How To Address Complications Of Plantar Fascia Release

Author(s): 
Michelle Butterworth, DPM, FACFAS

Key Insights On Resolving Persistent Pain

Continued pain or continued plantar fasciitis is another possible complication. If a patient has persistent pain following a plantar fasciotomy, the physician should look for other possible etiologies for the pain. Neuritis or nerve entrapments, especially Baxter’s nerve, are possible sources of continued pain. This nerve can be entrapped as it courses below the abductor hallucis muscle.

   Although most inferior calcaneal spurs are not the source of heel pain in the majority of patients with plantar fasciitis, patients with a large plantar protuberance or a pes plano valgus foot type may have persistent pain requiring resection of the prominence.22-24 If the surgeon removed a spur during the initial surgery and heel pain persists, evaluate the patient for a possible calcaneal fracture. Resection of the spur can produce stress risers, which can develop into a fracture with weightbearing. It is also possible that the patient had a calcaneal stress fracture prior to surgery that was never diagnosed.

   When it comes to the differential diagnosis for recalcitrant pain after a plantar fasciotomy, one may consider metabolic conditions including SLE, rheumatoid arthritis, Reiter’s syndrome, gout, psoriatic arthritis, ankylosing spondylitis and inflammatory bowel disease.

   Continued inflammation following a plantar fasciotomy may also be a source of continued pain. Once the plantar fascia can adequately stretch and the tension has been released along the insertion at the calcaneus, the inflammatory process usually starts to subside. However, this can be a slow process and one can employ anti-inflammatory measures, including rest, ice, NSAIDs and corticosteroid injections, postoperatively if needed.

How To Address Scarring And Complications Due To Surgical Technique

Besides complications resulting from altered biomechanics, scarring is one of the more common complications with a plantar fasciotomy regardless of procedure selection.

   Again, the key to avoid painful, thickened scarring is good surgical execution and incision placement. Surgeons can minimize scarring by making incisions within relaxed skin tension lines, making them parallel to the course of nerves to avoid neuritis or nerve entrapments, and keeping incisions on non-weightbearing areas. When painful scars occur, one can employ conservative treatments such as topical medications and massage, gel (silicone) sheeting and corticosteroid injections.

   Many of the painful scars do resolve with time. For scars with persistent pain, one can attempt scar excision. Also, if the scar is painful secondary to neuritis or nerve entrapment, one must address this. The use of NSAIDs and corticosteroid injections is often helpful for neuritis although nerve release and/or excision may be necessary to relieve the symptoms of nerve entrapment.

   Persistent pain may also result if one did not release enough of the plantar fascia and tight fibers remain. It is also possible that although the plantar fascia was released, if the opening of the fibers is not maintained, they can fibrose and reattach.

   Some surgeons take a small portion of the plantar fascia and perform a plantar fasciectomy to avoid this possible complication. Some surgeons employ immediate weightbearing postoperatively while others utilize splinting and casting to help keep the fibers of the plantar fascia separated. Stretching of the plantar fascia postoperatively may also be helpful to avoid this complication but take care not to be overaggressive as this can lead to plantar fascia rupture.

   Also, if the surgeon releases too much of the plantar fascia and employs an active postoperative course with weightbearing and stretching, one should be cautious of complete rupture. If not enough of the plantar fascia has been released or there is scarring along the plantar fasciotomy site, revisional surgery with possible plantar fasciectomy may be warranted for relief of pain.

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