Gastrocnemius Soleus

8/12/2019 Gastrocnemius Soleus

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18 January/February 2005 Vol 95 No 1 Journal of the American Podiatric Medical Association

Equinus deformity is defined as a limitation of dorsi-flexion motion of the ankle joint. Although many au-thors have attempted to specify the necessary degreesof ankle dorsiflexion, normative values have been lim-ited.1, 2 Biomechanically, the maximum amount ofdorsiflexion in the stance phase of normal gait oc-curs just before heel lift with the knee extended.1

The minimum amount of ankle range of motion nec-essary for normal gait is 10 of dorsiflexion and 20of plantarflexion.1-3 DiGiovanni et al2 differentiatedgastrocnemius equinus from gastrocnemius soleusequinus. Gastrocnemius equinus is defined as 5 orless of ankle dorsiflexion with the knee in full exten-sion, and gastrocnemius soleus equinus is defined as10 or less of ankle dorsiflexion with the knee in fullextension or in 90 of flexion.

Equinus imparts a major deforming force on thefoot and is a causative factor in many foot and anklepathologic entities, including plantar fasciitis, pesplanus, hallux abducto valgus, Achilles tendinosis,Charcots midfoot collapse, and diabetic ulcerations.3

DiGiovanni et al2 found either gastrocnemius or gas-trocnemius soleus equinus in patients with a symp-tomatic foot and ankle. In asymptomatic patients,

gastrocnemius and gastrocnemius soleus equinus arenot uncommon (33% and 17%, respectively).4

Many types of equinus have been described: os-seous equinus, pseudoequinus (plantarflexed fore-

foot without ankle equinus), gastrocnemius equinus,gastrocnemius soleus equinus, and a combination oftypes.3 In addition, an ankle joint capsule contracturecan produce or contribute to any type of equinus. 5

We present a review of the anatomy, biomechan-ics, and clinical assessment of equinus. A detailedsurgical technique for gastrocnemius soleus reces-sion is outlined, and an anatomical guide for surgicaltreatment is presented.

Anatomy

The gastrocnemius muscle has two heads (medialand lateral) that originate from the posterior aspectof the medial and lateral femoral condyles, the supra-condylar ridge, and the posterior capsule of the kneejoint. The gastrocnemius heads expand to reach theirgreatest size just proximal to the middle of the leg.The medial head is typically larger and extends moredistally than the lateral head. The gastrocnemiusmuscle fibers insert into an aponeurotic tendon thatforms along the anterior surface of the muscle. Thisaponeurotic junction marks the division between theproximal and middle thirds of the posterior leg.6

The soleus muscle arises from the posterior sur-face of the fibular shaft and head, from the posteriorproximal tibia at the soleal line, and from the middlethird of the medial border of the tibial shaft. In addi-tion, a fibrous arch forms proximally between thetibia and the fibula and gives rise to the soleus mus-cle. This fibrous arch is the upper end of a centralaponeurotic tendon of origin that descends on the

Gastrocnemius Soleus RecessionA Simpler, More Limited Approach

Bradley M. Lamm, DPM*

Dror Paley, MD*

John E. Herzenberg, MD*

Multiple surgical procedures have been described for the correction of

equinus deformity. We present a review of the anatomy, biomechanics,

and clinical assessment of equinus. In addition, we provide a detailed

surgical technique for gastrocnemius soleus recession and introduce

an anatomical guide for surgical treatment. (J Am Podiatr Med Assoc

95(1): 18-25, 2005)

*Rubin Institute for Advanced Orthopedics, Sinai Hospi-tal of Baltimore, Baltimore, MD.

Corresponding author: Bradley M. Lamm, DPM, RubinInstitute for Advanced Orthopedics, Sinai Hospital of Balti-more, 2401 W Belvedere Ave, Baltimore, MD 21215.


