale significantly improved to a mean of 92% postoperatively (Figure 3). The most common response to items pertaining to running, jumping and the ability to participate in sport activity at six months postoperatively was ‘extreme difficulty’ (score of 1 out of 4). At two years
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postoperatively, the most common response to these items improved to ‘slight difficulty’ (score of 3 out of 4). At two year follow up, all patients reported they were either completely satisfied or satisfied with minor reservations in regards to the gastrocnemius recession procedure and postoperative care. Each patient also reported between 75-100% pain reduction. Interestingly, patient perceived time to achieve the maximal result after surgery ranged between 2 - 4 months
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to greater than 12 months.
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3.2 Instrumented outcomes
Peak ankle dorsiflexion motion increased between the preoperative and six-month
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postoperative time points [Mean (SD) 95% confidence interval: Pre 12.2 (8.3) 5.3 – 19.1 vs. Post
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15.9 (9.4) 8.1 – 23.7 degrees; p < .01].
In all analyses of ankle power, there were significant linear trends indicating a
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progressive increase of ankle power from walking to standard step to high step ascent. Interactions in two of the analyses (AT postoperative vs AT preoperative and vs controls)
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indicated the rate of change was different between groups. Ankle power during walking and stair ascent was similar between the control and AT group preoperatively (group effect: F = .01; p = 0.94). Postoperative AT group ankle power during walking remained similar to preoperative values and to the control group. However, in comparison to preoperative values, AT group ankle
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power significantly declined during standard and high step ascent six months postoperatively (Figure 4). Postoperative AT group ankle power was also significantly lower than control group ankle power during high step ascent (Figure 4). Between limb within group (side-to-side) comparisons in total work during repeated heel rise testing were not significant (Figure 5). However, control group total work was 30-33% greater
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than AT preoperative group limbs and the AT postoperative group uninvolved limb. These differences were due to more heel rise repetitions and a greater average heel height in the control group. Control group total work was also approximately 54% greater than the AT postoperative group involved limb. AT group LSI significantly decreased between the preoperative and postoperative time points but were not different at either time point from the control group
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(preoperative p = .88; postoperative mean difference 17.1% p = .22) (Figure 6).
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4. Discussion
To our knowledge, this is the first study to prospectively evaluate a compendium of
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meaningful and validated outcomes in people with recalcitrant AT following an isolated
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gastrocnemius recession. Study findings illustrate marked improvements in pain and activities of daily living following treatment, which are noted at early follow-up and maintained at two years.
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Additionally, our findings suggest that reduced ankle plantarflexor muscle performance at six months postoperatively is most likely associated with operative treatment and postoperative care,
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as opposed to chronic AT. Importantly, patients reported improved participation in sport activities two years postoperatively, suggesting ankle plantarflexor muscle performance gradually returns or patients develop adequate compensatory strategies over a two-year time span.
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Patients and clinicians can expect improved motion and sustained improvements in pain,
as well as daily and sport function following treatment. Our patients experienced improvements in pain and function which exceeded the clinically meaningful change in both VAS pain and FAAM ADL scores [19, 31]. Additionally, active ankle dorsiflexion motion improved to approximately 16 degrees following treatment; within normal motion expectations. These
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findings are similar to previous investigations and suggest adequate tendon loading was achieved following gastrocnemius recession [9, 10, 13]. Further, while patient sport function is limited at 6 months (76%), patients rated their ability to participate in sport at 92% two years postoperatively. These outcomes likely reflect why all of our patients were satisfied with minor reservations or completely satisfied at two-year follow-up. It is interesting to note that these positive outcomes were observed without incorporating adjunct operative techniques, suggesting
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the gastrocnemius recession can be successful when used in isolation. Our findings serve to
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strengthen the growing evidence for the use of gastrocnemius recession in patients with
not return until one to two years postoperatively.
