Article by Dr. Misako McLeod, DPM
Patients often present with a complaint of pain in the back of the heel, the arch, the calf muscles, and often the hamstrings. A common complaint is cramping in the calves or legs which wakes the patient up at night. Many patients ignore the symptoms and often times, the symptoms will just resolve. However, cramps or muscle tightness during rest or during sleep often indicates other serious problem such as peripheral vascular disease (bad circulation) or nerve problems that commonly originate from the back, and lastly, tight calves, also known as ‘Equinus.’
When a patient reports cramps particularly during rest or at night, Dr. McLeod will obtain a history to rule out back issues such as sciatica, spine arthritis, radiculopathy (“pinched nerve”), as well as other vascular conditions such as peripheral vascular disease. Sometimes these symptoms are related to nerve and circulation issues and these more serious conditions will need to be ruled out first.
Another, less serious issue is called ‘Equinus.’ This is when a patient has very tight calf muscles that often times causes cramps at night. Equinus simply refers to tight hamstrings and calve muscles. This can be due to several reasons.
If Equinus is suspected, Dr. McLeod will evaluate the patient for the following:
The good thing is that most cramping and pain from Equinus can be relieved with a simple and consistent stretching program, and surgery is often not needed. Sometimes, an orthotic may be useful to elevate the heel and release tension on the achilles tendon when the patient is walking. Also, a night splint is often times recommended to help keep the achilles tendon gently stretched out and to prevent muscle spasm.
If a patient has an Equinus from more serious conditions such as cerebral palsy, stroke or other neurologic accidents, although conservative treatment such as stretching, bracing, and night splints do help, surgery may be of more benefit.
With regards to surgery, there are 2 main procedures:
1. Tendoachilles lengthening
This involves lengthening of the achilles tendon with very small stab incisions into the achilles tendon. The tendon is then gently lengthened by the surgeon manually. Once the desired lengthening of the tendon is achieved, the patient is placed in a non-weightbearing splint or cast depending as per the surgeon’s preference.
2. Gastrocnemius Recession
The next procedure, and the one most commonly used by Dr. McLeod, is an Endoscopic Gastrocnemius Recession (EGR). This procedure involves making a small incision on the inside of leg about 3 cm near the calve muscle belly. A small camera and blade are inserted, and under direct visualization are gently released. This improves the ankle joint range-of-motion and often alleviates the symptoms that the patient was suffering from. After the surgery, the patient is kept either non-weightbearing or protected weight bearing in a cam boot.
Here’s a video demonstrating Endoscopic Gastrocnemius Recession.
Another form of Gastrocnemius Recession involves an ‘open technique’ which involves an incision on the back of the leg and the release of the gastrocnemius aponeurosis.
Both Gastrocnemius recession and Tendoachilles lengthening is useful for diabetic patients with neuropathy to help prevent the development of a collapse of the foot (Charcot foot) and to relieve ulcers. Diabetics in particular are predisposed to the development of tight achilles, or equinus due to their disease process. The high sugars cause glycosylation of the achilles tendon and thus the development of equinus contracture. This doesn’t happen in all diabetics, but its a syndrome that commonly found in the diabetic population.