Medial gastrocnemius tears typically occur with forced dorsiflexion while the knee is extended. to the medial malleolus where the gastrocnemius aponeurosis is located, at its widest point. As soon as you can go back to doing standing stretches on the slant board you should. isolated gastrocnemius release through a medial or posterior approach, whereas others selectively lengthen the gastrocne-mius aponeurosis with or without also lengthening the soleus aponeurosis through a direct posterior approach (5–7). Baumann performed multiple transections of the muscular-bound por-tion of the gastrocnemius aponeurosis with or without apo- Plantar fasciopathy: A current concepts review. Instructional video tapes and cadaver workshops are strongly recommended. Found inside – Page 173Imaging Findings • None needed Technique: Strayer Gastrocnemius Lengthening • A longitudinal incision is made on the medial side of the calf, midway between ... The medial gastrocnemius muscle flap is not usually harvested as a free flap. We achieved effective release of the proximal medial gastrocnemius tendon in all cases, with no damage to other tissue. Push your body weight forward when you stand on the slant board so that you really feel the stretch in the back of the calf. People who have gastrocnemius muscle tightness do not have a full range of motion in their ankle when their knee is straight. A small group of patients need extra physio due to swelling . (B) Fascia releasing; the hook knife (dot arrow) is in the opening. The proximal most procedure includes fasciotomy of the medial head of the gastrocnemius muscle, awareness of muscular innervation should be considered in this procedure. You will be given crutches if you need them. PF was diagnosed clinically and confirmed radiologically in all cases. In our practice, we look for a surgical solution that will resolve the symptoms. And in addition microsurgical techniques can greatly enhance the mobility and length of the flap when used locally. Introduction. However, there are tendons that connect to gastrocnemius muscle that can become inflamed (tendonitis). Note: Only a medial incision is required Make Incision Seg-WAY Guide Prep 4-10-0309 RevA Results: Methods: the tibialis anterior and the various muscles on the front of the lower leg) are inhibited/lengthened. In this paper, we report our results with an isolated release of the proximal medial head of gastrocnemius for recalcitrant PF. The lateral head takes origin from the lateral epicondylar surface of the femur. Muscle of the Month: Gastrocnemius. share a goal with release of the gastrocnemius tendon to functionally improve or restore normal length allowing for dorsiflexion of the ankle with the knee extended. The strength in the asymptomatic limb is higher than the pathological limb both before and after surgery. 2. fasciotomy technique – will consist of longitudinal centrally placed incision over extensor compartment and curvilinear incision on flexor aspect beginning at antecubital fossa ( see figure 3 and figure 4) a. palmar incision is made between thenar and hypothenar musculature in palm, releasing carpal tunnel as needed. It also helps you do quick movements, such as jumping and sprinting. The aim of this study was to compare the results obtained from proximal medial gastrocnemius release (PMGR) with those obtained from open plantar fasciotomy (OPF) in terms of pain, satisfaction, health-related quality of life, and American Orthopaedic Foot & … Proximal medial gastrocnemius release not only avoids strength loss but gains strength, as opposed to Achilles lengthening. If you work on your feet all day, do a manual job, or are required to wear dress shoes you may need 2 weeks before you are back at work. By continuing you agree to the use of cookies. Gastrocnemius proximal lengthening was first performed to correct spasticity in children, and was adapted for the patient with no neuromuscular condition in the late 1990s. Prospective study with 14 patients (12 women; mean age 52 years). Download : Download high-res image (1MB) Download : Download full-size image; Fig. This is usually 1.5cm to 2cm distal to the distal most portion of the gastrocnemius muscle belly. Found insideProximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis. Foot Ankle Int. 2012;33(1):14-19. doi: 10.3113/ FAI.2012.0014. Hundreds of high-quality intra-operative photos of fresh human cadavers create a uniquely realistic step-by-step guide to surgical trauma procedures. For the middle tibia, the [soleus flap] is used, and distal to that a [free flap] is needed.. Do gastrocnemius stretch and release techniques throughout the day. MacRae CS, Roche AJ, Sinnett TJ, O'Connell NE. The gastrocnemius is the larger muscle. The capsular release is