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recalcitrant AT, with the important and new additive knowledge that near full sport activity may
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Awareness regarding the reduction of ankle plantarflexion power and endurance six months after gastrocnemius recession is important for patient selection and postoperative
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rehabilitation. With the exception of greater total work during heel rise in the control group (≈ 30%), AT preoperative versus control group differences in ankle muscle performance were not
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detected. This suggests altered patient function during chronic AT is largely driven by pain. However, with pain reduced at six months postoperatively, patients demonstrated a reduction of push off power during standard and high step ascent in comparison to preoperative values (Figures 1 and 4). Additionally, during repeated heel rise testing, early changes in plantarflexor
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muscle endurance were also observed (≈ 20% reduction in LSI) (Figure 6). While plantarflexion power was preserved during walking, muscle function declines during higher level activity for a period of time following gastrocnemius recession and postoperative rehabilitation. Accordingly, under the current operative and postoperative paradigm, a gastrocnemius recession may not be appropriate for patients who desire an early return to sports involving higher level power and
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endurance. However, it is not clear if the observed reductions in power and endurance could be mitigated with an earlier and more substantial rehabilitation program. Our findings provide rationale to emphasize, not only strength, but plantarflexion power and endurance during postoperative rehabilitation. Longer term prospective biomechanical studies are needed to determine if ankle plantarflexor muscle performance can approximate normal levels following gastrocnemius
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recession. At six months postoperatively, AT group ankle powers during high step ascent were
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lower than the control group (Figure 4). The control group also demonstrated greater total work during the heel raise work test (≈ 54%) (Figure 5). While the AT postoperative group LSI was
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not significantly different from our control group, they remained 17% below the control group
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and 10% below the normative LSI metric of 90% [28]. The patients of a previous, similar, retrospective case-control study who were evaluated 18 months following gastrocnemius
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recession for recalcitrant AT also demonstrated lower ankle power and endurance in comparison to controls [17]. In contrast, Molund et al. [15] retrospectively reported between limb
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similarities on 5/6 functional tests (i.e. heel rise, vertical jump) in people with AT 1-4 years following gastrocnemius recession. Since half of the tests involved multiple muscle groups, compensatory strategies may have contributed to their findings. Further study is needed to determine if anticipated improvements in sport performance by two years, as evidenced in our
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current study, represent improved ankle muscle performance or alternate compensatory strategies. Presently, our current study findings can aid surgeon to patient communication regarding expected outcomes and assist in the selection of gastrocnemius recession candidates. Limitations of our prospective study include the relatively short-term follow up of muscle performance measures. It is important to note that the six-month follow-up time point may not
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represent full recovery of ankle plantarflexor muscle function. Future studies with longer term follow-up may help clarify long term ankle muscle performance expectations. The strengths of our investigation include the prospective design, inclusion of a healthy matched control group, isolated application of the gastrocnemius recession, standardized postoperative procedures, and the use of a validated biomechanical model and patient reported outcome measures. Based on these strengths we offer the following conclusions. Patients can
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expect early and sustained improvements in pain and daily function following an isolated
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gastrocnemius recession for AT. Allied health should consider new strategies to mitigate
anticipated short-term deficits in ankle plantarflexor muscle performance. Physicians should
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counsel patients on the expected one to two year return to sport time frame.
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Funding
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Declaration of Interest
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This work was supported by the University of Rochester Department of Orthopaedics Louis A. Goldstein Scholarship Award. This funding source did not have a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Dr. DiGiovanni reports board or committee member from American Board of Orthopaedic Surgery, Inc., board or committee member from American Orthopaedic Foot and Ankle Society, and editorial or governing board from FootEducation.com (please see his COI form). These interests are outside of the submitted work.
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Data Statement We are not specifying any data sets. Data will be made available upon request. Acknowledgements: none
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References [1] Waldecker U, Hofmann G, Drewitz S. Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders. Foot Ankle Surg. 2012;18:119-23. https://doi.org/10.1016/j.fas.2011.04.007 [2] Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. J Bone Joint Surg Am. 2013;95:1620-8.
of
https://doi.org/10.2106/JBJS.L.01004
ro
[3] James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med. 1978;6:40-50. https://doi.org/10.1177/036354657800600202
-p
[4] Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic
re
science and clinical management. Br J Sports Med. 2002;36:239-49.
[5] Li HY, Hua YH. Achilles Tendinopathy: Current Concepts about the Basic Science and
lP
Clinical Treatments. Biomed Res Int. 2016;2016:6492597.
