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Lengthening of the Gastrocnemius-Soleus ComplexAn Anatomical and Biomechanical Study in Human Cadavers
Gregory B. Firth, MBBCh, FCS(Orth)SA, MMed(Orth)1; Michael McMullan, MPhil, FRCS(Tr&Orth)1; Terence Chin, MBBS1; Francis Ma, MBBS1; Paulo Selber, MD, FRACS1; Norman Eizenberg, MBBS2; Rory Wolfe, BSc, PhD2; H. Kerr Graham, MD, FRCS(Ed), FRACS1
1 Hugh Williamson Gait Laboratory (T.C., F.M.), Orthopaedic Department (G.B.F., M.M., P.S., H.K.G.), The Royal Children’s Hospital, Flemington Road, Parkville, Victoria 3052, Australia. E-mail address for H.K. Graham: kerr.graham@rch.org.au
2 Department of Anatomy and Developmental Biology (N.E.) and Department of Epidemiology and Preventive Medicine (R.W.), The Alfred Centre, Monash University, Commercial Road, Melbourne, Victoria 3800, Australia
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Investigation performed at the University of Melbourne, Melbourne, Victoria, Australia

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Aug 21;95(16):1489-1496. doi: 10.2106/JBJS.K.01638
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Lengthening of the gastrocnemius-soleus complex is frequently performed for equinus deformity. Many techniques have been described, but there is uncertainty regarding the precise details of some surgical procedures.


The surgical anatomy of the gastrocnemius-soleus complex was investigated, and standardized approaches were developed for the procedures described by Baumann, Strayer, Vulpius, Baker, Hoke, and White. The biomechanical characteristics of these six procedures were then compared in three randomized trials involving formaldehyde-preserved human cadaveric lower limbs. After one of the lengthening procedures was performed, a measured dorsiflexion force was applied across the metatarsal heads with use of a torque dynamometer. Lengthening of the gastrocnemius-soleus complex was measured directly, by measuring the gap between the ends of the fascia or tendon.


The gastrocnemius-soleus musculotendinous unit was subdivided into three zones. In Zone 1, it was possible to lengthen the gastrocnemius-soleus complex in either a selective or a differential manner—i.e., to lengthen the gastrocnemius alone or to lengthen the gastrocnemius and soleus by different amounts. The procedures performed in this zone (Baumann and Strayer procedures) were very stable but were limited with regard to the amount of lengthening achieved. Zone-2 lengthenings of the conjoined gastrocnemius aponeurosis and soleus fascia (Vulpius and Baker procedures) were not selective but were stable and resulted in significantly greater lengthening than Zone-1 procedures (p < 0.001). In Zone 3 (Hoke and White procedures), lengthenings of the Achilles tendon were neither selective nor stable but resulted in significantly greater lengthening than Zone-1 or 2 procedures (p < 0.001).


Surgical procedures for the correction of equinus deformity by lengthening of the gastrocnemius-soleus complex vary in terms of selectivity, stability, and range of correction. Procedures for the correction of equinus deformity have different anatomical and biomechanical characteristics. Clinical trials are needed to determine whether these differences are of clinical importance. It may be appropriate for surgeons to select a procedure involving the zone best suited to the clinical needs of a specific patient.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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