The gastrocnemius (gastroc) and the soleus are two muscles that make up the calf. The gastroc is the larger and more superficial of the two muscles. The soleus is a deeper muscle within the lower leg. The gastroc tendon combines with the soleus tendon to form the Achilles tendon.

Tightness in the calf can limit how far the ankle can flex up. This may make it difficult to walk with the heel on the floor. Over time, calf tightness may contribute to many foot problems, including heel pain, Achilles tendon pain, flatfoot deformity, toe pain, and bunions.

Gastrocnemius Release

A gastrocnemius release lengthens the gastrocnemius tendon. This is done to increase the flexibility of the calf muscle, which can decrease pressure at the front of the foot, improve function, and decrease deformity.

Diagnosis

Your foot and ankle orthopedic surgeon may recommend this surgery if you have tightness of the gastroc that has not improved with stretching exercises. This procedure can be combined with other reconstructive procedures or be performed by itself.

Surgery may not be recommended if you can obtain an appropriate range of motion and flexibility with conservative treatment (stretching). It should also be avoided if there are contractures of multiple tendons in the leg, and not just the gastroc.

Treatment

Your surgeon may perform this surgery through several different incisions. Most commonly, a small incision is made on the inner side of the lower leg. Sometimes an incision directly in the back of the calf is used, or even an endoscopic incision, which is about ½ inch. Once the gastroc tendon is identified, it is separated from the underlying muscle belly of the soleus, then cut straight across. Once the tendon is released, the ankle is flexed up and an increased range of motion is noted intraoperatively.

Recovery

For the first two weeks after surgery, the patient typically is immobilized in a splint or boot. It is important to keep the ankle in a proper position while the tendon is healing. A cramping feeling in the back of the calf is normal. Gentle range of motion and stretching exercises begin once the ankle is removed from the splint/boot. Timing can vary depending upon the other procedures that are performed.

Risks and Complications

After a gastroc release, some patients experience nerve injury that results in irritation or numbness over the outside of the heel. This usually is temporary. In addition, some patients may notice a difference in the appearance of one calf compared to the other and temporary calf weakness.

FAQs

Why are my calf muscles tight?

Most frequently a tight calf muscle is an inherited problem that only causes problems later in life. Other reasons for calf tightness are nerve injuries, muscle problems, and other medical problems like stroke and diabetes. People can also get tight calf muscles after trauma to the leg, ankle, or foot.

Will a gastrocnemius lengthening affect my strength or ability to walk?

This procedure will cause some weakness but most patients will not notice it. Some patients may have a subtle limp, but this typically resolves within six months of surgery.

Ganglion Cyst

A ganglion is a cyst that forms on top of a joint, ligament, or tendon. The cyst is filled with fluid. Because the ganglion is not cancerous and may disappear in time, if you do not have symptoms such as pain, your doctor may recommend observation only to make sure that no unusual changes occur.

The procedure to remove a ganglion is called ganglion resection. The initial treatment of a ganglion is not surgical, but if pain becomes a problem, your foot and ankle orthopedic surgeon may recommend aspiration, a procedure to remove the cyst’s fluid through a needle. If the cyst returns, surgery to remove the ganglion might be an option.

Diagnosis

A ganglion may cause pain. The enlargement of the ganglion may cause skin irritation or make it difficult to wear shoes. The ganglion may cause pressure on nerves and produce burning, tingling, or numbness. For some patients, the appearance of a ganglion may not be acceptable.

If the ganglion is not causing any problems, non-surgical treatment may be preferable. Your doctor may recommend surgery if your symptoms are not relieved by non-surgical methods, or if the ganglion returns after aspiration.

Treatment

Ganglion resection typically is an outpatient procedure and patients are able to go home the same day. You can be given a local or a general anesthetic. The choice depends partly on which you prefer, and partly on what your surgeon thinks is best. Often, local anesthesia is used in conjunction with IV sedation.

Usually open surgery is done, though in certain circumstances your surgeon may recommend arthroscopic surgery. The entire ganglion wall is removed and some surrounding tissue that may be the root of the ganglion is removed to prevent recurrence of the ganglion cyst. The cut made in the skin to resect the ganglion is at least as wide as the lump. The wound will be closed with sutures and covered with a dressing.