[6] Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, et al.
ur na
Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018;48:A1-A38. https://doi.org/10.2519/jospt.2018.0302 [7] Barske HL, DiGiovanni BF, Douglass M, Nawoczenski DA. Current concepts review: isolated gastrocnemius contracture and gastrocnemius recession. Foot Ankle Int. 2012;33:915-
Jo
21. https://doi.org/10.3113/FAI.2012.0915 [8] DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen STJ, Cziernecki J, et al. Isolated gastrocnemius tightness. J Bone Joint Surg Am. 2002;84-A:962-70.
15
[9] Duthon VB, Lubbeke A, Duc SR, Stern R, Assal M. Noninsertional achilles tendinopathy treated with gastrocnemius lengthening. Foot Ankle Int. 2011;32:375-9. https://doi.org/10.3113/FAI.2011.0375 [10] Gurdezi S, Kohls-Gatzoulis J, Solan MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. Foot Ankle Int. 2013;34:1364-9. https://doi.org/10.1177/1071100713488763
ro
noninsertional Achilles tendinopathy. Foot Ankle Int. 2013;34:481-5.
of
[11] Kiewiet NJ, Holthusen SM, Bohay DR, Anderson JG. Gastrocnemius recession for chronic
https://doi.org/10.1177/1071100713477620
-p
[12] Laborde JM, Weiler L. Achilles tendon pain treated with gastrocnemius-soleus recession.
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Orthopedics. 2011;34:289-91. https://doi.org/10.3928/01477447-20110228-16 [13] Nawoczenski DA, Barske H, Tome J, Dawson LK, Zlotnicki JP, DiGiovanni BF. Isolated
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gastrocnemius recession for achilles tendinopathy: strength and functional outcomes. J Bone Joint Surg Am. 2015;97:99-105. https://doi.org/10.2106/JBJS.M.01424
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[14] Tallerico VK, Greenhagen RM, Lowery C. Isolated Gastrocnemius Recession for Treatment of Insertional Achilles Tendinopathy: A Pilot Study. Foot Ankle Spec. 2015;8:260-5. https://doi.org/10.1177/1938640014557077 [15] Molund M, Lapinskas SR, Nilsen FA, Hvaal KH. Clinical and Functional Outcomes of
Jo
Gastrocnemius Recession for Chronic Achilles Tendinopathy. Foot Ankle Int. 2016;37:1091-7. [16] Smith KS, Jones C, Pinter Z, Shah A. Isolated Gastrocnemius Recession for the Treatment of Achilles Tendinopathy. Foot Ankle Spec. 2017;11:49-53. https://doi.org/10.1177/1938640017704942
16
[17] Nawoczenski DA, DiLiberto FE, Cantor MS, Tome JM, DiGiovanni BF. Ankle Power and Endurance Outcomes Following Isolated Gastrocnemius Recession for Achilles Tendinopathy. Foot Ankle Int. 2016;37:766-75. https://doi.org/10.1177/1071100716638128 [18] Delp SL, Statler K, Carroll NC. Preserving plantar flexion strength after surgical treatment for contracture of the triceps surae: a computer simulation study. J Orthop Res. 1995;13:96-104. [19] Martin RL, Irgang JJ, Burdett RG, Conti SF, VanSwearington JM. Evidence of validity for
of
the foot and ankle ability measure (FAAM). Foot Ankle Int. 2005;26:968-83.
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[20] Silfverskiold N. Reduction of the uncrossed two-joints muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand. 1924;56:315-30.
re
(strayer procedure). Foot Ankle Int. 2004;25:247-50.
-p
[21] Pinney SJ, Sangeorzan BJ, Hansen ST. Surgical anatomy of the gastrocnemius recession
[22] Strayer LM. Recession of the gastrocnemius; an operation to relieve spastic contracture of
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the calf muscles. J Bone Joint Surg Am 1950;32-A:671-6.
[23] Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976;2:175-84.
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https://doi.org/10.1016/0304-3959(76)90113-5
[24] Milne AD, Chess DG, Johnson JA, Ring GJW. Accuracy of an electromagnetic tracking device: a study of the optimal range and metal interference. J Biomech. 1996;29:791-3. [25] Rao S, Baumhauer JF, Tome J, Nawoczenski DA. Comparison of in vivo segmental foot
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motion during walking and step descent in patients with midfoot arthritis and matched asymptomatic control subjects. J Biomech. 2009;42:1054-60. https://doi.org/10.1016/j.jbiomech.2009.02.006 [26] Houck J, Tome J, Nawoczenski DA. Subtalar neutral position as an offset for a kinematic model of the foot during walking. Gait Posture. 2008;28:29-37.