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Journal of the American Podiatric Medical Association Vol 95 No 1 January/February 2005 19

anterior surface of the soleus muscle, protecting thedeep neurovascular bundle and giving rise to thebulk of the muscle fibers. The soleus muscle is bi-pennate, with the fibers directed in an inferior andposterior direction, making the soleus muscle thickerdistally. The most distal soleus muscle fibers markthe division between the middle and distal thirds ofthe posterior leg.6

In the distal third of the posterior leg, the gastroc-nemius aponeurosis and the soleus tendon mergeand form the Achilles tendon, which inserts into theposterior upper third of the posterior calcaneus. TheAchilles tendon is the largest and strongest tendon inthe body, measuring up to 2.5 cm in diameter.6, 7 TheAchilles tendon fibers, from origin to insertion, spiralfrom medial to lateral such that the gastrocnemiusfibers insert on the lateral aspect of the calcaneusand the soleus fibers insert on the medial aspect ofthe calcaneus.6-8

The plantaris is a small muscle that arises from thedistal lateral femur and posterior knee joint capsule.This small, flat muscle runs inferomedially betweenthe gastrocnemius and soleus muscles to the medialedge of the Achilles tendon. The plantaris muscle in-serts on the posteromedial calcaneus adjacent to theAchilles tendon insertion. As in the gastrocnemiusmuscle, the plantaris muscle flexes the knee and plan-tarflexes the ankle. Compared with the gastrocne-mius and soleus muscles, the plantaris muscle ismuch weaker and smaller.6

We defined anatomical levels that are simple toidentify topographically and proposed a surgicaltreatment guide for each level. The posterior leg and

the triceps surae muscle (the gastrocnemius and so-leus muscles) can be divided into five anatomical lev-els. A surgical guide is presented for each specifictype of equinus correction in conjunction with theseanatomical levels. The proximal fifth of the leg islevel 5, which consists of the origin and the tendonsor the medial and lateral heads of the gastrocnemiusmuscle. At level 5, a proximal gastrocnemius tenoto-my can be performed. Level 4 begins with the gas-trocnemius muscle and includes the medial and later-al heads of the gastrocnemius muscle. At level 4, adeep gastrocnemius or soleus recession (intermuscu-lar lengthening) can be performed. Level 3 begins as

the gastrocnemius muscle becomes tendon and com-prises the soleus muscle and the distal gastrocne-mius tendon. The distal extent of level 3 is defined bythe aponeurotic tendon (combined gastrocnemiusand soleus tendon). At level 3, a distal gastrocnemiustenotomy can be performed. Level 2 begins at thegastrocnemius soleus aponeurotic tendon and endsat the most distal extent of the soleus muscle. At

level 2, a gastrocnemius soleus recession can be per-formed. The distal fifth of the leg is defined as level 1,at which a tendo Achillis lengthening can be per-formed. Level 1 consists of the rotating tendon fibersof the triceps surae muscle that constitute the Achillestendon (Fig. 1).

Biomechanics

Ankle equinus is most noticeable during the mid-stance phase of gait. By inducing a more rapid en-trance and exit into and out of the midstance phaseof gait, equinus produces a reduced step length andthus a slower walking velocity. Compensatory mech-anisms for equinus deformity include forward torsolean, pelvic rotation, hip flexion, knee hyperexten-sion, and external rotation of the leg.9 Equinus of theankle results in compensatory subtalar pronation,thereby unlocking the midtarsal joint and producingmidtarsal joint pronation. This motion results in dor-siflexion of the forefoot on the rearfoot. Pronation ofthe subtalar and midtarsal joints then produces a hy-

Figure 1. The posterior leg can be divided into fiveanatomical levels. Based on anatomical level andclinical assessment, specific surgical procedures areindicated. The location for superficial gastrocnemiussoleus recession is highlighted. GT, gastrocnemiustenotomy; GSR, gastrocnemius soleus recession; TAL,tendo Achillis lengthening.

Surgical

Procedure Eponym

Anatomical

Level


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permobile first ray and a subsequent forefoot patho-logic abnormality.3

In static stance, the soleus and gastrocnemiusmuscles are active postural stabilizers that help main-tain balance. The gastrocnemius muscle is active in-termittently when the knees flex but shows no activi-ty when the knees are fully extended. The lateralportion of the soleus muscle is the only muscle in the

leg that is active during bipedal postural stance.5

The gastrocnemius, soleus, and plantaris musclesare located in the superficial posterior compartmentof the leg, and they all cross the subtalar and anklejoints. The soleus and plantaris muscles have beendescribed as two-joint muscles. Because the gastroc-nemius muscle spans the knee, ankle, and subtalarjoints, it has been described as a three-joint muscle.3

