Although the literature has shown favorable results for plantar fascia release, patients can experience complications such as biomechanical instability and persistent post-op pain. Accordingly, this author reviews the literature on surgical options for plantar fascia release, discusses key techniques for avoiding complications and provides a guide for remediating complications if they do occur.
Heel pain is one of the most common disorders that foot and ankle surgeons treat. Investigators have stated that of all adult foot complaints, 15 percent result from heel pain.1 It is important that the physician knows how to properly diagnose and treat this common problem.
Although there are many etiologies of plantar heel pain, plantar fasciitis or plantar heel spur syndrome are the most common.2 Fortunately, conservative treatment is successful in roughly 90 percent of patients seeking treatment with this diagnosis.3,4 These studies have shown that one should attempt six months of quality conservative treatment before considering surgery.
Research has shown surgical treatment for plantar fasciitis to be very effective with good results routinely reported throughout the literature.5-14 However, complications can occur as with any surgical procedure so the foot and ankle surgeon must know how to identify complications when they arise and institute a rapid, effective treatment plan.
The best way to address complications is to avoid them. Surgeons can avoid many complications through proper patient selection, accurate diagnosis, appropriate procedure selection, good surgical technique and implementation of an appropriate postoperative regimen.
To reiterate, due to the high rate of success with conservative therapies for plantar heel pain, one should exhaust non-operative measures prior to surgical intervention. Sometimes patients want a quick fix to their problem and want to proceed with surgery in an expeditious manner. It is the physician’s responsibility to ensure that appropriate conservative therapy occurs and not let patients control their own treatment protocol.
Some patients must also be willing to make certain lifestyle changes to ensure good results. This can be very difficult for many patients and they may view surgery as an easier option. These changes may include shoe modifications, weight reduction, decreased activities and employment alterations. One needs to discuss this thoroughly with patients and emphasize that even when they undergo surgery, if some of these changes do not happen, persistent pain may ensue.
Although plantar fasciitis or heel spur syndrome is the most common reason for plantar heel pain, the physician still needs to have a good working differential diagnosis, especially in recalcitrant cases.2 Other possible sources of plantar heel pain include but are not limited to neuritis or nerve entrapments, stress fractures and bone tumors. Other sources of heel pain are metabolic entities such as systemic lupus erythematosus (SLE), rheumatoid arthritis, Reiter’s syndrome, gout, psoriatic arthritis, ankylosing spondylitis and inflammatory bowel disease.
When a patient does not respond to conservative therapy, be sure to consider the possibility of these other etiologies prior to surgical intervention or the surgery could be doomed to failure.
How Much Of The Fascia Should The Surgeon Release?
When pursuing surgical intervention for plantar heel pain, the foot and ankle surgeon has several options. A plantar fasciotomy is the most common surgical procedure for plantar fasciitis but there are different techniques that one may employ.7,9,12,13,15-17 These techniques primarily include open, endoscopic, minimal incision and in-step plantar fasciotomies. All of these procedures can produce good postoperative results with satisfied patients.8,11
Regardless of which procedure the surgeon prefers, incising the proper amount of plantar fascia is one of the keys to a successful outcome and avoiding possible complications.
Barrett and Day originally advocated complete resection of the plantar fascia.15,18 However, two years later, they recommended releasing only the medial two-thirds of the plantar fascia.17 With continued experience and evaluation of postoperative complications, their final recommendation is releasing only the medial one-third of the plantar fascia.9 The reason for the change in the amount of plantar fascia to be cut is to reduce the common complication of lateral column destabilization. When the lateral fibers of the plantar fascia are intact, the locking mechanism for the calcaneocuboid joint will not be disrupted.
Cheung and colleagues recommend partial release of less than 40 percent of the fascia to minimize the effect of arch instability and maintain normal foot biomechanics.19 Brugh and co-workers found that lateral column symptoms were more likely to result when releasing more than 50 percent of the plantar fascia.20
Besides releasing the proper amount of plantar fascia, incision placement is another important component to the success of the surgical procedure. For this reason, the medial in-step plantar fasciotomy is my procedure of choice for plantar fasciitis. This technique is easy to perform, has few complications, has a quick recovery and postoperative healing course, and the results are predictable with a high patient satisfaction rate.7,8
Although the open procedure has been popular and still is with many surgeons, it can lead to larger, painful scars, requires significantly more dissection and can lead to other complications such as nerve entrapments.12,21-23
Endoscopic plantar fasciotomy is also a very common procedure employed by foot and ankle surgeons and also has a high rate of success.9,15,16,18 However, the portals can become painful and nerve entrapment is possible.24
The in-step plantar fasciotomy is not without reported complications such as scarring.7,8 Fortunately, I have been able to avoid painful scarring with accurate incision placement. The incision is a small transverse incision, approximately 2 cm in length, in the proximal medial arch just distal (about 1.5 to 2 cm) to the calcaneal fat pad. This incision is ideal because it is in line with the relaxed skin tension lines and is on a non-weightbearing surface, which minimizes scarring. It can be tempting, however, for the surgeon to make the incision too distal where the plantar fascia is more prominent. There is very little subcutaneous tissue in this area and scarring can be problematic at this location.
