Updated: 10/4/2016

Gastrocnemius Recession

Review Topic

Preoperative Patient Care


Intermediate Evaluation and Management


Obtains focused history and physical

  • history
  • screens for conditions that can cause equinus
  • e.g. cerebral palsy, muscular dystrophy, charcot-marie-tooth
  • duration of equinus contracture
  • symptoms
  • pain, weakness, callusing, tripping, diificulty with shoe or brace wear
  • physical exam
  • recognizes factors that could predict complications or poor outcome
  • dystonia


Orders and interprets required diagnostic studies

  • radiographs (often not needed)
  • weight bearing foot films if unclear if cavus is the cause of toe-walking
  • hip xrays if associated condition (e.g. Charcot-Marie-Tooth) is associated with hip dysplasia


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • failure of serial casting
  • failure of bracing
  • describes accepted indications and contraindications for surgical intervention
  • Indications
  • persistent equinus in gait after failed nonoperative management
  • with a postive silverskild test for equinus only with the knee extended and not when it it flexedo
  • contraindications
  • lateral xray demonstrating cavus instead of equinus
  • negative silverskiold test
  • persistent equinus with the knee flexed and extended- and achilles lengthening may be indicated
  • dystonia- must exercise caution with tendon lengthenings in the presence of dystonia as the opposte reaction can occur.


Postop: 3-4 Week Postoperative Visit

  • wound check
  • change the short leg walking cast
  • measure for AFO brace (to be provided when second cast removed 6 weeks post-op)
  • diagnose and management of early complications
  • prescribe postoperative physical therapy and bracing
  • silverskiold test
  • popliteal angle, knee flexion contractures
  • range of motion hips, arms, asses for scoiliosis
  • asses gait, look for crouch

Advanced Evaluation and Management


Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
  • recurrent equinus
  • initiate stretching casts
  • night time stretching brace with knee immobilizer

Preoperative H & P


Obtains history and performs basic physical exam

  • check range of motion
  • performs a silverskiold test which evaluates ankle dorsiflexion with the knee flexed and extended
  • if tight only in knee extension but not in knee flexion then a gastronemius recession is necessary
  • if tight in both knee flexion and extension then an achilles lengthening may be necessary
  • identify medical co-morbidities that might impact surgical treatment
  • dystonia
  • hamstring contractures
  • if equinus is corrected and hamstring contracture is not corrected the child will crouch more


Screen medical studies to identify and contraindications for surgery

  • history of cardiac pathology need cardiac clearance
  • bronchopulmonary dysplasia, recurrent pneumonias, pulmonary insufficiency, need pulmonary clearance
  • screen for malnutrition if any GI history or malabsorpstion


Orders appropriate initial imaging and laboratory studies

  • weight bearing lateral foot films are occasionally indicated
  • can distinguish between cavus and equinus
  • gait analysis study
  • will identify associated pathologies in spastic patients with cerebral palsy that should be addressed at the same time for optimal care of the child
  • observers tend to overestimate equinus, so gait analysis is important to avoid lengthening the calf in children who do not require such surgery


Perform operative consent

  • describe complications of surgery including
  • overlengthening of the triceps surae

Operative Techniques


Preoperative Plan


Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
  • injury to sural nerve
  • injury to the lesser saphenous vein

Room Preparation


Room setup and equipment

  • standard OR table
  • this procedure is commonly performed as part of a SEMLS procedure (single event multilevel surgery)
  • may need a radiolucent table for the other procedures
  • tourniquet
  • right angle retractors


Patient positioning

  • prone for posterior incision
  • supine for medial incision
  • more conducive to doing concomitent procedures
  • patient is brought to end of table

Strayer Procedure


Makes either a posterior or medial incision

  • makes a 2- 2.5inch incision either posteriorly over the midcalf with the patient prone or medially with the patient supine
  • carry the dissection to the posterior fascia, which is then incised
  • do not confuse this with the gastrocnemius tendon


Protect the neurovascular structures

  • retract and protect the sural nerve and lesser saphenous vein

Fascia Lengthening


Divide the fascia

  • divide the fascia that overlies the superficial posterior compartment
  • place right angle retractor posterior to the gastrocnemius
  • this protects the saphenous vein and sural nerve


Identify the gastrocnemius tendon

  • identify the underlying tendon
  • identify the tendon of the gastrocnemius proximal to the conjoined tendon
  • identify the interval between gastroc tendon and the underlying soleus fascia
  • divide the fascia of the gastrocnemius transversly proximal to the conjoined tendon and leave the underlying muscle intact
  • gastrocnemius recession is done with a 15 blade


Test the lengthening procedure performed

  • test to see if the ankle can be dorsiflexed to ten degrees with the knee extended
  • it is essential that the hind-foot be inverted when performing this test
  • failure to do this will result in dorsiflexion coming from the foot (rather than the ankle) and will result in inadequate correction of equinus

Wound Closure


Perform a multilayer subcuticular closure

  • release tourniquet prior to closure and obtain hemostasis
  • the subcutaneous layer is closed with an absorbable 2-0 suture in a running locking layer
  • the skin is closed with a running, undyed absorbable monofiliament suture and steristrips
  • place in a cast with the foot in 5-10 degrees of dorsiflexion and inverted

Postoperative Patient Care


Perioperative Inpatient Management


Write comprehensive admission orders for patients undergoing SEMLS

  • advance diet as tolerated
  • IV fluids
  • pain control
  • physical therapy
  • cast management
  • keep cast elevated and heel off of bed


Discharges patient appropriately

  • orders pain medication for 7-10 days
  • orders diazepam for 14-21 days for spasm
  • schedule follow up in 1 week and 4 weeks
  • cast care instructions

Complex Patient Care


Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings

  • able to read do an obsevational gait analysis and make surgical recommendations based on this and physical examination findings
  • postoperative Infection
  • orders labs as part of baseline work up
  • manages wound infection in the outpatient setting with dressing changes and antibiotics when appropriate
  • recognizes and performs irrigation and debridement when necessary for a wound infection the requires more aggressive treatment.
  • complex regional pain syndrome
  • identifies the condition when it is present
  • limits immobilization and prescribes therapy for desensitization
  • refers to pain management in cases not responding quickly to desensitization

Please rate topic.

Average 5.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (1)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Case ID Date Hospital Faculty CPT Codes
Topic COMMENTS (0)
Private Note