How To Perform An In-Step Plantar Fasciotomy

By Lawrence Karlock, DPM, FACFAS,and Dan Kirk, DPM

    Heel pain is obviously one of the most common complaints we see in podiatric office. The causes of heel pain are varied and include tarsal tunnel syndrome, Baxter’s neuritis, calcaneal stress fracture and spondyloarthropathies, just to name a few. For the majority of these patients, the diagnosis is plantar fasciitis.     Many of these patients will get better with conservative care, which includes stretching, orthotic devices and steroid injections. Those who still have pain may find relief with extracorporeal shockwave therapy. Patients who still do not respond to these treatments are left with the option of surgical cutting of the plantar fascia. However, research has shown that a total release of the fascia causes an increased incidence of lateral column instability.     In 1957, DuVries described the classic surgery for plantar fasciitis or heel spur syndrome.1 He performed the surgery through a medial incision in which he removed the fascia from its insertion and subsequently removed the heel spur. Others have used a minimal incision technique with just a stab incision on the plantar or medial aspect of the foot. According to current podiatric thought, it is the inflamed/degenerative fascia rather than the heel spur itself that is the source of the heel pain.     With the medial DuVries incision, Gormley showed in his study that 84 of the 94 patients had postoperative numbness along the incision and 36 had numbness after six months.2     Some physicians have used an endoscopic approach to release the plantar fascia. In an anatomic study, Reeve, et. al., showed the inability to transect the most medial band of the plantar fascia using the endoscopic plantar fasciotomy double portal technique that Barrett and Day described.3 Kim, et. al., showed in their study that using the traditional endoscopic approach can lead to the formation of a neuroma of the calcaneal nerve.4     Foot and ankle surgeons also have used the plantar transverse in-step approach to release the fascia. Woelffer, et. al., showed a 91 percent excellent or good result up to 6.5 years after surgery.5 Fishco, et. al., showed a 93.6 percent success rate with 95.7 percent of the patients recommending the procedure.6     The main complications reported with this surgery are scarring, medial arch pain, cramping in the arch, lateral column pain, pain across the dorsum of the foot, and burning or tingling in the ball of the foot.6 These complications occurred infrequently in patients.     Accordingly, let us take a closer look at the plantar in-step fasciotomy and our experience with it over the past 12 years.

Detailing The Advantages Of In-Step Plantar Fasciotomies

    We feel this procedure has several advantages over the traditional medial approach, endoscopic plantar fasciotomy (EPF) and minimal incision technique. This procedure allows direct visualization of the plantar fascia in an area that is at low risk for nerve entrapment. This procedure also equivocally allows the surgeon to transect the appropriate percentage of the plantar fascia due to this direct visualization. As reported previously by Reeve, surgeons are often unable to release the abductor hallucis fascia with the endoscopic plantar release.4 The in-step plantar fasciotomy avoids direct transection of the medial calcaneal nerve branches, which is common with the traditional DuVries medial approach.     Even after the EPF procedure, medial calcaneal nerve damage has been reported in up to 10 percent of feet. The in-step plantar fasciotomy also has the advantage of allowing early weightbearing if the surgeon desires. As mentioned by previous authors, the EPF as well as the DuVries incision puts “cutaneous innervation of the medial heel region at risk to injury.”4

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