During the midstance and propulsive phases ofgait, the soleus and gastrocnemius muscles are active.The gastrocnemius and soleus muscles plantarflexthe ankle joint and, because of the ankle jointsoblique axis, act to invert the rearfoot during plan-tarflexion.3 The gastrocnemius muscle acts on theankle joint only when the knee is flexed. During thepropulsive phase of gait, the knee is slightly flexed;therefore, the gastrocnemius and soleus muscles acton the ankle joint during propulsion. Gait analysishas shown the importance of a minimum of 10 ofankle dorsiflexion in the propulsive phase of gait toallow for foot clearance.1, 5 The soleus muscle acts in-dependently of the knee position but serves as a sta-bilizer of the tibia by preventing anterior translationof the tibia at the knee joint when the foot is planted.This is important in the anterior cruciate ligament

deficient knee.10

Clinical Assessment

Equinus should be measured with the knee extendedand with the knee flexed. The amount of ankle dorsi-flexion is measured using a goniometer. Measure-ments can be obtained by determining the angle be-tween the plantar aspect of the heel (medially orlaterally) and the tibia. When clinically assessing forequinus, care must be taken to maintain the subtalarjoint in a neutral position and to measure ankle dor-siflexion and not midfoot dorsiflexion (rocker-bot-

tom) or midfoot equinus (pseudoequinus). Osseousand muscular equinus can be differentiated radio-graphically in standing mortise lateral radiographs ofthe foot and ankle in maximum dorsiflexion.11 Os-seous equinus may result from bony procurvatum ofthe distal tibia or from osteophytes on the anterior lipof the distal tibia or neck of the talus.9

Once osseous equinus is ruled out, the Silfverskild

test is performed to differentiate gastrocnemiusequinus from other types of equinus.12 The medialand lateral heads of the gastrocnemius and plantarismuscles originate from the femoral condyles proxi-mal to the knee joint. Therefore, when the knee isflexed, the gastrocnemius and plantaris musclesrelax. The generally accepted amount of normalankle dorsiflexion is approximately 10 with the kneeextended and 20 with the knee flexed (Fig. 2).1-3, 13

Gastrocnemius equinus is indicated by the inabilityof the ankle to dorsiflex normally with the knee ex-tended but the ability of the ankle to dorsiflex morethan 10 with the knee flexed (Fig. 3). Gastrocnemiussoleus equinus is defined by the inability of the ankleto dorsiflex beyond a neutral position with the kneeextended (it remains


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A B

Figure 2. Silfverskild test results show normal ankle dorsiflexion with the knee extended (A) and with the kneeflexed to 90 (B).

A B

Figure 3. Silfverskild test results show limited ankle dorsiflexion with knee extension (A) and improved ankle dor-siflexion with knee flexion (90) (B). This is an example of pure gastrocnemius equinus, which would benefit fromisolated gastrocnemius recession or gastrocnemius soleus recession.

A B

Figure 4. Silfverskild test results show that ankle dorsiflexion greater than neutral (0 ) is not present with theknee extended (A) or with the knee flexed to 90 (B). This is an example of gastrocnemius soleus equinus, whichwould benefit from tendo Achillis lengthening or gastrocnemius soleus recession.

10 Dorsiflexion20 Dorsiflexion

10 Dorsiflexion

20Plantarflexion

20 Plantarflexion

20 Plantarflexion

20 Plantarflexion

Straight knee tightens

gastrocnemius muscle

Bent knee relaxesgastrocnemius muscle,

allowing further dorsiflexion

Dorsiflexionachieved with a

relaxed gastrocnemiusmuscle

No improvementin dorsiflexion despite

relaxing thegastrocnemius muscle

Soleus musclelimits dorsiflexion

Tight soleus muscle,gastrocnemius muscle, or both?

Tight soleus muscle,gastrocnemius muscle, or both?

Normaldorsiflexion

Interpretation:Soleus, normal

Gastrocnemius, normal

Diagnosis:No equinus

Interpretation:Soleus, normal

Gastrocnemius, tight

Diagnosis:Gastrocnemius equinus

Recommendation:Gastrocnemius recession

Gastrocnemius soleusrecession

Interpretation:Soleus, tight

Gastrocnemius, tight

Diagnosis:Gastrocnemius soleus

equinus

Recommendation:Tendo Achillislengthening

Gastrocnemius soleusrecession

Limiteddorsiflexion

Limiteddorsiflexion

tion, calling this technique a gastrocnemius recession.The advantage of the Vulpius technique over that

presented by Strayer is that the gastrocnemius soleusrecession includes intramuscular lengthening of thesoleus muscle. The Baumann procedure, which hasbeen described for cases of cerebral palsy, is a gas-

trocnemius and/or soleus recession performed atlevel 4.18, 19At level 5, Silfverskild described a proxi-mal gastrocnemius tenotomy. A tendo Achillis length-ening at level 1 can be performed by percutaneous Z-lengthening,9percutaneous triple hemisectioning,20 oropen Z-lengthening.21


