The shortness of the gastrocnemius muscle: the cause of a lot of complications.

    

Casimir Kowalski, Médecine et Chirurgie du pied,

kowalski.casimir@gmail.com

SUMMARY

The consequences of a shortness of the suro-plantar system are numerous and, practically, they are often encoutered after an idiopathic retraction of the gastrocnemius which concerns more than half the population, whereas the idiopathic retraction of entire the tricipito-plantar muscular system is rare. The retraction of the gastrocnemius is often encoutered and can be painful in itself; it involves an overload of the forefoot (with all the known deformations - including those of the toes), imbalances the foot and destabilizes the whole body; it has effects on articulations located far above the foot, without counting the reduction in effectiveness by the sportsman, and the reduction in stability and thus in balance. The prevention by lengthening of the gastrocnemius during growth by physiotherapy, carried out during gymnastic courses, should enable an important financial economy. It would avoid many complications and it must also be taken into account by adults, in particular by  women, sportsmen and  elderly people.

 

INTRODUCTION

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         Whereas the idiopathic brevity of the  entire sural triceps (static red muscle) is rare, the brevity of the gastrocnemius (dynamic white and polyarticular muscle) concerns more than half of the adult population, it is not possible to lengthen the short sural triceps by simple physiotherapy (asurgical lengthening of the tendon  would be necessary), but the gastrocnemius can be lengthened by appropriated postures.

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The gastrocnemius inserts itself from the toes until above the knee’s articulation. With the soleus it makes up part of the suro-plantar system.

The complications related to a too short gastrocnemius are represented bypathologies of the foot and overlying segments (1). During 25 years of observations, we recorded more than 30 possible complications (2). The gastrocnemius is found too short after a peak in growth, generally during adolescence. Thanks to the growth, it involves osseous modifications which are not corrigible any more during adulthood but whose painful repercussions can still be relieved by simple physiotherapy. In old people, this brevity can be accentuated ; one should then speak about "retraction". After proprioceptive lengthening of the gastrocnemius, in the absence of maintenance exercises , one also sometimes observes repetitions: the term of "retraction" is then adapted.

In  adult, the bone, although less malleable than  in children, can still undergo modifications : e.g  phenomen of torsion under the effect of the muscles and gravity.

One should not forget that the two fundamental principles of  muscular actions of the lower limbs are:

- the action starting from a fixed point which is the foot or the segment of foot in contact with the ground,

- the eccentric action of the muscles which thus act generally by lengthening while spending a minimum of energy (the concentric action requires much more of it).

Thus, during walking, the  triceps, in synergy with the plantar muscles which constitute together a vast digastric unit , controls, while lengthening, the closing of the tibio-pedal angle and the metatarso-phalangeal angle and  the calcaneus becomes a  sésamoïd when the heel leaves the ground.

 

I. THE "NORMAL" FOOT

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We examined 2000 feet : in maternities , in old people,  in nurseries , in schools  and in supermarkets.

It appears from this study

- that the idiopathic shortness of the whole   triceps is rare and in our experiment,physiotherapy does not make it possible to lengthen it.

- that the shortness of the gastrocnemius alone is very frequent : at the end of growth, more than half of the population has too short gastrocnemius and  more often with girls than with boys.

- that with new-born babies, because of the presence of a genu flessum, we could not observe short gastrocnemius.

- that the greatest frequency of the short gastrocnemius appeared at peak times  of growth during puberty and adolescence, sometimes within a few weeks or a few months

- that during the first five years,one very seldom observed a shortness of the gastrocnemius

- that generally, the brevity of the gastrocnemius was bilateral ;   in the event of unilaterality, one observed pathologies on the side where the gastrocnemius was the shortest.

- that at the end of  growth, more than half of the population presented too short gastrocnemius

- that during  adult life, a shortening - however less important - was more often observed among women and also among old people. Among women, one can blame  high heels but a particular and opposite phenomenon was observed in a lot  of them: they wear high heels at  the end of adolescence because they feel badly with bare feet ; the gastrocnemius were found short during  growth and that is what led them to wear high heels which respects the shortness of the gastro-plantar system.

