How To Address Complications Of Plantar Fascia Release

Michelle Butterworth, DPM, FACFAS

Although the literature has shown favorable results for plantar fascia release, patients can experience complications such as biomechanical instability and persistent post-op pain. Accordingly, this author reviews the literature on surgical options for plantar fascia release, discusses key techniques for avoiding complications and provides a guide for remediating complications if they do occur.

Heel pain is one of the most common disorders that foot and ankle surgeons treat. Investigators have stated that of all adult foot complaints, 15 percent result from heel pain.1 It is important that the physician knows how to properly diagnose and treat this common problem.

   Although there are many etiologies of plantar heel pain, plantar fasciitis or plantar heel spur syndrome are the most common.2 Fortunately, conservative treatment is successful in roughly 90 percent of patients seeking treatment with this diagnosis.3,4 These studies have shown that one should attempt six months of quality conservative treatment before considering surgery.

   Research has shown surgical treatment for plantar fasciitis to be very effective with good results routinely reported throughout the literature.5-14 However, complications can occur as with any surgical procedure so the foot and ankle surgeon must know how to identify complications when they arise and institute a rapid, effective treatment plan.

   The best way to address complications is to avoid them. Surgeons can avoid many complications through proper patient selection, accurate diagnosis, appropriate procedure selection, good surgical technique and implementation of an appropriate postoperative regimen.

   To reiterate, due to the high rate of success with conservative therapies for plantar heel pain, one should exhaust non-operative measures prior to surgical intervention. Sometimes patients want a quick fix to their problem and want to proceed with surgery in an expeditious manner. It is the physician’s responsibility to ensure that appropriate conservative therapy occurs and not let patients control their own treatment protocol.

   Some patients must also be willing to make certain lifestyle changes to ensure good results. This can be very difficult for many patients and they may view surgery as an easier option. These changes may include shoe modifications, weight reduction, decreased activities and employment alterations. One needs to discuss this thoroughly with patients and emphasize that even when they undergo surgery, if some of these changes do not happen, persistent pain may ensue.

   Although plantar fasciitis or heel spur syndrome is the most common reason for plantar heel pain, the physician still needs to have a good working differential diagnosis, especially in recalcitrant cases.2 Other possible sources of plantar heel pain include but are not limited to neuritis or nerve entrapments, stress fractures and bone tumors. Other sources of heel pain are metabolic entities such as systemic lupus erythematosus (SLE), rheumatoid arthritis, Reiter’s syndrome, gout, psoriatic arthritis, ankylosing spondylitis and inflammatory bowel disease.

   When a patient does not respond to conservative therapy, be sure to consider the possibility of these other etiologies prior to surgical intervention or the surgery could be doomed to failure.

How Much Of The Fascia Should The Surgeon Release?

When pursuing surgical intervention for plantar heel pain, the foot and ankle surgeon has several options. A plantar fasciotomy is the most common surgical procedure for plantar fasciitis but there are different techniques that one may employ.7,9,12,13,15-17 These techniques primarily include open, endoscopic, minimal incision and in-step plantar fasciotomies. All of these procedures can produce good postoperative results with satisfied patients.8,11

   Regardless of which procedure the surgeon prefers, incising the proper amount of plantar fascia is one of the keys to a successful outcome and avoiding possible complications.

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