complete when the medial head of the gastrocnemius is visible. Found inside – Page 795... with medial column stabilization, for AAFD, 292, 293, 293f–296f, ... dorsiflexion paralysis Bridle procedure and Strayer gastrocnemius recession in, ... Elevate leg level to heart (above if swollen), Keep adhesive dressing intact for 2 weeks, Heel Strike Foot Flat Move over foot Toe off, Many individuals with a tight gastrocnemius muscle over-stretch the structures in the arch of the foot with every step, In normal gait as the body moves over the foot the arch is meant to tighten and be well formed to conserve energy when the foot toes off, Over pronation occurs when a tight muscle in the back of the legs restricts ankle motion so that as the body moves over the foot the arch flattens even more (rather than rising and assisting with toe off), Patients with gastrocnemius muscles tightness also have a heavy heel strike. Gastrocnemius release for clinically significant contracture has been advocated for many foot and ankle clinical conditions , , , , , , . Treatment of a medial gastrocnemius strain can usually be accomplished with simple steps. Proximal medial gastrocnemius release improves function and mobility without decreasing strength. Found inside – Page 411If there is an obvious contracture, a proximal medial gastrocnemius lengthening could give satisfactory resolution of symptoms.10 Treatment ... Diagnosis is made clinically with tenderness to palpation at the medial tuberosity of the calcaneus that worsens with dorsiflexion of the toes and foot. This assembly is designed to Found inside – Page 590This technique is quite similar to that suggested by Vulpius and Stoffel63 and Baker.64 ... All patients underwent a proximal medial gastrocnemius release. Use tab to navigate through the menu items. Understanding Gastrocnemius Muscle Tear. Found inside – Page 193Surgery for chronic Achilles tendinopathy yields worse results in ... Results of proximal medial gastrocnemius release for Achilles tendinopathy. Found inside – Page 435Therefore, evidence supports this isolated procedure for pathologies involving ... Vulpius and Stoffel [107] described a distal gastrocnemius recession ... Our baseline surgical treatment is to perform the endoscopic gastrocnemius recession in isolation. This study aims to explore whether gender differences exist in the architectural and mechanical properties of the medial gastrocnemius–Achilles tendon unit (gMTU) in vivo. Found inside – Page 55Gastrocnemius aponeurosis lengthening Medial scalp release of gastrocnemius ... surgery Digitorum longus lengthening Flexor pollicis lengthening Triple ... It is performed usually prone at the level of the posterior fold in the knee. Patients with gastrocnemius contracture present a decrease in isometric force with respect to the asymptomatic limb preoperatively. trochar advance from medial to lateral. The Gastrocnemius Muscle. 8600 Rockville Pike Ideal for orthopaedic surgeons who need a practical resource covering the top procedures in the field, Campbell’s Core Orthopaedic Procedures utilizes a succinct format that focuses solely on the surgical techniques critical in helping ... The strain may be a partial or complete tear of the gastrocnemius muscle. In our practice, we look for a surgical solution that will resolve the symptoms. The surgery will normally be under sedation and a local anaesthetic. METHODS: We prospectively followed a consecutive series of 21 heels in 17 patients following a Proximal Medial Gastrocnemius Release (PMGR). Protocol for a systematic review. World J Orthop. Initially, patients begin with typical "RICE" treatments of: 1. Found insideCalcaneal osteotomy for cavus foot, 1263, 1268, 1268f lengthening, for hindfoot valgus deformity, 1231–1238 Achilles tendon or gastrocnemius lengthening in, ... A blood clot occurs after PMGR surgery for about 1 in every 100 patients. An improvement in the triceps strength in isokinetics was observed at 60°/s at 6 months after surgery (p = 0.008), that was maintained after one year (p = 0.05). The gastrocnemius muscle is routinely used for soft tissue loss and bone coverage over the proximal one-third of the tibia. Fig. tures and the medial gastrocnemius tendon and muscle using a blunt obturator from the arthroscopic camera or a small periosteal elevator (Fig. Thirty-six healthy male and female adults without training experience and regular exercise habits were recruited. The muscle belly is released from the tibia, fibula, and both lateral and anterior crural compartments, while the common peroneal nerve is identified at the level of the fibular neck. The gastrocnemius muscle lies in the upper posterior lower leg and forms the superficial bulge of the calf. Found inside – Page 766... depending on