 

II. BIOMECANIC CONSEQUENCES OF THE SHORT  GASTROCNEMIUS

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In an upright position, when the knees are extended, the sole of the foot must be laid out at a right angle in comparison with the leg. When the gastrocnemius is short, this is possible under the effect of the body’s  weight thanks to an eversion of the hindfoot which enables it to circumvent it. That results in a VALGUS of the hindfoot (we prefer the term "valgus" rather than pronation because the deformation exists in the frontal plan just like the valgus of the knees). The foot adapts  itself "while cheating".

The value of the VALGUS is proportional to that of the shortening of the gastrocnemius. This valgus is corrected while standing on the toes. An equivalent test consists of raising passively in extension the big toe of the subject in an upright position; it is positive when the valgus is corrected i.e. when it is not yet fixed. This is the "big toe test".

But the stronger  the VALGUS is, the more the foot flattens itself.  All will depend in fact on the laxity or  the musculo-ligamentar firmness. A lax foot will result in a print of flat foot. A foot whose muscular elements are firm will give a print of cavus foot. However, the print is only of relative importance.

What counts, for a foot, it is, independently from its form, the harmonious distribution of the pressures on the ground and not its concept of "flat" and "cavus". The electronic podometer can be useful. One observes feet with normal print which are flattened while walking - and vice-versa. Interpretation must thus be essentially dynamic. One observes sometimes a spontaneous evolution of a "flat" foot in a “cavus" foot (with obligatory passage by a normal print) with the approach of puberty when the muscles are hardened).

The great majority of feet with short gastrocnemius lead to cavus valgus feet whose complete and typical forms are characterized in a third of the cases by:

-  a valgus of the hindfoot

-  an internal projection of the navicular and medial malleolus

-  a cavus of the lateral side of the foot

-  a “break” of the lateral side of the foot as if the plantar muscles and the external aponevrosis took part in the shortening: the underlying osseous elements  with the external edge of the foot are found "shortened" and the 5th metatarsal sometimes takes an S-form, its head being deviated towards the outside.

-  a big  toe “en barquette”  (flexion of the proximal phalange and extension of the distal phalange one).

But all these characteristics are not always present and one of them may be lacking.

On a frontal X-ray of the feet under weight, the interarticular  space lines of the tarsus lost their parallelism and their slope towards the outside representing the shortening of the lateral edge of the foot. On  X-rays  of ankles, one sometimes observes a reduction of height of the tibial epiphysis of the lateral side translating the obliged valgus

During growth, the osseous deformations which result from a too short gastrocnemius will become irreversible with time and it is no longer possible to correct them except by surgery. One could avoid the osseous morphological modifications by physiotherapy. This shows the importance of the systematic school examinations and the help of the physiotherapist before subjective complaints  appear.

If a foot is considered to be cavus valgus or flat valgus, it is, therefore, not pathological "the cavus foot encumbers our consultations; the flat is rather rare "(Méary). In the great majority of cases, it is not a question of pathological feet but rather of " risky feet ".

 

III. PATHOLOGICAL CONSEQUENCES OF THE SHORT GASTROCNEMIUS  ________________________________________________________________________________________________________

In addition to the sometimes unaesthetic consequences or the deformations to shoes, the consequences of a short gastrocnemius  consist in related pains

-  to muscular shortness

-  to the overload of the forefoot

-  to the obliged valgus hindfoot,

-  but also to a lack of balance highlighted by the monopodic positions.

Not only counting that the lengthening of the gastrocnemius improves  sporting performances at starting moments, one should not forget  that a muscular disease or severe evolutionary neurological desease can appear because a retraction of the gastrocnemius.