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Gastrocnemius Soleus RecessionTechnique

We found that most children and adults present withcombined gastrocnemius soleus equinus. As an alter-native to tendo Achillis lengthening, which weakensthe entire triceps surae muscle, we prefer gastrocne-mius soleus recession, except in cases of very severe

contracture, for which maximal lengthening is need-ed. Since 1996, the senior author (D.P.) has used thismodified Vulpius technique when performing gas-trocnemius soleus recession.

The patient, under general anesthesia, is posi-tioned supine, with a thigh tourniquet in place. Afterexsanguination with elevation of the lower extremityand inflation of the tourniquet, an assistant holds theleg up at an angle of 45 from the table, with the ankleplaced in a neutral position. A 3-cm longitudinal mid-line incision is made at the distal end of level 2 (Fig.1). Careful dissection is then performed at that inter-

val to identify the sural nerve and lesser saphenousvein (Fig. 5). These structures are retracted to eitherside. The tendon sheath is identified, and a longitudi-nal incision is made through it. The plantaris muscleis identified and completely released. With the anklemaintained in a neutral position, the gastrocnemiustendon is transversely incised. The underlying soleustendon is then cut, stopping when the soleus musclefibers are seen. The soleus tendon extends farthermedially than laterally, covering the soleus musclefibers. It is important to retract one side at a time sothat the tendon can be cut under direct visualization(Figs. 6 and 7). The ankle should then be maximally

dorsiflexed with the knee in full extension to separatethe cut tendons (recession). The Silfverskild test isagain performed to assess the remaining equinus de-formity. If the equinus deformity is not completelycorrected, the soleus tendon median raphe is identi-fied and cut. To cut this safely, the median raphe, orcentral tendon portion of the soleus muscle, is dis-sected from the muscle medially and laterally (Fig. 8).Direct visualization of the median raphe is recom-mended to avoid injury to the posterior tibial nervebundle. Using a Beaver blade (BD Ophthalmic Sys-tems, Waltham, Massachusetts), the thick longitudi-nal soleus raphe is released. The wound is then irri-

gated with normal saline. The sheath covering theouter border of the tendon is closed if possible. Theskin incision is closed in two layers. A small gauzepad and a transparent dressing (Tegaderm; 3M HealthCare, St Paul, Minnesota) are then applied.

Rehabilitation typically depends on the concomi-tant procedures. In general, after undergoing thistype of recession, patients are protected in a weight-

bearing, removable, short-leg cast or boot for 3 weeksand undergo early range-of-motion exercises. The pa-tient should be encouraged to keep the knee extend-ed with a knee immobilizer to maintain the maxi-mum recession effect of the gastrocnemius muscle

obtained at surgery. Active physical therapy is start-ed 3 weeks after surgery.

Discussion

We present a new technique of gastrocnemius soleusrecession. A surgical guide for each specific type ofequinus correction has been introduced in conjunc-tion with the respective anatomical levels (Fig. 1).When a positive Silfverskild test result is elicited, aproximal gastrocnemius tenotomy (level 5, Silfver-skild), a deep gastrocnemius recession (level 4,Baumann), or a distal gastrocnemius tenotomy (level

3, Strayer) is recommended. When the Silfverskildtest result is negative, the recommended treatment iseither tendo Achillis lengthening (level 1)9, 20, 21 or su-perficial gastrocnemius soleus recession (level 2).

Our approach, like the Vulpius approach, is gas-trocnemius soleus recession. Our technique differs,however, in that the incision through the tendons is asingle transverse cut, not a single or multiple chevron-

Figure 5. Cross-sectional view of level 2. The brokenline represents the tendon portion of the gastrocne-mius and soleus muscles and the median raphe ofthe soleus muscle. Steps in performing gastrocne-mius soleus recession are numbered sequentially.

