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

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

Yes.

After conservative options for plantar fasciitis fail, these authors argue that release of the plantar fascia can be beneficial for those with chronic pain, citing good success rates in the literature.

By Mark Hofbauer, DPM, FACFAS, and Alexander Pappas, DPM

Arguments over the proper way to treat chronic plantar fasciitis have probably been going on for as long as people have had heel pain. Not a meeting goes by without a lecture or two recommending some new state-of-the-art treatment modality, machine or magic potion that will cure heel pain.

   We spend millions of dollars a year on injections, medications, acupuncture, lasers, night splints, orthotics, platelet-rich plasma and on many other treatments, all promising the ultimate cure or holy grail. The bottom line is that just like all of the other conditions that we treat as foot and ankle specialists, the time comes when conservative care has failed and we need a definitive option.

   The idea of exhausting conservative options for eight to 12 months for chronic plantar fasciitis may look good in the medical record and may pad the pocketbook or the bottom line. However, it doesn’t really help Mr. Jones, who has been suffering, limping and just trying to make it through his day deep in the bottom of a coal mine for 10 straight hours because he needs to keep food on the table for his family.

   There are protocols and algorithms that will supposedly take us down the proper “highway” in dealing with the patient with plantar fasciitis. It is important to realize, however, that on the other side of that algorithm are patients with different circumstances and pain tolerance levels.

   That said, there are certain algorithms and treatment guidelines with which we do agree. We do believe in trying conservative treatment first. We typically exhaust conservative or non-surgical treatment for four to six months. This follows highly regarded guidelines.1 We have to remember that when a patient is suffering to the point where it is affecting his or her way of life, it is our job to determine that problem and provide an excellent, proven way to handle or fix the problem.

   There is no argument that the majority of patients with plantar fasciitis will respond to conservative care, especially in the acute setting. We do believe there is an argument as to the success rate in treating this condition. Some authors declare conservative cure rates exceeding 90 percent, which, in our opinion and experience, is hogwash, and there is evidence that confirms this.2-4 Many patients who no longer show up in your office after three injections, orthotics and a month of physical therapy are not necessarily cured but wind up seeking your competitors’ advice and treatment.

   How often do you see cases in which some new technology, such as shockwave therapy, has been developed and mass marketed? All of a sudden, the Mrs. Smiths of the world, whom you have not seen for months, show up in your office and have questions as to whether you offer shockwave therapy. If you take the time to talk and listen to these patients, you will learn that they have just given up coming back because they just assumed there was nothing else you could do for them. All along, these patients have continued to suffer with varying degrees of heel pain.

Why You Should Consider Plantar Fascia Release

The pathophysiology of acute versus chronic heel pain is really the determining factor with regard to continued conservative care versus surgical plantar fascia release. Not unlike the chronic wound that needs debridement to stimulate an inflammatory response to heal, chronic plantar fasciitis requires similar therapy.

   Chronic mucoid degeneration of the plantar fascia causing confirmed pain is a surgical disease, like osteomyelitis or Achilles tendinosis.5 One needs to address this “dead,” non-viable, painful, diseased tissue.

   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.

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