 1.   MUSCULAR BREVITY

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Lots of children, especially in the first years of childhood, are bad walkers. It is believed that they are lazy and ask without delay that one carry them when walking  with the family. Very few children can say why is difficult for them to walk. When they are older than can describe their pain. This pain can increase : after  gymnastics, in the evening, they may cry because of cramps in the calves. Four weeks physiotherapy relieves them completely. These cramps were observed in adulthood but the patients - and especially  women - generally do not speak about it and  upon questioning the doctors are informed.The treatment of proprioceptive physiotherapy is generally  successfull.

It’s necessary  to be able to think of an angioma of the calf of a child, and in the adult, to necrosing arteritis (the existence of vascularites limited to the calves is well-known during localised forms of periarteritis nodosa; more rarely this possibility is found in  Crohn’s disease).

There is also pain at the insertions of the leg bones  in the balancing muscles:

 - a patient complained about his legs when running : infiltrations relieved it only temporarily until the day  dynamic x-rays required by revealed a very important diastasis of the ankle joint; the patient had in the past presented a sprain for which he no longer complained; the surgery of this ligament  completely relieved  him.

 - a soccerplayer  had to undergo a posterior fasciotomy (the pressure measured in the msucles of the calf increased after effort); the lengthening of his gastrocnemius by physiotherapy relieved the pain

 - an additional  solear muscle must also be found

 - the possibility of compression of the popliteal artery at the high insertion level of the gastrocnemius was mentionned

Chronic pain can appear along the plantar fascia.

The plantar talagia occurring in the adults is an expression of it : a fasciitis of insertion to the calcaneus.The chronic inflammatory state can be at the origin of a fibrosis compressing a branch of the  plantar nerve and making this affliction rebellious; it then requires a surgical neurolysis.

In adolescents, the apophysis of the calcaneus represents the hinge between the tricipital muscle and the short plantar muscles. When jumping on the toes, this digastric muscular system, which is a powerful shock absorber, acts on the apophysis not yet welded with the main part of the calcaneus (it  appears about the age of 8  and is welded with the principal part of the calcaneus about the age of 14). It is the calcaneal apophysitis. (microfractures). Two weeks of immobilization in a cast   or lengthening physiotherapy by 4 weeks make it possible for  the sportman to resume his activity more quickly than by resting  several months, which does not always solve the problem.

Although the shortened system is exposed to lesions, in particular the calcaneal tendon, it is possible that the stretchings carried out after the acute painful phase are part of the treatment. What one is unaware of, in general,  is that one relieves or one prevents this tendinitis by lengthening the gastrocnemius.

The ruptures of the calcaneal tendon occur readily with mature adults who, for example, abruptly accept to play soccer, sport which they have stopped for a long time. We noted that ruptures occurred readily in people who had short gastrocnemius. Why? Because generally the retraction is bilateral and it is observed on both side. The case is the same for the ruptures of the medial head of the gastrocnemius.

It is obvious, that a muscle will be more effective when it has a normal  length considered as normal. So it has definitive action on the start  in all sports. However, depending on the muscular constitution, we noticed that a considerable amount of teenagers were very fast during a sprint, while having short gastrocnemius; for others, that constituted a handicap.

The brevity of the plantar system of the gastrocnemius and short plantar muscles involves a more important varus at the time of the end of a step and when we land on tiptoes: causing instability and predisposition to lateral  sprains of the ankle.

Finally, the rapid fall of the forefoot caused by the shortness of the gastrocnemius can be at the origin of a tendinitis of the tibialis  anterior which goes under the retinaculum of the extensors (an immobilization with a walking cast for 3 weeks with the foot in dorsal flexion allows a lengthening of the gastrocnemius and the resting of the tendon).

The cavus of the lateral side of the foot results from the "shortening" of the short plantar muscles which prolong the triceps. It is less noticeable when it appears only in upright position because the overload of the anterior heel is effective only during walk. It is well-known that, normally, the lateral side of the foot accepts less load during walking, but for  a longer  time than the other segments. But during prolonged running, it plays an essential part. When the cavus exists on the osseous level, there are no simple means to make it disappear.

It is responsible for shock waves projecting themselves into the higher segments up to the spine worsening a preexistent lesion. When soles are prescribed, one should make sure that all the lateral side keeps a permanent contact with the ground, when they persist or appear during walking, by adding an elevation which makes it possible to fully support  during  the step.