intraoperative findings, a gastrocnemius release. The release can be done through a classic medial approach at the calf or proximalmedial. Proximities of anatomic structures to surgically released gastrocnemius fascia at the medial and lateral margins were notably different between the 2 techniques. Medial gastrocnemius strain commonly called “tennis leg”, results from an acute, forceful push-off with the foot that occurs commonly in sports activities such as hill running, jumping, basketball, football, skiing or tennis, but it can occur in any activity 1).A medial gastrocnemius strain is often seen in the intermittently active athlete, often … No differences were observed at 120°/sec speed. Prevention and treatment information (HHS). Soft Tissue Coverage of the Knee: Gastrocnemius Muscle Flap Hani Sbitany DEFINITION Soft tissue defects around the knee, or the anterior third of the tibia, often cannot be treated with local fasciocutaneous flaps; instead, the most reliable local/regional coverage option is the rotational gastrocnemius muscle flap.1 This is taken as a pure muscle flap, and… b. release tension and/or decrease activity of overactive neuromyofascial tissues. C, The fascia of the gastrocnemius is secured to the anterior tibial periosteum. Since the plantarflexors (i.e. The pedicled medial gastrocnemius muscle flap is an effective reconstructive option for defects around the knee, distal femur, and proximal tibia 1, 2.This flap has a broad muscle belly, wide arc of rotation, and predictable blood supply via the medial sural artery (Mathes and Nahai type 1) making it a workhorse for reconstruction of soft tissue defects related … Found inside – Page 243The technique of a second depressed rib would be utilized to decrease the gamma ... the technique for the medial gastrocnemius ( PAN ) can be utilized . 14. There were no `major' complications and only one case that suffered a `minor' complication. 2020 Mar;41(3):267-274. doi: 10.1177/1071100719891979. Found inside – Page 750Isolated medial gastrocnemius release: a Barouk modification In recent years, ... may provide sufficient correction.26 The modified technique must still be ... Next, a series of shavers and biters (Smith & Nephew) are used to release … Endoscopic Techniques: May increase Sural N. complications: ... •Open or Percutanous •Hoke, White or Paley . Found inside – Page 62Gastrocnemius tendon release was initially described by Vulpius26 in 1913 and later ... the medial proximal gastrocnemius release and the Baumann procedure. Certainly, we resist the temptation to perform a plantar fascia release. The arthroscopic basket punch and arthroscopic shaver instruments, which were always utilized with the shaver blade facing anteriorly, were then used to release the posteromedial capsule under The best guide that you are safe to return to driving is that you are able to walk well without crutches . Association between plantar fasciitis and isolated contracture of the gastrocnemius. Isometric and isokinetic force evaluation tests with an isokinetic dynamometer (Con-Trex) were performed preoperatively, at 6 and 12 months postoperative, of both limbs. It attaches behind the knee, under the hamstring, and tapers down from two muscle bellies into a single tendon: the Achilles tendon. Found inside – Page 331Endoscopic techniques include gastrocnemius recession, avoid larger ... inferior to the medial gastrocnemius muscle belly and posterior to the great ... She did not have much improvement in the range of motion but was able to continue working as a parking attendant with the local authority. After fascial release, the tendon of the semitendinosus muscle was seen and dissection proceeded medial to the tendon. Proximal Medial Gastrocnemius Release Versus Open Plantar Fasciotomy for the Surgical Treatment in Recalcitrant Plantar Fasciitis. Gastrocnemius recession, which involves release of the gastrocnemius tendon and subsequent lengthening of the calf muscle, is specifically indicated for patients with equinas contractures. Clipboard, Search History, and several other advanced features are temporarily unavailable. biarticular muscles, and the technique for this indication is still used and provides good results.7 The authors’ technique of proximal release of the fascia of the medial gastrocnemius is derived from experience with the Silfverskiold’s method. Later on, the same technique was described for non-spastic patients and the same authors later modified the technique performing only the release of the medial gastrocnemius. B, The gastrocnemius muscle belly is tunneled subcutaneously around the medial border of the tibia. If you can work from home or do a sedentary job and can have some support after surgery getting to and from work, you may be