How To Address Complications Of Plantar Fascia Release

Michelle Butterworth, DPM, FACFAS

   Zimmerman and colleagues did a retrospective study comparing three types of postoperative management for endoscopic plantar fasciotomy.25 One group immediately bore weight. A second group wore a below-the-knee walking cast with a molded medial longitudinal arch for two weeks. The third group remained non-weightbearing with crutches for two weeks. Their results showed that the patients who wore the below-the-knee walking cast for two weeks required less time to obtain 80 percent pain relief, needed less time to return to full activities and had fewer complications than those patients who bore weight immediately. They were also more satisfied with their postoperative results than the patients who were non-weightbearing for two weeks.

How To Address Post-Op Biomechanical Instability

Even when you have operated on the ideal surgical candidate and employed the best surgical technique, complications can result. The physician has to identify the complication so treatment can occur quickly and efficiently. As with any surgical procedure, complications may happen with a plantar fasciotomy but fortunately they are few in number and most complications are usually temporary.

   The most common complications with a plantar fasciotomy derive from instability with lateral column pain and instability being most pronounced.5,9,15,16,18,26 When patients undergo a plantar fasciotomy, they lose some degree of support to the foot. There are numerous structures (including muscles and ligaments) involved with this support besides the plantar fascia. This loss of support is usually temporary while the other structures adapt and accommodate to this loss. During this time, patients may experience lateral column instability, sinus tarsitis, medial arch pain and fatigue, metatarsalgia and strain along the lesser tarsus. With continued strain, stress fractures may also arise.

   There are many studies that discuss the biomechanical consequences with plantar fasciotomy. Tweed and co-workers found weakness of the medial longitudinal arch and pain in the lateral midfoot in cadaver specimens with a total release.27 Sharkey and colleagues also report significant collapse of the arch in the sagittal plane with a complete fasciotomy.28

   In a follow-up study, Sharkey and co-workers found cutting only the medial half of the plantar fascia did significantly increase peak pressure under the metatarsal heads. Yet this had little effect on pressures in other regions of the forefoot or second metatarsal strain and loading.29 However, dividing the entire plantar fascia caused significant shifts in plantar pressure and force from the toes to beneath the metatarsal heads, and significantly increased strain and bending in the second metatarsal.

   What we can conclude from these biomechanical studies is the same conclusion from the previous studies: the surgeon should cut 50 percent or less of the plantar fascia to try to minimize postoperative instability.

   All of the above complications are due to instability created by the procedure itself. During the healing process and fibrosis, the arch regains some stability and these instability issues are typically temporary. Fortunately, these biomechanical instability problems usually resolve with conservative measures.

   Postoperative biomechanical control is very important as the foot accommodates to the temporary destabilization. Most patients usually have an orthotic device or arch support as part of their conservative therapy. I recommend continued use of these devices postoperatively as well, especially when the patient is having symptoms of instability. Balance padding can also be beneficial, particularly along the lateral column.

   One can also utilize nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections for inflammation. If pain from biomechanical instability continues even with these measures incorporated into the treatment plan, immobilization may be necessary.

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