SLR - September 2018 - Albert A. Elhiani

Prevalence of Isolated Gastrocnemius Tightness in Patients with Foot and Ankle Pathology

Reference: Malhotra, K, Chan O, Cullen S, Welck M, Goldberg AJ, Cullen N, Singh D. Prevalence of Isolated Gastrocnemius Tightness in Patients with Foot and Ankle Pathology. The Bone & Joint Journal 2018 Jul;100-B(7):945–952.

Scientific Literature Review

Reviewed By: Albert A. Elhiani DPM
Residency Program: Cedars Sinai Medical Center, Los Angeles, CA

Podiatric Relevance: Gastrocnemius tightness has been implicated in a number of forefoot pathologies. However, the literature is vague in regards to how foot and ankle pathology correlates to gastrocnemius tightness. The restriction of dorsiflexion at the level of the ankle does not necessarily translate into gastrocnemius tightness. This paper seeks to determine an evidence-based relationship between gastrocnemius tightness and forefoot pathology. Furthermore, the data could be extrapolated to define a threshold to treat this tightness in the general population in order to prevent or alleviate foot and ankle pain.

Methods: A single center, prospective observational study was conducted in an orthopaedic facility in the UK over a three-month period between 2016 and 2017. Two groups were observed: a control group of healthy individual volunteers and a group of patients with foot and ankle pathology. The modified lunge test as described by Krause et al was used to assess for gastrocnemius tightness. An inclinometer was used to measure the angle between the foot and tibia. Maximum dorsiflexion was appreciated without the heel leaving the floor both with the contralateral knee extended and flexed >20 degrees. A control-to-case ratio of 3:1 (291 control to 97 pathological) was used. More people were recruited in the control; however, the data was accounted for using power calculation software. Furthermore, the groups were matched for age, gender and ethnicity. Activity level, dorsiflexion with and without the knee extended and BMI were all accounted for in this study.

Results: Regression models and statistically significant differences between the pathological group and the control groups were observed with activity levels, BMI and age. Elevated BMIs, increased age and lower activity levels were all found to correlate to increased tightness. Normal dorsiflexion with the knee extended was calculated based on the mean of the control group and was found to be between 0°–13°, and 11°–40° with the knee flexed. The control group had a mean gastrocnemius tightness of 6°, whereas the pathological group was 8°. Twelve patients (37.5 percent) in the pathological group were found to have abnormal gastrocnemius tightness whereas only nine (13.8 percent) were observed in the control group. Furthermore, those with forefoot pathology, such as hallux valgus, rigidus and metatarsalgia, were found to have a significantly tighter gastrocnemius.

Conclusions: The authors of this study sought to quantify the degree of gastrocnemius tightness that may become pathological. They suggest that >13° of gastrocnemius tightness is clinically significant. This study found that gastrocnemius tightness correlated with older age, elevated BMI and reduced physical activity. These correlative factors were proposed to be a result of the changes in elastic properties of muscles and tendons as the aforementioned factors were increased. It is important for the podiatric physician to recognize that ankle stiffness does not necessarily equate to gastrocnemius tightness. A gastrocnemius recession is a technically straightforward procedure for which I may have a lower threshold to include on patients with a tight gastrocnemius complex in the future. 

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