Point-Counterpoint: Recalcitrant Plantar Fasciitis: Is Fasciotomy Ever Necessary?
This author says there is still a very important role for plantar fasciotomy in the treatment of recalcitrant plantar fasciopathy, citing high success rates and minimal complications.
By Stephen L. Barrett, DPM, MBA
First, let us get the nomenclature right. “Fasciitis” is incorrect as it is not an inflammatory condition but a degenerative one. Therefore, we should really call the condition either plantar fasciopathy or plantar fasciosis.1,2 It is well established that there is a certain subset of cases of plantar fasciopathy, perhaps higher than 10 percent, which simply does not respond to other treatments, either conservative or minimally invasive ones.
Since the introduction of the endoscopic plantar fasciotomy (EPF) procedure in 1990, surgeons have performed more than 1 million of these procedures worldwide.3 Even with the incredible advancements that have been made with extracorporeal shockwave therapy (ESWT), ultrasound guided partial plantar fasciectomy and other modalities, there are still thousands of patients who need a plantar fasciotomy. For the record and contrary to much outside opinion, I do not like to cut the plantar fascia and will do everything possible to avoid having to perform an EPF. However, when needed, the EPF is highly efficacious with minimal complication and postoperative morbidity.4-6
With today’s technology, especially high-resolution diagnostic ultrasound, not only can physicians make an assured diagnosis of plantar fasciopathy within minutes, they can also accurately measure the level of severity of the degeneration within the plantar fascia itself. Ultrasongraphy is definitive for the diagnosis of plantar fasciopathy. If normal or mildly affected fascia is present, this takes the consideration of plantar fasciotomy out of the debate.7-11 This technology allows for the institution of better treatment paradigms with faster and more beneficial outcomes for patients who suffer from this condition.
The fact of the matter is there are some patients — and with grading we know who they are — who will not get relief with lesser invasive or conservative techniques. For example, a patient who has a symptomatic plantar fascia, which measures greater than 7.5 mm in thickness with a severe hypoechoic signal intensity (Grade IV C), will not likely benefit from anything less than a fasciotomy.12 In my experience, this even includes treatments such as ultrasound guided partial plantar fasciectomy with autologous platelet concentrate (APC+) and ESWT. There is also a high level of association of nerve entrapment with plantar fasciopathy and the use of modalities such as the Pressure Specified Sensory Device (PSSD) proves extremely valuable in determining the true pain generators responsible for a patient’s heel pain.13-16
Certainly, much of the controversy over the use of plantar fasciotomy to treat recalcitrant plantar fasciosis (plantar fasciitis) stems from potential biomechanical consequences. Additionally, prior to the introduction of endoscopic and minimally invasive techniques, open heel “spur” surgery had significant postoperative morbidity, which made the use of fasciotomy a last-ditch attempt to treat the patient with plantar heel pain due to fasciosis. The severe postoperative morbidity also masked many of the biomechanical sequela, such as lateral column stress, simply because the surgery was associated with so much pain the patient, in many cases, could not walk for months. Accordingly, this eliminated signs of biomechanical breakdown.
Many foot specialists would advise folks that they were better off suffering from their condition as opposed to possibly developing a painful amputation neuroma of the medial calcaneal nerve or being off their feet for a year or more. I was certainly in that camp prior to developing the EPF because I had seen such horrific situations after open heel surgery in my residency training.