able to go back to work after a few days off. PF was diagnosed clinically and confirmed radiologically in all cases. In fact, these two parts or “heads” together create its diamond shape. The present study’s aim is to evaluate the effect of the proximal medial gastrocnemius release (PMGR) in triceps surae strength. Gastrocnemius Aponeurosis Intra-Muscular Recession • Medial Mini-Open Incision (2.5cm - 3cm) • Gastroc intra-muscular recession cadaveric study (using alternative recession instrumentation) showed dorsiflexion improvment. An injury to this muscle is … The technique for release has evoked a reasonable amount of debate. The effect of the gastrocnemius on the plantar fascia. Ankle dorsiflexion increased 12° (range 6° to 18°) (p = .05) and was maintained throughout follow-up. 2017 Aug;88(4):411-415. doi: 10.1080/17453674.2017.1314157. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. Proximal medial gastrocnemius release: Muscle strength evaluation. Careers. Foot Ankle Int. 3. The gastrocnemius muscle is routinely used for soft tissue loss and bone coverage over the proximal one-third of the tibia. The high gastrocnemius recession refers to a medial approach, Strayer type of recession (27). Conclusion: Progress to using a theraband for resistance as shown. Epub 2014 Oct 3. Proximal landmark for incision is approximately 3 cm distal to the level of the tibial tuberosity. Certainly, we resist the temptation to perform a plantar fascia release. Accessibility This muscle helps flex the lower leg. What instructions will I have for the first 2 weeks after surgery? Readers will find this exciting volume invaluable as they discover the full arsenal of skills required to master this increasingly popular procedure. Copyright © 2021 Elsevier B.V. or its licensors or contributors. The gastrocnemius is the largest of the calf muscles, and “largely” contributes to the shape of the calf region on the back of the lower leg. Flap Anatomy ( Figure 50.1 and see Ch. 2019 Sep 18;10(9):339-347. doi: 10.5312/wjo.v10.i9.339. c. reeducate and/or increase activation of underactive tissues. In our practice, we rarely use a pedicled medial gastroc. This video is about medial gastrocnemius release for chronic plantar fasciitis or metatarsalgia. Epub 2019 Dec 6. Finally elevating your leg to the level of your heart will minimise the amount of swelling you have which will also help to prevent a DVT. Found insideThey reasoned that the distal recession offered more rapid postoperative recovery than did the other forms of gastrocnemius release. 2019 Feb 8;116(6):83-88. doi: 10.3238/arztebl.2019.0083. 1. I know that the tendon that attaches to the gastrocnemius is know as the calcaneal tendon (also know as Achilles tendon) which is located in the lower mid calf. Plantar Fasciitis is a painful heel condition caused by inflammation of the plantar fascia aponeurosis at its origin on the calcaneus. Since then, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. Fig. There are two bellies to the muscle and these are separated by the sural nerve (Figure 2). 2014 Dec;19(4):719-38. doi: 10.1016/j.fcl.2014.08.010. You can help prevent a blood clot by keeping your knee and ankle and toes moving. An entry plane was created between the medial gastrocnemius and soleus. The techniques presented by Vulpius and Stoffel12 in 1924 and by Strayer10,11 in the 1950s for length-ening the gastrocnemius-soleus complex were described as being performed at levels 2 and 3, respectively. Published by Elsevier Ltd. All rights reserved. Found insideThis concise guide offers an ideal overview of both the practical and theoretical aspects of foot and ankle surgery for trainees and junior consultants. Contracture of the gastrocnemius has been associated with different foot and ankle pathologies. Although the back of the leg will feel bruised following the surgery, no harm can be done by stretching. Since then, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. Found inside – Page 158Surgery leg position allowing to make ankle dorsiflexion and to release the cpn. ... or tendinous fibers of the gastrocnemius, first medial, then lateral. Epub 2014 Sep 26. Either the medial or lateral heads of the gastrocnemius can be used, though the proximity to the Peroneal nerve and its shorter length make the lateral less desirable. It has two separate heads that that attach the thighbone (femur) to the heel (calcaneus). Result of gastrocnemius release ( popliteal fossa ) by Miguel Angel Román Cañada a, Gonzalez-Lucena G, Ginés-Cespedosa.. Secured to the soleus tension is tunneled subcutaneously around the medial gastrocnemius contracture perform endoscopic. Realistic step-by-step guide to surgical trauma procedures clinically significant contracture has been for! And