Gastrocnemius release is an effective management option for Achilles tendinopathy: a systematic review

Achilles tendinopathy research has a gender data gap: A systematic review and meta-analysis

PURPOSE

A persisting gender bias has been recently highlighted in orthopaedics and sports medicine. The aim of this study was to evaluate the volume of gender-specific data and gender-specific results in the treatment of a common tendon disease, Achilles tendinopathy.

METHODS

Pubmed, Cochrane, and Web of Science were searched to identify all clinical studies focusing on Achilles tendinopathy treatment. The Visual Analogue Scale (VAS) and Victorian Institute of Sport Assessment-Achilles (VISA-A) data of women and men of the studies that disaggregated results by gender were collected, and a meta-analysis was conducted. Treatment response within and in between gender categories was evaluated, focusing on overall gender-disaggregated data, as well as within each of the three treatment categories: conservative treatment, injective treatment and surgical treatment. A formal risk of bias analysis was conducted using Downs and Black's grading system.

RESULTS

Out of the 8796 papers screened, 178 were included after the screening. The number of female study participants grew from 20% up to 1990 to 48% in the years 2019-2022. Only 373 out of 3423 (11%) female patients and 685 of 4352 (16%) male patients were found in sex-disaggregated studies. A meta-analysis was conducted on the 14 papers that reported sex-disaggregated data for VAS and VISA-A. The meta-analysis revealed that there was no difference in the overall treatment response between women and men and that both genders showed an overall significant treatment benefit in terms of VAS and VISA-A values. However, significant differences were documented within the treatment categories. While no differences were found in surgical studies, in conservative treatment studies, men experienced lower posttreatment VAS values (p = 0.004). The largest difference was found in injective treatments, with men experiencing a larger change in VAS values (men = -3.0, women = -1.0, p = 0.016) and higher posttreatment VISA-A values (p = 0.032).

CONCLUSION

This systematic review and meta-analysis showed a lack of awareness of the importance of sex-specific data within Achilles tendinopathy treatment research. The proportion of female study subjects has grown over the years, but there is still a large data gap caused by the absence of sex-disaggregated data. The omission of sex-disaggregated data causes the loss of valuable knowledge on the true effectiveness of current Achilles tendinopathy treatment. The results of this study indicate that women profit less from available treatments, particularly injective approaches, which prompts further research for treatment adaptation by gender.

LEVEL OF EVIDENCE

Level IV.

Common Painful Foot and Ankle Conditions: A Review

Importance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment.

Observations

Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used.

Conclusions and Relevance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.

Outcomes of Isolated Open Gastrocnemius Recession for the Treatment of Chronic Insertional Achilles Tendinopathy: A Retrospective Cohort Study

BACKGROUND

Insertional Achilles tendinopathy (IAT) is a common condition causing pain and dysfunction. Patients with diabetes, hyperlipidemia, hypothyroidism, and obesity are at increased risk of developing IAT. These comorbidities also carry an increased risk of wound healing complications following surgery. Therefore, there is a need for alternative management strategies for this high-risk patient population. This study investigated the potential role of isolated GR in patients with chronic IAT.

METHODS

This study is a single-institution retrospective review of adult patients who underwent isolated GR to address chronic IAT with a minimum 1-year follow-up. Demographics, complications, radiographic findings, and preoperative and postoperative patient-reported outcome scores (PROs) were collected. The primary outcome was improvement in PROMIS scores from preoperative to postoperative. Secondary outcomes were complication and reoperation rates.

RESULTS

Sixteen patients underwent open GR with a mean follow-up of 2.7 years. Postoperative PROMIS domain scores improved significantly from preoperative scores for physical function, pain interference, pain intensity, and global physical function. Two patients (13%) underwent reoperation (open calcaneal exostectomy and tendon debridement) at a mean time of 7 months from gastrocnemius recession. One patient developed a postoperative hematoma that resolved with conservative management.

CONCLUSION

This single-institution series reports on a small cohort of patients with chronic IAT treated with open GR. We found significant improvement in patient-reported outcomes. Rates of complication and reoperation were low. This study supports the potential use of isolated gastrocnemius recession in IAT patients who, because of age or medical comorbidities, may benefit from a less invasive surgery and faster rehabilitation.

LEVEL OF EVIDENCE

Level III, retrospective case control study.