Point-Counterpoint: Recalcitrant Plantar Fasciitis: Is Fasciotomy Ever Necessary?
Historically, the Joe DiMaggio case is probably the most illustrative in this regard. Due to the type of incision used (Griffith’s), arguably the greatest baseball player of the time was relegated to the plastic surgery service at Johns Hopkins University for treatment of a chronic wound dehiscence with maggot therapy for more than a month. DiMaggio’s baseball career was never the same and he soon retired.
Even if the numbers in the literature are accurate regarding the 80 to 90 percent efficacy of conservative, non-surgical care for the treatment of plantar fasciopathy, then an epidemiological analysis quickly reveals that there are thousands of patients every year who will require some type of surgical intervention to relieve their heel pain. It is rare for a week to go by without someone presenting to my clinic who has been treated for years with conservative measures for “plantar fasciitis.” In fact, many have a perfect fascia as determined by ultrasound and have another etiology causing their pain. For those who have such severe fasciopathy, none of their eight different conservative care modalities, including several pairs of orthoses, could ameliorate the symptoms.
Examining The Efficacy Of EPF
Endoscopic plantar fasciotomy is a well established technique. It has been documented in the seminal podiatric and orthopedic textbooks, and has an extremely high efficacy (nearly 99 percent in our experience.).4,6,17-19 Additionally, the technique results in less pain and a faster return to normal recovery in comparison to open fasciotomy.18 With accurate diagnosis and grading, as well as judicious postoperative management, the complication rate is extremely low at approximately 3 percent.12 Most complications are biomechanical sequelae of the lateral column, which one can effectively and quickly manage with biomechanical support.
In my opinion, many of those on the side of believing that fasciotomy should never occur are erroneously grounded in their beliefs regarding the potential biomechanical consequences of cutting part of the plantar fascia. I respect that philosophy and have already stated that I really hate having to partially and sometimes totally cut the plantar fascia. However, physicians have to realize that in patients for whom we are forced to make that decision, there are already severely altered biomechanics. (Sometimes, the compensation is so bad that patients break down their forefoot trying to offload the heel.) Therefore, the risk to benefit tradeoff is stacked in favor of fasciotomy.
Another consideration to discuss is that surgeons can prevent most of the complications of EPF with accurate diagnosis, excellent intraoperative technique and stringent postoperative management. There really can be no credible academic debate about whether fasciotomy is effective and efficacious, especially with EPF, as there is an abundance of literature from various authors confirming a very high success rate with fewer complications than open surgery.20
The only counterpoint that one can take, with any academic credibility, is from a complication perspective and that is weak. Would anyone not consider a technique with a manageable complication that occurs 3 percent of the time when there is greater than a 97 percent success rate?12 All surgical techniques have complications and there is little value in the attempt to discredit a procedure on this myopic basis alone.
Additionally, techniques that are not effective and fraught with unmanageable complications are not continually implemented more than a million times throughout the world by more than 5,000 surgeons since the inception of the technique, and to the order of 15,000 to 20,000 times this past year in the United States.12
Endoscopic plantar fasciotomy is a valid, well-established and documented method to treat recalcitrant plantar fasciosis with high inter-surgeon reliability. We should focus on developing a better paradigm for the grading of plantar fasciosis. This will allow for more accurate and faster diagnosis with subsequent interventions that are based on pathology rather than outdated dogma.