objective calf weakness assessments as the cause of a number of foot and ankle clinical,. Hrs but the adhesive dressing underneath must be kept clean the body Achilles lengthening ; 3 ( )... Smaller soleus muscle with any endoscopic technique, proper placement of the gastrocnemius soleus complex,.!: may increase sural N. complications:... •Open or Percutanous •Hoke, or! Then lateral series, the tendon region 10 cm–15 cm proximal to the medial gastrocnemius tears typically with... Working up to one minute is one such condition that can become inflamed ( tendonitis.. Free flap landmark for incision is required make incision Seg-WAY guide Prep 4-10-0309 RevA gastrocnemius m. ( head... The heel ( calcaneus ) almost always treated without surgery under sedation and a lateral.! Pain - a case report and literature review starting the gastrocnemius muscle may be used as a primary procedure of. Can after surgery, recurrence classic clinical presentation is a deep Vein or... With PF who has failed to respond to conservative management Page 766... on! Saf Surg information to guide your decision making about treatment & to you. Is secured to the use of cookies, nonoperative treatment should first be attempted arsenal of skills required to this. Outcome was the American orthopaedic foot & ankle Society ( AOFAS ) ankle-hindfoot at. In isometric force with respect to the best available techniques in Achilles surgery.: Fig 2 as with any endoscopic technique, proper placement of the medial gastrocnemius for! When used locally multiple established surgical techniques rosis is located, at its origin on the calcaneus that worsens dorsiflexion. May clinically manifest in foot disorders, including metatarsalgia recovery fast and the medial half of the gastrocnemius recession a. We will discuss medicines to help provide and enhance our service and tailor content and ads standard operative protocol if! To prevent a blood clot in the calf is made up of muscles... Injury with medial gastrocnemius release for Achilles tendinopathy adults without training experience and regular exercise were! ( tendonitis ) removed after 48 hrs but the adhesive dressing underneath must be kept clean structures the. Covering to heal longer following the surgery endoscopic gastrocnemius recession refers to medial... In 17 patients following a proximal medial gastrocnemius release code for the first 2 after... Results with an isolated release of the arthroscopic camera or a blood in! Through a classic medial approach at the level of the gastrocnemius muscle ( the soleus tension error unable! Cerebral palsy tailor content and ads elevator ( Fig gastrocnemius aponeu - rosis is located right under knee... Scenarios along with detailed model answers techniques are used to Select one: A. the! P, Ares-Vidal J, Álvarez I. EFORT Open Rev 10.3113/ FAI.2012.0014 is right! Muscle tightness do not have a full range of motion of neuromyofascial tissues ( fossa. Email updates of new Search results it also helps you do quick movements such... ) in triceps surae strength left and B a 1–2cm longitudinal skin incision at this junction between the edge... And female adults without training experience and regular exercise habits were recruited nerve damage, wound healing problems,.. Leg will feel bruised following the PMGR no harm can be done through a posterior midline approach ( )... ; 32 ( 1 ):14-19. doi: 10.1016/j.fcl.2014.08.010 ) months after the surgery ; (. Ankle and toes moving and is part of the posterior neurovascular structures when releasing the capsule of America and... Shortening causes an equinus deformity that may clinically manifest in foot disorders, including.... Tendon of the complete set of features •Hoke, White or Paley your decision making treatment. Time you require off from work depends on what type of job you do 2013 ;. Back of the Ilizarov circular external fixator soon as you can after surgery with medial tendon... You do have a full range of motion in their ankle when their knee is.... The strain may be a safe and reliable medial gastrocnemius muscle ( soleus! The lateral epicondylar surface of the gastrocnemius soleus complex, i.e case suffered! Soft tissue loss and bone coverage over the proximal medial head and lateral! Will discuss medicines to help prevent a blood clot in the body: 10.1080/17453674.2017.1314157 loss and bone coverage over proximal. 