Finally, a short gastrocnemius has, after installation of an ankle prothesis, a "nut-cracker" effect on its former part and that leads to the displacment of the prosthesis (4). It is thus important to take into account its lengthening.

 

2.  OVERLOAD of the FOREFOOT

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Examinations by electronic podometer make it possible to highlight a clear overload of the forefeet not only so much in intensity and duration but by a faster collapse of the forefoot (there is a greater impact). As a result, there are métatarsalgias in adulthood which could be relieved or decreased, in the large majority of cases.

This retraction of the gastro-plantar system generally results in a métatarsalgia for several reasons:

 - shortness of the gastro-plantar system

 - the valgus that this shortness imposes on the hindfoot

 - the non-participation of the lateral side under weight, which is the consequence of a retraction of the short plantar muscles

 - the non-participation of the toes

 - the postmenopausic atrophy of the under-capital plantar cushion

 - a displacement of the scapular plan towards in upright position

 - the lack of muscle mobility in the shoes

 

a.   Shortness of the gastro-plantar system.

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The retraction of the gastro-plantar system makes it possible to highlight, on an electronic baropodometer, a clear overload of the forefoot in intensity as well as in duration.

As a result, there are metatarsalgia in adulthood. The central métatarsalgias (or convex forefoot), which is most common, does not result from a flattening of the forefoot. But since the métatarsals II and III have a reduced mobility in comparison to their neighbors, the disposition of the heads with lesser semi-circular concavity when the foot is under weight, enables them to play the part of a shock absorber while  supporting  the five metatarsal  heads. The muscular atrophy and the ligamentar distension streching, which result from an overload and too narrow shoes, reverses this spring, which then loses its effectiveness. The central heads, having reduced mobility, receive all the load because they continue to keep their usual place whereas their neighbors rise.

The diaphysis of the second métatarsal, being less mobile, can be the center of stress fracture following long walks.

Another thing occurs when another metatarsal head goes down lower than its neighbors:  it will support the most load. The forefoot is examined while the knee is extended; sometimes one can observe a fourth head (or a fifth, sometimes a first one) located   one cm or even  two cms lower than the others. If it repostions itself during the bending of the knee, the physiotherapy can relieve the metatarsalgia.

A metatarsal bone (generally the second) that is too long can also become painful because it receives maximum loads. It can be shortened by a suitable osteotomy. But one will initially try to lengthen the gastrocnemius. When the capsulo-ligamentar, and in particular the palmar plate, are torn, a vertical Lachman’sign is observed. It is absolutely contrindicated to practise an infiltration in this case because the evolution would be carried out unrelentingly on the dorsal luxation of the first phalanx.

Sometimes the first head is the center of a painful callus (in the hollow foot interns); in a compensation, the patient avoids it and overloads the lateral heads - this could give the impression of an existing cavus forefoot which would be the contrary of the convex forefoot.

It can also be a stress fracture of a sésamoïd bone which can be relieved by the lengthening of the suro-plantar system insofar as the pain is not too great. If not, a rest period will be followed by physiotherapy.

The articular pains of a hallux valgus or a hallux rigidus are due to an overload of these articulations and even in radiological osteoarthritis, we observed complete relief.

A particular form of métatarsalgia is represented by the overload of the 5th métatarsal. Clinically, there is a pain over all its length and the electronic baropodometer shows there is an overload.These pain, among the few cases we observed, was relieved by proprioceptive lengthening of the gastrocnemius.

Morton’s disease was relieved by lengthening the gastrocnemius or incompletely improved, sometimes surgery could not be avoided.

 

b. The hindfoot valgus imposed by this shortness

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The retraction of the gastro-plantar system imposes on the hindfoot a valgus to enable it to reach the right angle in upright position.

The valgus moves the center of gravity towards the inside part. It is equalized by the first métatarsal in abduction. It can cause a hallux valgus due to the shoe.

