How To Address Complications Of Plantar Fascia Release
Barrett and Day originally advocated complete resection of the plantar fascia.15,18 However, two years later, they recommended releasing only the medial two-thirds of the plantar fascia.17 With continued experience and evaluation of postoperative complications, their final recommendation is releasing only the medial one-third of the plantar fascia.9 The reason for the change in the amount of plantar fascia to be cut is to reduce the common complication of lateral column destabilization. When the lateral fibers of the plantar fascia are intact, the locking mechanism for the calcaneocuboid joint will not be disrupted.
Cheung and colleagues recommend partial release of less than 40 percent of the fascia to minimize the effect of arch instability and maintain normal foot biomechanics.19 Brugh and co-workers found that lateral column symptoms were more likely to result when releasing more than 50 percent of the plantar fascia.20
Besides releasing the proper amount of plantar fascia, incision placement is another important component to the success of the surgical procedure. For this reason, the medial in-step plantar fasciotomy is my procedure of choice for plantar fasciitis. This technique is easy to perform, has few complications, has a quick recovery and postoperative healing course, and the results are predictable with a high patient satisfaction rate.7,8
Although the open procedure has been popular and still is with many surgeons, it can lead to larger, painful scars, requires significantly more dissection and can lead to other complications such as nerve entrapments.12,21-23
Endoscopic plantar fasciotomy is also a very common procedure employed by foot and ankle surgeons and also has a high rate of success.9,15,16,18 However, the portals can become painful and nerve entrapment is possible.24
The in-step plantar fasciotomy is not without reported complications such as scarring.7,8 Fortunately, I have been able to avoid painful scarring with accurate incision placement. The incision is a small transverse incision, approximately 2 cm in length, in the proximal medial arch just distal (about 1.5 to 2 cm) to the calcaneal fat pad. This incision is ideal because it is in line with the relaxed skin tension lines and is on a non-weightbearing surface, which minimizes scarring. It can be tempting, however, for the surgeon to make the incision too distal where the plantar fascia is more prominent. There is very little subcutaneous tissue in this area and scarring can be problematic at this location.
After making the skin incision, there is usually minimal dissection needed before the plantar fascia is ready for release. Once you have incised the plantar fascia, the muscle belly should be visible.
My preference is to release between one-third to one-half of the medial plantar fascia. I keep the digits dorsiflexed and release the plantar fascia until the tension has resolved. One may encounter the muscle septum in the lateral aspect of the incision. I do not incise this or cut any of the fibers of the plantar fascia lateral to this landmark.
However, it is important to ensure that one releases all of the medial fibers of the plantar fascia. Since the incision is small, I manually probe under the skin along the abductor hallucis muscle belly. If I encounter any taut fibers, I will incise them with a Metzenbaum scissor.
Pertinent Insights On Optimal Post-Op Care
Fortunately, patients undergoing a plantar fasciotomy, regardless of surgical technique, typically have a fairly quick healing and recovery time. My typical postoperative course following an in-step plantar fasciotomy is immediate weightbearing in a surgical shoe with limited activities. Walking places the plantar fascia under tension and allows the site of the plantar fasciotomy to remain open, avoiding re-adherence and fibrosis of the site.