Recovery

Your doctor will decide whether the foot and ankle requires immobilization in a cast or boot following surgery and also whether or not you can walk with full weight on the foot right away. If not, you may require crutches for a period of time.

There is some tenderness, discomfort, bruising, and swelling after surgery. Pain medications, elevation and rest help during wound healing. The wound should be kept clean and dry. It usually will heal within two weeks.

You will have a scar instead of a ganglion. The skin around the scar may be permanently numb. You should avoid footwear rubbing against the scar.

Normal activities may be resumed 2-6 weeks after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications from a ganglion resection are rare and seldom serious. Ganglion resection surgery can occasionally result in pain or scarring. Recurrence of the ganglion will happen in 1 out of 5 patients.

FAQs

Would you recommend removal rather than aspiration?

Aspiration (removal of fluid through a needle) of the ganglion cyst and injection of steroid is less invasive than ganglion resection but there is a relatively high rate of recurrence. It is reasonable to simply observe the ganglion cyst if it is causing no problems or to have it aspirated and injected to see whether this is effective before considering surgery.

May I continue to exercise after surgery?

Depending on several factors, including the size and location of the wound, your doctor will advise you when it is safe to return to exercise. It is usually between 2 and 6 weeks after surgery.

Can this surgery make me worse?

This is possible but unlikely. Ganglion resection will result in a scar and there is a 1 in 5 chance of the ganglion coming back after the operation.

Will my foot be pain-free after surgery?

If you have foot pain that is not related to the ganglion then this may not be relieved by ganglion resection.

Flexible Hammertoe Deformity

This surgery is used to treat flexible hammertoe deformity. A hammertoe deformity is one in which the toe is bent and looks like a hammer. A flexible deformity is one in which the toe can be manipulated into a straight position. This deformity can cause shoe problems, corns, and pain with walking.

This procedure also can be used to treat conditions in which the toe deviates or crosses over the remaining toes. Prior to considering surgery, a course of non-surgical treatment should be attempted, including shoe modification, splinting and toe sleeves.

The goals of the surgery are to improve the alignment of the toe and reduce pain, eliminate any prominences that can lead to corn formation, and improve shoe accommodation.

Patients with a history of poor circulation and loss of feeling in the feet and toes are at higher risk of wound healing problems, infection, and compromise of the blood flow to the toe.

Treatment

This surgery is performed as an outpatient procedure, meaning the patient can go home the same day. The patient may be under general anesthesia or awake with numbing medication injected into the foot. A tourniquet is applied to your foot to minimize blood loss.

Your foot and ankle orthopedic surgeon makes an incision on the bottom of the involved toe. There are two tendons to each toe that help to flex or bend the toe. One of the tendons is transferred to the top of the toe. It is then attached to the tendon that extends or straightens the toe through an incision on the top of the toe. A pin may be inserted into the toe to help maintain alignment for a number of weeks after the procedure.

Recovery

Patients typically are allowed to walk after the procedure in a post-operative shoe. If other procedures are done simultaneously, this may restrict your ability to weight bear for a period of time after surgery. Sutures generally are removed two weeks after surgery. The toe sometimes is taped to help maintain alignment for several weeks. Patients can be allowed to return to regular shoes approximately four to six weeks after surgery. Swelling can be expected within the toe, possibly for many months after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications from this procedure include stiffness of the toe and potential recurrence of the deformity.

FAQs

When can I return to work?

Return to work is variable and depends on the nature of your occupation. In general, return to a sedentary job can occur over a few days to two weeks. More physically demanding occupations will require a longer recovery.

When will I be allowed to drive?

If the surgery involves the non-driving foot, you can drive within a few days of surgery. If it involves the driving foot, it may be several weeks before you can drive. It is important to discuss this with your physician prior to undergoing surgery.

Flexor Hallucis Longus (FHL)

A flexor hallucis longus (FHL) tendon transfer to the proximal phalanx is used to treat clawing of the toe.

Small muscles in the foot help to stabilize the toes. When those muscles are weakened by disease, an imbalance occurs that leads to clawing. The clawing puts abnormal pressure on the ball of the foot that can cause an ulcer to form. In addition, clawing may lead to pressure on top of the toe from shoes. Clawing is associated with a variety of underlying disorders, including Charcot-Marie-Tooth disease, diabetic neuropathy, traumatic brain injury, polio, and stroke.

