Can a Less Invasive Procedure Replace the Classic Gastrocnemius Release? Partial Postero-Medial Superficial Release of the Proximal Crural Fascia in Positive Silfverskiold Patients: A 3 Year Follow-up

Research Type: Level 4 – Case series Introduction/Purpose: Ankle limitation to dorsiflexion in an extended knee is observed during the second rocker of gait in patients with positive Silfverskiold confirming an isolated gastrocnemius contracture (IGC). Tendons and muscles share intrinsic contractility and relaxation properties which can be modified during physiotherapy in comparison to the fascia which lacks it. The present study describes a case series of patients with positive Silfverskiold associated with various foot pathologies who underwent a selective fasciotomy of the postero-medial superficial portion of the crural fascia. The purpose of this study is to describe the surgical technique and clinical outcomes of this procedure. We hypothesize that this procedure can reach satisfactory clinical outcomes compared to the classic medial gastrocnemius release with the advantage of being a less invasive procedure. Methods: From January to October 2021, 26 patients with idiopathic gastrocnemius contracture (IGC) and associated chronic foot pain were treated with partial postero-medial superficial release (PMSR) of the crural fascia. Inclusion criteria included foot pain without structural abnormalities and a positive Silfverskiold test. A transverse incision, 2 cm distal to the flexion crease and 4 cm medial to the intermuscular line of the gastrocnemius, was made. Subcutaneous dissection exposed the neurovascular bundle, followed by a 7 cm horizontal incision of the superficial posterior fascia, leaving the medial gastrocnemius muscle aponeurosis intact. Patients completed the Foot and Ankle Disability Index (FADI) before surgery and at final follow-up. Data analysis was conducted using SPSS 20, and paired samples t-tests were performed to evaluate differences in pain and function pre- and postoperatively, with significance set at p < 0.05. Descriptive statistics were applied to demographic data. Results: Eighteen patients underwent partial PMSR of the crural fascia, while eight had additional procedures. The mean follow-up was 37.2 months, and the mean age was 40.6 ± 18.5 years. Diagnoses included metatarsalgia (4 feet), metatarsalgia with plantar fasciitis (3 feet), metatarsalgia, plantar fasciitis, and cavus foot (6 feet), plantar fasciitis (5 feet), plantar fasciitis with insertional Achilles tendinopathy (3 feet), non-insertional Achilles tendinopathy (4 feet), and flexor hallucis longus tendinopathy (1 foot). Average ankle dorsiflexion improved significantly (p < 0.0001) from -1.15 ± 2.15 degrees preoperatively to 10.65 ± 2.02 degrees postoperatively. FADI scores also significantly increased (p < 0.0001), from 47.54 ± 12.26 preoperatively to 80.46 ± 14.04 postoperatively. All patients had a negative Silfverskiold test at final follow-up. Conclusion: Partial postero-medial superficial release (PMSR) of the crural fascia was found to be an effective outpatient procedure when used to relieve foot pain in those patients with an isolated gastrocnemius contracture. Patients who have failed conservative treatment can expect notable improvement with satisfactory FADI scores after the procedure. Future prospective studies should involve a larger number of patients with no additional procedures to be compared with gastrocnemius muscle release procedure for isolated gastrocnemius contracture with associated foot pain.