Soleus

Posteriortibialnerve

Soleus

Sural nerve

Lessersaphenous vein

1.Vertical midline

skin incision

2.Divide superficial

fascial sheath3. Divide

gastrocnemius tendon

4. Dividesoleus tendon

5. Dividemedian raphe

of soleus muscle

6. Divideplantaris tendon


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type cuts. In addition, we use a minimally invasiveapproach that is performed exclusively in level 2.

Differentiation between the need for tendo Achillislengthening and the need for gastrocnemius soleusrecession is based on the degree of the deformity andthe cause of the equinus. Large equinus contracturestypically require open tendo Achillis lengthening to

gain the needed amount of length and to determinethe appropriate length-tension ratio for the tendon.Smaller amounts of equinus can be corrected throughpercutaneous slide-type procedures, such as thetriple hemisection technique; however, slide-typetechniques render an unpredictable final length. Gas-trocnemius soleus recession leaves some of the soleusmuscle strength undisturbed compared with tendoAchillis lengthening, which weakens the entire soleusmuscle. Gastrocnemius soleus recession allows forsequential lengthening and obviates the need for re-suturing the cut tendons. After transverse release ofthe gastrocnemius soleus tendon, the Silfverskild

test is conducted to reassess the deformity before re-lease of the median raphe of the soleus muscle. Thisclinical reassessment of equinus during the proce-dure allows for more accurate correction. It is impor-tant to remember that restriction of ankle motion canbe attributed to contracture of one muscle or a groupof muscles. A recession of the soleus muscle main-tains muscle strength and is preferred to a tendo

Figure 6. After the midline vertical incision, verticaldivision of the superficial fascia, and horizontal re-

lease of the gastrocnemius tendon, the soleus tendonis released. Deep retraction allows for full release atthe more anterior edge of the tendon laterally.

Figure 8. Locate the median raphe (central tendon)of the soleus muscle. Release of this tendon using ablade or dissecting scissors achieves additional length-ening.

Figure 7. The soleus tendon is also released hori-zontally to the opposite edge (medially) of the tendon

using deep retraction.

Achillis lengthening, which causes maximum loss ofstrength, especially if the tendon is overlengthened.

The advantage of performing gastrocnemius orgastrocnemius soleus recession is that these proce-dures preserve the magnitude of muscle strength be-


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cause they are intramuscular lengthenings.3, 22 TendoAchillis tendon lengthening has been shown to mark-edly decrease the strength of the triceps surae mus-cle because of partial or complete division of the ten-don.22 Delp and Zajac22 found that lengthening thesoleus tendon by 1.2 cm or lengthening the gastroc-nemius tendon by 1.5 cm reduces the respectivemuscle force by 50%. Their results confirm the im-

portance of conservative lengthening of the tendoAchillis to avoid plantarflexion weakness.

In static bipedal stance, the soleus is active andthus important for balance. Patients who undergotendo Achillis lengthening may have decreased strengthin the soleus muscle during static stance, thereby im-pairing imbalance. Therefore, the gastrocnemius so-leus recession may be advantageous for patients withdiabetes mellitus with peripheral neuropathy, whotypically have diminished proprioception and lack ofbalance after lengthening of the tendo Achillis. Patientswith diabetes often undergo tendo Achillis lengthen-

ing to reduce excessive pressure on the forefoot. Com-plete disruption of a tendon will inhibit the stretch re-flex, whereby sufficient impulses cannot be releasedfrom the Golgi tendon organs and the spindle fibersof the muscle to excite the motor neuron.23 Theoreti-cally, this muscular deficiency could create a staticand dynamic postural imbalance, especially in the al-ready insensate patient with diabetes. Simmons etal24 studied patients with diabetic neuropathy andloss of protective sensation as confirmed by a 10-gmonofilament. They found significantly reduced ac-tive and passive ankle joint mobility compared withcontrol participants. These authors also theorized

that limited ankle joint mobility might contribute to adecrease in postural stability.

Surgical decisions should be made systemically toobtain optimal results. Osseous equinus should betreated initially with a bone procedure and thenretested intraoperatively to assess the soft tissues.After completion of each step of a procedure, the sur-geon should repeat the Silfverskild test to reassessthe deformity. Long-standing deformities can also re-sult in ankle joint capsule contracture, which may re-quire capsulotomy or gradual distraction with exter-nal fixation.

