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

Mark Hofbauer, DPM, FACFAS, and Alexander Pappas, DPM; and Steven Shannon, DPM, FACFAS

   The next point to make here is that all plantar heel pain is not plantar fasciitis. There are a number of other conditions that one needs to rule out prior to consideration of an invasive approach such as plantar fasciotomy. Certainly, stress fractures of the calcaneus, lateral plantar nerve entrapment, tarsal tunnel syndrome and plantar fascia tear all conceivably mimic plantar fascial pain.

   It seems to be accepted that patients with plantar heel pain must have a minimum of six months of conservative/non-surgical care prior to considering surgical options. If that time approaches or if their symptoms change in that time period, and I have a suspicion that there is another pathology at work, I will generally order magnetic resonance imaging (MRI) to evaluate the heel prior to discussion of any surgical options.

   Personally, when it comes to patients with plantar heel pain that is consistent with plantar fasciitis, I have found a number of MRI studies come back with varying degrees of evidence of partial tears of the medial and central bands of the fascia itself. If I find partial tears, I will immobilize the patient between three to six weeks in a fracture boot or cast, which has resolved the problem for a number of my patients. In these cases, it may prevent the patient from having to undergo an invasive procedure.

Pertinent Insights On The Complications Of Plantar Fasciotomy

After confirming the diagnosis of plantar fasciitis and determining that the patient is not improving with the usual non-surgical treatments, we must consider the effectiveness and side effects of the procedures we are performing. One can perform a plantar fasciotomy endoscopically, via a minimally invasive or mini-open approach, or as an open procedure. There are varying degrees in the success rates of these procedures in the literature, ranging between 70 to 90 percent.3-5 If the percentage is in the 70s, that represents a significantly high complication rate for patients undergoing the procedure.

   What I have seen and relayed to patients is that there are four distinct groups with differing results of plantar fasciotomy. The first 25 percent are the patients who do very well and whose pain has basically resolved as soon as they ambulate after the surgery. The second 25 percent are patients who still have pain after the surgery but after approximately three to six months are able to report full resolution of their symptoms. The third 25 percent are patients who have a significant decrease in pain after surgery but never get full relief. The last 25 percent are patients who have no change in their pain, worsen or have a complication from the procedure.

   That results in a 75 percent patient satisfaction rate, which is in line with some of the studies that focused on plantar fasciotomy.3-5 It also results in one out of every four patients not having the desired outcome. I believe this approach gives patients some perspective so their expectations are not out of proportion with what the surgeon can reasonably achieve.

   The complications that can result from plantar fasciotomy can be significant for the physician and the patient. Biomechanically, the plantar fascia has an important role in stance and gait, stiffening the arch during propulsion. Altering the mechanics of the fascia by sectioning all or part of the ligament can have repercussions on the function of the foot during these phases. Calcaneocuboid or lateral column instability, a decrease in the medial and lateral arches, medial column strain and metatarsalgia as well as the potential for hammertoe or claw toe deformities are possible results of over-aggressive plantar fasciotomy.

   These complications may require more or different treatment than the patient had previously, including the need for custom-molded orthotics to support a foot that has suffered some of these complications or surgical intervention to correct subsequent deformity.

In Conclusion

There is certainly a role for the plantar fasciotomy in the lexicon of treatment for plantar heel pain. I personally do perform these procedures. However, I would say that I only perform about two or three of these procedures a year. I think this number reflects that the non-surgical treatments for plantar heel pain are extremely effective to this day.

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