The primary goal of an FHL tendon transfer is to decrease the abnormal pressures on the big toe. This will prevent ulcer formation, or in the case of an existing ulcer, promote healing. An FHL tendon transfer often is done at the same time as other foot procedures.

Diagnosis

Indications for the FHL transfer are clawing of the toe with pain and/or ulcer formation that cannot be improved with shoe modification.

This procedure should not be done when there is uncontrolled infection of the soft tissue or bone of the toe. Also, surgery is not recommended if you have poor circulation that would prevent proper healing.

Treatment

Once the patient is under anesthesia, the foot and ankle orthopedic surgeon makes an incision along the inside of the toe. The surgeon takes care to protect the nearby nerve and artery. The tendon is released from its attachment and a stitch is placed into the end of it. A hole is drilled in the bone at the base of the toe close to the metatarsophalangeal (MTP) joint. The tendon is passed through the hole from the bottom of the toe up to the top of the toe, and a stitch is used to tie the tendon securely back to itself.

Although releasing the tendon can allow the toe to straighten, release of the contracted joint capsule often is necessary as well. In many cases, the FHL tendon transfer is used in combination with other procedures to correct other foot deformities.

Recovery

Typically, the foot is splinted for 10-14 days while the incision heals. At that point, stitches are removed and a walking boot is worn for four weeks. During that time weight bearing in the boot may be allowed. If there are other procedures performed at the same time, weight bearing may be delayed and a cast may be necessary. Swelling can persist for several months.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Complications specific to the tendon transfer include loss of fixation of the transfer and/or recurrence of the deformity. Stiffness at the big toe MTP joint also can be a problem.

FAQs

I have an ulcer on my big toe. Can I still have surgery?

While not ideal, some ulcers may not be a barrier to surgery, especially since an FHL tendon transfer usually helps with ulcer healing.

Flexor Hallucis Longus

The flexor hallucis longus (FHL) is the primary flexor muscle of the big toe. It originates at the back of the leg, transitions into a long tendon as it enters the foot and attaches on the bottom of the big toe.

The peroneus brevis (PB) muscle starts in the leg and continues along the outside of the ankle. It then takes a sharp turn and ends on the outside of the foot. The peroneus brevis works with the peroneus longus (PL) to turn the ankle and foot outward.

The FHL to PB tendon transfer is a surgery to improve the function of the foot. The FHL is passed behind the ankle to the outside of the foot to either assist or replace the damaged PB tendon.

The goal of this surgery is to restore the power of the ankle and foot to turn outward, which is required for cutting and turning movement.

Diagnosis

Repeat ankle sprains can lead to peroneal tendon tears. If left untreated, the tendon may be irreparable, requiring a tendon transfer. Nerve disorders with poor muscle function (often seen in the cavus foot) also may require a tendon transfer.

Patients with active infection should not have this surgery. Vascular disease, poorly controlled diabetes, or heavy smoking also can be reasons to not have this surgery.

Treatment

An incision is made over the course of the PB around the outside of the ankle. The PB is examined carefully and any degenerative portion is removed. A second incision is made on the inside of the foot and the FHL is identified and pulled from the inside of the foot to the outside of the foot where the PB inserts. The FHL can be directly attached with a screw or suture to the bone where the PB inserts. After the tendon transfer, the wound is closed with sutures.

Recovery

Recovery varies from patient to patient. Six to eight weeks of rest may be needed and is dependent on associated procedures. This is followed by physical therapy and gradual return to activity. Return to full function may take up to a year.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. With this procedure there also is the risk of continued PB problems, persistent weakness and scarring.

FAQs

What happens to my big toe if you are transferring the FHL?

Full toe function will not be lost because there is another tendon that attaches to the great toe to help flex it. Following transfer, it is expected that the patient will lose some strength of the great toe. Despite this, patients are satisfied with their toe function.

What outcome can I expect from this procedure?

Isolated tendon transfer has shown good results. However, outcomes are difficult to predict as the procedure is often performed with other procedures, such as correction of a cavus foot.