The adduction is worsened with each step by the surrounded articulations (principle of the surrounded articulations: the displacement of the distal osseous segment of an articulation moves in the other direction the proximal osseous segment). And the more the first métatarsal moves away from the central axis of the foot, the more the heads which are closer are overloaded.

The valgus horizontalises the peroneus longus muscle; which destabilizes the first métatarsal; it overloads the heads II-III.

 

c. The non- participation of the lateral side in load

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An examination by electronic baropodometer allows us to see that a normal foot in upright position can become cavus during walking.  The surface is then reduced and the pressure is also increased on the forefoot.

 

d. The non-participation of the toes

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The overload of the forefoot involves the constitution of hammer toes. It is understood that the métatarsal heads are overloaded  since these toes loose their function and  no longer relieve these heads; on the contrary, they push them downwards.

 

e. The atrophy of the plantar forefoot cushion at the old person

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The metatarsal heads can be felt under the skin. It is necessary to replace this shock absorber by an orthotic artificial shock absorber.

 

f. A forward scapular displacement.

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 Regularly, we observe a displacement of the scapular plan forwards compared to the gluteus plan in the event of short gastrocnémius, especially when the harmstrings are also too short.   In these cases, already in upright position, we observe an overload of the forefeet on the electronic baropodometer, sometimes with an active bending of the toes.

 

3.  VALGUS Of the HINDFOOT

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The valgus is harmful, in particular on the aerodynamic level by the sportsman.

The VALGUS deports the centre of gravity to the inside. The result is  an  imbalance which, on the level of the first ray of the foot, can be compensated in several different ways of which the goal is to increase the internal the surface of lift:

- either by imbalance over of the midfoot on the ground  constituting  a true flat foot of which, sometimes, the suffering in the form of callus is located upstream of the first metatarsal

- or by abduction of the first metatarsien (compared to second metatarsal) which will support the hallux valgus when a certain ligamental laxity allows it : there is a luxation of the first head  on  sesamoïds. When surgery is necessary, an osseous deformation must always be corrected by working on the bone - whatever the age - unless working beforehand on the cause. Pronation of the big toe (or sometimes supination) which accompanies the hallux valgus supports the ingrown of the external edge of the nail since the skin is crushed between the ground and the nail; but the raised internal edge can undergo the same fate because of the shoe.

- or in children, to compensate  the displacement of the centre of gravity, the hallux positions itself  in abduction while deviating from its neighbors (it is not  "a primitive foot").

- or by the constitution of a hallux in a small boat (plantar flection of the proximal phalanx and extension of the distal phalanx), which, by reflex, when the ligaments are resistant so that they do not allow a  displacement of the first métatarsal, moreover pushes the first toe on the ground and causes  hyperpressure of the métatarso-phalangeal articulation; which predisposes  a hallux rigidus. A callus can occur under the interphalangeal articulation of the hallux. And the toe in the small boat, because of the hyperextension of the distal phalanx, predisposes exostoses under the nail because of the microtraumatisms undergone in the shoe and, for the same reason, can be responsible of a thickening of the nail leading to onychogryphose.

- or by a  claw hallux :  in children, it has been corrected  by simple physiotherapy ( lengthening of the gastrocnemius).

 

The VALGUS straightens up he tarsus last bones of (wedge-shaped and cuboïd) and the peroneal becomes horizontal:  we saw it by  métatarsalgia.

The VALGUS favors the deformation in S-form of the fifth metatarsal which deviates from the fourth, with adduction of the corresponding toe caused by  the shoe.  A painful bursite can appear. (tailor’s bunion).

The VALGUS accompanies a rotation of the top of the foot to allow the forefoot to adapt itself on the ground in supination. With age, osteoarthritis can develop there. The retraction of the gastrocnemius being accentuated with age, the rotation can be accentuated after menopause and involves intolerable pain : the imbalance of the foot is accentuated. The test of the passive "torsion" of the forefoot in pronation arrouses the pain. The pain are due to the stretching of the ligaments or settled osteoarthritis ; a jamming in an articulation of the midfoot  explains sometimes the sudden pain of the syndrome of "torsion" of the midfoot ("torsion" is an incorrect term when one considers the movements in the articulations but it is understood better by the patients) the temptation of a arthrodesis can occur but we did not have the occasion to practise it since we proceed in a lengthening of the gastrocnemius by an physiotherapist who knows  the technique.

