Plantar Fasciitis Surgery: Are We Going Full Circle?
We have seen quite an evolution over the years in regard to surgical procedures for plantar fasciitis. In the 1980s, the standard procedure was open heel spur resection for patients that had failed conservative treatment. Podiatrists released the fascia to gain access to the spur. Little consideration was given to the amount of fascia that was released. Frequently, the entire fascia was released in the open procedure.
Patients often would develop pain on the dorsal lateral aspect of their foot and we assumed it was because they were shifting their weight to avoid walking on the surgical site.
This pain could be even more severe than the original heel pain. It seemed resistant to injections and supportive measures but fortunately appeared to be self-limiting and would eventually resolve.
Occasionally a patient did not have hospital coverage with his or her health insurance, or could not take the time off for the postoperative period of the open procedure. For these patients, we would perform a percutaneous medial fascial release in the office. We did this with a local anesthetic and released the fascia with a Beaver blade. The blade was not very long so you could not release too much of the fascia. The surgical site would heal in about two weeks and shortly after that, all heel pain had subsided.
Even though this little office procedure worked well, the procedure of choice remained the open heel spur resection.
In the early 1990s, percutaneous endoscopic plantar fasciotomy was introduced to our profession. We could use a scope to see the fascia and release exactly the desired amount. This was pretty high tech. The results were excellent although it could take the novice 30 to 60 minutes to perform the procedure. With experience, the procedure usually only took 15-20 minutes.
With the percutaneous approach, one was less likely to cut the branches of the medial calcaneal nerve in comparison to the open procedure. Healing was also much faster and there was less postoperative pain.
Perhaps the greatest contribution to the endoscopic procedure for our profession was the realization that we did not have to remove the heel spur to get good results.
Over the years, I gradually resorted back to the open heel spur resection. I just came across a number of patients who wanted the spur removed and I started performing the open spur resection routinely.
Getting Back To The Percutaneous Fascial Release
Last year, I performed several procedures using the percutaneous fascial release on patients who had no heel spurs. I performed these procedures as outpatient procedures. As we saw in the 1980s, these patients all did very well and after several weeks, all of the heel pain resolved.
I have been performing this procedure more frequently. I make a small 3 to 4 mm incision distal to the heel and release the medial band of the fascia. The patients have almost no postoperative pain since I did not perform the procedure on the weightbearing surface of the heel.
Lateral column pain? It does not occur with this procedure since we only release the medial band. We no longer use the endoscopic equipment.
Will this simple procedure become popular with our profession? I do not know but I do know that it is fast, has little postoperative pain and our patients love it.