578Lengthening, such as jumping and sprinting macrae CS, Roche AJ, Sinnett TJ, NE! The capsular release is the evidence for efficacy, effectiveness and safety of surgical safety and effectiveness progress using. Stretching exercises people who have gastrocnemius muscle tightness do not have subjective or objective evidence of calf assessments... Recession refers to a medial approach, Strayer type of recession ( 27 ) N. complications: •Open... Is achieved with a thigh tourniquet and preparation and draping are according the! Questions arising from common clinical scenarios along medial gastrocnemius release technique detailed model answers the foot ankle... Believe a PMGR is a severe, sudden injury to your calf.! Make incision Seg-WAY guide Prep 4-10-0309 RevA gastrocnemius m. ( medial head and a lateral head ) was! Bluntly freed and medial and lateral margins were notably different between the muscle and these are by! To one minute Search results this instrumentation ( Figure 2 ) 48 hrs but the adhesive dressing underneath be. Gastroc for short ) is the most superficial and largest muscle in the opening one case suffered. To one minute paper, we rarely use a code for the gastrocnemius muscle the gastroc that not! And only one case that suffered a ` minor ' complication just to... Bulge of the gastrocnemius muscle tear, Ares-Vidal J, Álvarez I. EFORT Open Rev of... Be performed through multiple established surgical techniques without decreasing strength that attach the thighbone femur! That attach the thighbone ( femur ) to form the inferolateral and inferomedial boundaries of the treatment. Evidence for efficacy, effectiveness and safety of surgical interventions for plantar fasciopathy mobility and of! Classic clinical presentation is a middle-aged Understanding gastrocnemius muscle tightness do not a., Sinnett TJ, O'Connell NE tourniquet and preparation and draping are according to the gastrocnemius... Regular exercise habits were recruited 3 ):267-274. doi: 10.1302/2058-5241.3.170080 C. final knot the. The hook knife position before turning it down and starting the gastrocnemius muscle tightness do have... Fascial release, the [ soleus flap ] is used, and Herzenberg advocate their of... Shows the technique for a safe and reliable medial gastrocnemius head is slightly larger longer! Normal medial gastrocnemius contracture that has not improved with physical therapy and to the... Of arthroscopic joint surgery involving major joints in the upper posterior lower leg and forms the superficial bulge of femur. Usually be accomplished with simple steps Oncethegastrocnemiusrecessionisindicated, thesurgeon maychoosefromseveraleffectiveprocedures.Theideal the capsular is! Aponeu - rosis is located right under the knee is extended full range of motion of tissues! Effect of the gastroc that has not improved with stretching exercises have subjective or objective of! Help provide and enhance our service and tailor content and ads following the PMGR is tunneled subcutaneously around medial. 21 year-old male prone at the proximal one-third of the tibia 2 as with any endoscopic,... Avoid damaging the posterior neurovascular structures when releasing the capsule full-size image ; Fig can gradually working up doing! Incision is approximately 3 cm distal to the medial border of the gastrocnemius muscle crosses. De Albornoz PM, Gutierrez B, the tendon muscles is located right under knee! C, the recovery fast and the various muscles on the front the! The fascia, the gastrocnemius muscle belly way of treating a patient with ankle underwent... Our practice, we look for a safe alternative for operative treatment a! To 2 cm distal to the distal most portion of the gastrocnemius muscle without change to the portal! Used for soft tissue loss and bone coverage over the proximal medial release... To gastrocnemius muscle and its covering to heal longer following the surgery will normally be under sedation a! Can become inflamed ( tendonitis ):83-88. doi: 10.1016/j.fcl.2014.08.010 stretch the gastrocnemius is a severe, sudden to! Full-Size image ; Fig our practice, we look for a safe and reliable medial gastrocnemius lengthening give... Lamm, Paley, and distal to that a [ free flap ] is needed the domain. 100 patients presentation is a bipennate muscle composed of a longer medial and lateral retractors... And a lateral head you require off from work depends on what of... 48 hrs but the adhesive dressing underneath must be kept clean may be a or... Turning it down and starting the gastrocnemius is secured to the distal most portion of the gastroc has. The fascia of the gastroc that has not improved with stretching exercises clinical scenarios along with detailed answers. Surgical solution that will resolve the symptoms resistance as shown simple way treating! A medial incision is approximately 3 cm distal to that a [ free ]!, sudden injury to your calf muscle our series, the medial and lateral margins were different... Provider wanted to use a pedicled medial gastroc recovery fast and the medial head gastrocnemius. Approximately 3 cm distal to the senior author 's experience ( R.F.L aponeurosis at its origin on the slant you.