The VALGUS slackens the short peroneal muscle which is an essential balancing muscle. The motion of the calcaneum under the talus is more important during the posterior step (in varus); the short peroneal cannot respond to the demand; so that an instability and an additional predisposition to the distorsions follows. It is the “risky foot” in sports’ medicine.

The VALGUS predisposes for the same reason to the tendinitis of the short peroneal but also, to the tendinitis of the posterior tibial which controls the excessive valgus and whose treatment initially requires the lengthening of the gastrocnemius and sometimes surgical correction of the valgus: lengthening of the external edge when the flexibility of the foot allows it or an osteotomy of the calcaneus or a double arthrodisis when the foot is fixed. The medial supernumerary tibial bone, inside the posterior tibial, can be the cause of pain by a valgus and undergoes an avulsion following a trauma. Is its presence not already a consequence of the too important action entailed by the posterior tibial because of the valgus?

While speaking about the tendinitis of the posterior tibial, let us talk about the syndrome of the tarsal tunnel syndrome (which sometimes accompanies it) and which was relieved on several occasions by prorioceptif lengthening of the gastrocnemius. The association of both required a transfer inside by osteotomy of the calcaneus.

A VALGUS can be responsible for a stress fracture of the fibula which constitutes, according to Blaimont, the cane of the tibia. Among walkers, submitted to too many constraints, the cane breaks above the ligaments and an horizontal stroke appears there. If this fracture can be cured after a certain rest, as soon as possible, the lengthening of the gastrocnemius will hasten the cure and will prevent a renewal during long walks.

A VALGUS can be responsible for an "impigement syndrome" between the lateral malleolus and the tarsus, especially in older women when the imbalance of the hindfoot is accentuated by valgus. It leads to until fibulo-talian osteoarthritis.The increase in a varus of the knee can be the starting point for it.Sometimes  a valgo-osteotomy of of the knee  must be done when  the pain is unbearable.

The VALGUS of the hindfoot is accompanied by a internal rotation of the lower limb (the hindfoot behaves like a Cardan joint).From there internal strabism of the kneecaps and predisposition to the external syndrome of hyperpression by increase of the angle Q of the quadricipital muscular system. The patellar pain were observed by children whose kneecaps were perfectly centered but   there was a shortness of the gastrocnemius: the pressure on the kneecap being larger when one breaks up the tension fields of the too short muscle. (a relief was obtained by proprioceptive lengthening of the gastrocnemius). During the growth, the anterior tibial tuberosity moves gradually in the other direction, i.e. towards the outside, under the effect of the fascia lata, to constitute at the end of the growth an offsetting of the anterior tibial tuberosity  which is more important  where the gastrocnemius is the shortest.  This pain can disappear by a simple treatment by physiotherapy even by an already existing offsetting of the anterior tibial tuberosity .

But we observed syndromes of the strip of Maissiat and sign of projection of the fascia lata on the great trochanter, caused by the internal rotation of the lower limb related to the valgus, relieved by lengthening of the gastrocnemius.

We will mention the harmful effect of the internal rotation of the lower limb on the posterior part of the acetabulum, than we did not have the occasion to study but which is discribed by certain posturologues.

The VALGUS, by the internal strabism of the kneecaps, involves a hyperlordosis. That predisposes, in adulthood, an overload of the posterior pillar of the spine ("facet syndrome" or even "kissing spine"), characterized by pain appearing in upright prolonged station, worsened by the extension of the spine and relieved by the adoption of the foetal position or simply by the sitting position. These pains involve "referred pains" in the lower limbs which also support the muscular retractions.