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[27] Farris DJ, G.S. S. The mechanics and energetics of human walking and running: a joint level perspective. J R Soc Interface. 2012;9:110-8. https://doi.org/10.1098/rsif.2011.0182 [28] Silbernagel KG, Nilsson-Helander K, Thomee R, Eriksson BI, Karlsson J. A new measurement of heel-rise endurance with the ability to detect functional deficits in patients with Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc. 2010;18:258-64. https://doi.org/10.1007/s00167-009-0889-7
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[29] Graham JW. Missing data analysis: making it work in the real world. Annu Rev Psychol.
ro
2009;60:549-76. https://doi.org/10.1146/annurev.psych.58.110405.085530
[30] Schafer JL, Graham JW. Missing Data: Our View of the State of the Art. Psychol Methods.
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2002;7:147-77.
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[31] Kelly AM. The minimum clinically significant difference in visual analogue scale pain
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score does not differ with severity of pain. Emerg Med J. 2001;18:205-7.
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Figure Legends
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Figure 1. Achilles tendinopathy (AT) group pain scores. Data are given as means ± 95% CI. Friedman’s ANOVA: χ2 = 15.2; p < .01. Dunn’s post hoc tests: AT Pre vs AT 2 yr Post *p <
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.01. Pre = preoperative; mo = months; Post = postoperative; yr = year.
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Figure 2. Achilles tendinopathy (AT) group Foot and Ankle Ability Measure Activity of Daily Living subscale scores. Data are given as means ± 95% CI. Repeated measures
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ANOVA: F = 30.1; ήp2 = .81; p < .01. Pairwise comparisons: AT Pre vs AT 6 mo Post *p = .01; AT Pre vs AT 2 yr Post *p < .01. Pre = preoperative; mo = months; Post = postoperative;
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yr = year.
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Figure 3. Achilles tendinopathy (AT) group Foot and Ankle Ability Measure sport participation self-rating scores. Data are given as means ± 95% CI. Friedman’s ANOVA: χ2
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= 14.0; p < .01. Dunn’s post hoc tests: AT Pre vs AT 2 yr Post *p < .01. Pre = preoperative;
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mo = months; Post = postoperative; yr = year.
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Figure 4. Ankle power during functional activity. Data are given as means ± 95% CI. AT Pre vs AT Post mixed ANOVA: group F = 11.3; ήp2 = .62; p = .01; activity F = 94.2; ήp2 = .93; p < .01; interaction F = 11.9; ήp2 = .63; p < .01. Pairwise comparisons: Standard step *p = .02;
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High step *p = .01. AT Post vs Control mixed ANOVA: group F = 3.9; ήp2 = .22; p = .07; activity F = 169.6; ήp2 = .92; p < .01; interaction F = 5.6; ήp2 = .28; p = .01. Pairwise comparisons: High step *p = .02. AT = Achilles tendinopathy; Pre = preoperative; mo =
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months; Post = postoperative.
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Figure 5. Total work during the heel raise work test. Data are given as means ± 95% CI.
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Between limb within group (side-to-side) paired t-tests: all p ≥ .09. AT = Achilles
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tendinopathy; Pre = preoperative; mo = months; Post = postoperative.
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Figure 6. Limb symmetry index during the heel raise work test. Data are given as means ±
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95% CI. Paired t-test: AT Pre vs AT 6 mo Post *p = .02. AT = Achilles tendinopathy; Pre =
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preoperative; mo = months; Post = postoperative.
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Tables Table 1. Subject characteristics. Means and standard deviations (SD) of the matching variables of age, gender, and body mass index (BMI) are displayed along with additional patient cohort
Control (n = 8)
Mean (SD)
Mean (SD)
Gender (male : female)
80%
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Involved Limb (left : right)
30.9 (3.2)
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Limb Dominance (left : right)
55.7 (10.2)
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51.5 (10.2)
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AT (n = 8)
Age (years)
BMI (Kg/m2)
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information.
0:8
80%
31.9 (5.8) 2:6
4:4
Type of AT (insertional : non-insertional)
5:3
Duration of AT (months)
20.3 (6.1)
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AT = Achilles tendinopathy; Limb dominance was determined by asking participants which foot they use to kick a ball.