Conclusion

This article presents a new technique for gastrocne-mius soleus recession and introduces an anatomicalguide for surgical treatment of equinus deformity. Anaccurate clinical assessment and Silfverskild test,coupled with an understanding of the anatomical lev-

els of the posterior leg, provide a specific guide forthe surgeon. Our gastrocnemius soleus recession, amodified Vulpius procedure, is performed in level 2as a simpler and more limited approach. Moreover,our technique is an intermuscular lengthening of thesoleus, which limits the amount of triceps surae mus-cle weakening.

References

1. ROOT ML, ORIEN WP, WEED JH: Normal and AbnormalFunction of the Foot, Clinical Biomechanics Corp, LosAngeles, 1977.

2. DIGIOVANNI CW, KUO R, TEJWANI N, ET AL: Isolated gas-trocnemius tightness. J Bone Joint Surg Am 84: 962,2002.

3. DOWNEY MS, BANKS AS: Gastrocnemius recession in thetreatment of nonspastic ankle equinus: a retrospectivestudy. JAPMA 79: 159, 1989.

4. BRODERSEN A, PEDERSEN B, REIMERS J: Foot deformitiesand relation to the length of leg muscles in Danish chil-dren aged 3-17 years. Ugeskr Laeger 155: 3914, 1993.

5. PALEY D: Gait Considerations, in Principles of Defor-mity Correction, 2nd Ed, p 717, Springer-Verlag, Berlin,2003.

6. GRAY H: Grays Anatomy, 37th Ed, p 647, Churchill Liv-ingstone, London, 1989.

7. CUMMINS EJ, ANSON BJ, CARR BW, ET AL: The structureof the calcaneal tendon (of Achilles) in relation to or-thopedic surgery: with additional observations on the

plantaris muscle. Surg Gynecol Obstet 83: 107, 1946.8. VAN GILS CC, STEED RH, PAGE JC: Torsion of the human

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foot, ankle, and lower limb. Clin Podiatr Med Surg 21:305, 2004.

12. SILFVERSKILD N: Reduction of the uncrossed two-jointmuscles of the leg to one-joint muscles in spastic con-ditions. Acta Chir Scand 56: 315, 1924.

13. DOWNEYMS: Ankle Equinus, in Comprehensive Textbookof Foot Surgery, 2nd Ed, Vol 1, ed by ED McGlamry, ASBanks, MS Downey, p 687, Williams & Wilkins, Balti-more, 1992.

14. V ULPIUS O, STOFFEL A: Orthopdische Operationslehre,Verlag von Ferdinand Enke, Stuttgart, Germany, 1924.

15. STRAYER LM JR: Recession of the gastrocnemius: an op-eration to relieve spastic contracture of the calf mus-

cles. J Bone Joint Surg Am 32: 671, 1950.16. STRAYER LM JR: Gastrocnemius recession: five-year re-port of cases. J Bone Joint Surg Am 40: 1019, 1958.

17. BAKER LD: A rational approach to the surgical needs ofthe cerebral palsy patient. J Bone Joint Surg Am 38:313, 1956.

18. BAUMANN JU, KOCH HG: Lengthening of the anterioraponeurosis of the gastrocnemius muscle [in German].Operat Orthop Traumatol 1: 254, 1989.


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19. SARAP H V, ZWICK EB, UITZ C, ET AL: The Baumann pro-cedure for fixed contracture of the gastrosoleus in cere-bral palsy: evaluation of function of the ankle aftermultilevel surgery. J Bone Joint Surg Br 82: 535, 2000.

20. HOKE M: An operation for the correction of extremelyrelaxed flat feet. J Bone Joint Surg 13: 773, 1931.

21. WHITE JW: Torsion of the Achi lles tendon: its surg icalsignificance. Arch Surg 46: 784, 1943.

22. DELP SL, ZAJAC FE: Force- and moment-generating ca-

pacity of lower-extremity muscles before and after ten-don lengthening. Clin Orthop 284: 247, 1995.

23. GANON G WF: Excitable Tissue: Muscle, in Review ofMedical Physiology, 16th Ed, p 56, Appleton & Lange,East Norwalk, CT, 1993.

24. SIMMONS RW, RICHARDSON C, DEUTSCH K: Limited jointmobility of the ankle in diabetic patients with cuta-neous sensory deficit. Diabetes Res Clin Pract 37: 137,1997.

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Gastrocnemius Soleus