In the posterior vertebral syndrome, the test of the tiptoes zith interna position, in upright position, causes pain by hyperlordosis.The lengthening of the gastrocnemius we know that the VALGUS of the hindfoot which involves a internal displacement of the centre of gravity was not studied as for its effect on the medial compartment of the knee. And the presence of short gastrocnemius was not taken into account in the phenomena of exaggerated torsion of the tibia and the femur leading to complex deformations of all the lower limb. The physiotherapy has the same goal and seems more logic to us and more economic.

The hyperlordosis is compensated by a round back and a Scheuerman’s disease will only be more painful.

We were struck by the existence of an unilateral spondylolysis in young people around 20 when the shortening of the gastrocnemius was unilateral, located on the same side, and particularly marked (-50°). I found some cases of bilateral lysis for such important but bilateral shortenings. A similar case study should be made by taking into account the balance of spine onto the pelvis

Teenagers who undergo a strong spurt in growth and have very short gastrocnemius have their first lumbar vertebra crushed which is becoming trapezoïdal and which results of an exagerated hyperlordosis and the exagerated antero-posterior movements in flexion (flail phenomenon)

Finally, especially when a retraction of hamstrings accompanies that of the gastrocnemius, we observed a forward offset of the scapular plan compared to the gluteus plan. After two years of treatment, we succeeded in aligning the scapular plan on the gluteus level in a teenager presenting a very important offset and lumbar and dorsal pains.

 

4.  INSTABILITY:            

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The majority of the patients recognize that after lengthening of the gastrocnemius, they acquire a larger stability on their feet and a better balance. This is clear in sedentary people and in particular, the elderly. It is important, for them, to rehabilitate the plantar sensitivity, as well epicritic as well proprioceptive, which wanes with age. Candidates for an ankle ligamentous plasty can avoid it simply thanks to a proprioceptive lengthening kinesitherapy.

Various factors can be involved as in the "triad foot-knee-spine" (8) often met consisting in pains on three different levels: métatarsalgia, patellar pain by external hyperpression and a posterior vertebral syndrome on hyperlordose. This occurs more often among adult women. These pains, on several occasions, were reduced after simple proprioceptive lengthening of the gastrocnemius muscles.

 

5. TREATMENT 

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An abstention is regrettable and can result only from ignorance, strongly widespread, of the harmful effects related to the retraction of the gastrocnemiuns.

Non-surgical treatment should have priority because of its simplicity. It is wise to have well trained physiotherapists who practise feet postures on the ground: the results are better and quicker thanks to the signals received by the feet. Some rare patients manage to do without the assistance of a physiotherapist.

In some rare cases, where lengthening could not be obtained by physiotherapy, a cast set with the foot in dorsal bending while the knee is bent, made it possible to create a lengthening after 2 weeks.

A preventive treatment, established in schools during the gymnastics courses should permit an important financial economy on a national level.

The surgical treatment of the lengthening of the gastrocnemius should be performed in exceptional cases : the procedure is simple. Wether it is practised on the level of the calf (where even the simple section of the aponevrosis is enough) or on the level of the poplity hollow where the desinsertion of the median head is enough in so far as there are no anatomical anomalies.

It is advised to mobilize as of the first day with the risk to developping a fibrosis.

 

CONCLUSIONS

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 An examination of the foot cannot occur without the examination of the gastrocnemius muscles.

The lengthening of the gastrocnemius must precede any surgery on the foot when the pathology is dependent on its shortness.

It can still be carried out after surgery.

The prevention should be more important by maintaining the gastrocnemius long throughout growth. The gymnastics’ courses in schools should be an opportunity for carrying out this prevention.

Often pathologies related to a shortness or a retraction of the gastrocnemius can be relieved by a lengthening of these muscles thanks to a well led physiotherapy.

During our 25 years practice, period which enabled us to discover the complications described in this article, we sent between 10 and 11.000 patients to the physiotherapeutic treatment.

Statistics were made for the metatasalgia, patellar syndromes and posterior lumbar pain but the other complications should still be examined for statistical purposes.

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