Point-Counterpoint: Should We Do Plantar Fascia Releases For Heel Pain?

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Author(s): 
Mark Hofbauer, DPM, FACFAS, and Alexander Pappas, DPM; and Steven Shannon, DPM, FACFAS

   Steroids, cryotherapy, shockwave and whatever magic pixie dust you can come with will not solve this patient’s condition. It is no different than believing that continuing to put wound products on infected bone will cure osteomyelitis.

   What is even more compelling is that the postoperative results have shown high patient satisfaction rates with low rates of complication for surgical plantar fascia treatment.6-9 In one study, 48 patients (56 feet) had follow-up for an average of 49.5 months after undergoing endoscopic plantar fasciotomy.11 Pain resolved completely in 37 feet, decreased in 11 feet and increased in one foot. The mean postoperative AOFAS hindfoot score improved 39 points.

   Fishco and colleagues looked at 83 patients (94 feet) who underwent plantar fasciotomy.12 At an average follow up of 20.9 months, researchers deemed the surgery successful in 93.6 percent of patients with 95.7 percent of patients saying they would recommend the surgery to someone with the same condition.

   In a 1993 study we did at the Podiatry Hospital of Pittsburgh, 39 of 40 patients interviewed five years following a plantar fascia release said they would recommend the procedure to someone with the same problem. The argument as to whether open plantar fasciotomy versus instep fasciotomy versus endoscopic plantar fasciotomy is a better way to go is beyond the scope of this discussion.

   We do believe, however, that some type of surgical release of the fascia is warranted in patients with chronic plantar fasciitis. We also believe that removing all or a portion of that mucoid degeneration plays a role in the patient’s immediate and long-term pain reduction. Complications such as calcaneocuboid syndrome, calcaneal stress fractures and nerve entrapment are rare, and one can usually prevent them with proper surgical technique.

Final Advice

A proper history and physical, X-rays and listening to the patient will tell us a great deal about the procedure needed. It is important to evaluate for tarsal tunnel syndrome and at times such conditions as seronegative arthritides.3,4,10

   It is worth noting that there is a small percentage of patients who present with plantar fasciitis and concomitant tarsal tunnel syndrome. In 51 patients with chronic heel pain and entrapment of the posterior tibial nerve, Hendrix and colleagues reported 96 percent of patients demonstrated significant improvement in pain levels while 90 percent had complete relief following surgery.6 In another study, surgeons performed partial plantar fasciectomy with neurolysis for 26 patients (35 feet) with recalcitrant plantar fasciitis and 92 percent attained satisfactory outcomes.9

   It is also important to distinguish between the classic plantar medial pain over the medial tubercle, arising most commonly in 80 percent of the patients, versus the direct plantar heel pain with a decreased fat pad and a plantigrade calcaneal bone spur. Surgical treatment options in those types of patients will obviously be somewhat different.

   Dr. Hofbauer is a Diplomate of the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons. He is a member of The Orthopedic Group in Pittsburgh.

   Dr. Pappas is the Reconstructive Foot and Ankle Surgery Fellow with The Orthopedic Group in Monongahela Valley, Pa.

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