After making the skin incision, there is usually minimal dissection needed before the plantar fascia is ready for release. Once you have incised the plantar fascia, the muscle belly should be visible.
My preference is to release between one-third to one-half of the medial plantar fascia. I keep the digits dorsiflexed and release the plantar fascia until the tension has resolved. One may encounter the muscle septum in the lateral aspect of the incision. I do not incise this or cut any of the fibers of the plantar fascia lateral to this landmark.
However, it is important to ensure that one releases all of the medial fibers of the plantar fascia. Since the incision is small, I manually probe under the skin along the abductor hallucis muscle belly. If I encounter any taut fibers, I will incise them with a Metzenbaum scissor.
Pertinent Insights On Optimal Post-Op Care
Fortunately, patients undergoing a plantar fasciotomy, regardless of surgical technique, typically have a fairly quick healing and recovery time. My typical postoperative course following an in-step plantar fasciotomy is immediate weightbearing in a surgical shoe with limited activities. Walking places the plantar fascia under tension and allows the site of the plantar fasciotomy to remain open, avoiding re-adherence and fibrosis of the site.
Zimmerman and colleagues did a retrospective study comparing three types of postoperative management for endoscopic plantar fasciotomy.25 One group immediately bore weight. A second group wore a below-the-knee walking cast with a molded medial longitudinal arch for two weeks. The third group remained non-weightbearing with crutches for two weeks. Their results showed that the patients who wore the below-the-knee walking cast for two weeks required less time to obtain 80 percent pain relief, needed less time to return to full activities and had fewer complications than those patients who bore weight immediately. They were also more satisfied with their postoperative results than the patients who were non-weightbearing for two weeks.
How To Address Post-Op Biomechanical Instability
Even when you have operated on the ideal surgical candidate and employed the best surgical technique, complications can result. The physician has to identify the complication so treatment can occur quickly and efficiently. As with any surgical procedure, complications may happen with a plantar fasciotomy but fortunately they are few in number and most complications are usually temporary.
The most common complications with a plantar fasciotomy derive from instability with lateral column pain and instability being most pronounced.5,9,15,16,18,26 When patients undergo a plantar fasciotomy, they lose some degree of support to the foot. There are numerous structures (including muscles and ligaments) involved with this support besides the plantar fascia. This loss of support is usually temporary while the other structures adapt and accommodate to this loss. During this time, patients may experience lateral column instability, sinus tarsitis, medial arch pain and fatigue, metatarsalgia and strain along the lesser tarsus. With continued strain, stress fractures may also arise.
There are many studies that discuss the biomechanical consequences with plantar fasciotomy. Tweed and co-workers found weakness of the medial longitudinal arch and pain in the lateral midfoot in cadaver specimens with a total release.27 Sharkey and colleagues also report significant collapse of the arch in the sagittal plane with a complete fasciotomy.28
In a follow-up study, Sharkey and co-workers found cutting only the medial half of the plantar fascia did significantly increase peak pressure under the metatarsal heads. Yet this had little effect on pressures in other regions of the forefoot or second metatarsal strain and loading.29 However, dividing the entire plantar fascia caused significant shifts in plantar pressure and force from the toes to beneath the metatarsal heads, and significantly increased strain and bending in the second metatarsal.
What we can conclude from these biomechanical studies is the same conclusion from the previous studies: the surgeon should cut 50 percent or less of the plantar fascia to try to minimize postoperative instability.
All of the above complications are due to instability created by the procedure itself. During the healing process and fibrosis, the arch regains some stability and these instability issues are typically temporary. Fortunately, these biomechanical instability problems usually resolve with conservative measures.
Postoperative biomechanical control is very important as the foot accommodates to the temporary destabilization. Most patients usually have an orthotic device or arch support as part of their conservative therapy. I recommend continued use of these devices postoperatively as well, especially when the patient is having symptoms of instability. Balance padding can also be beneficial, particularly along the lateral column.
One can also utilize nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections for inflammation. If pain from biomechanical instability continues even with these measures incorporated into the treatment plan, immobilization may be necessary.
Key Insights On Resolving Persistent Pain
Continued pain or continued plantar fasciitis is another possible complication. If a patient has persistent pain following a plantar fasciotomy, the physician should look for other possible etiologies for the pain. Neuritis or nerve entrapments, especially Baxter’s nerve, are possible sources of continued pain. This nerve can be entrapped as it courses below the abductor hallucis muscle.
Although most inferior calcaneal spurs are not the source of heel pain in the majority of patients with plantar fasciitis, patients with a large plantar protuberance or a pes plano valgus foot type may have persistent pain requiring resection of the prominence.22-24 If the surgeon removed a spur during the initial surgery and heel pain persists, evaluate the patient for a possible calcaneal fracture. Resection of the spur can produce stress risers, which can develop into a fracture with weightbearing. It is also possible that the patient had a calcaneal stress fracture prior to surgery that was never diagnosed.
When it comes to the differential diagnosis for recalcitrant pain after a plantar fasciotomy, one may consider metabolic conditions including SLE, rheumatoid arthritis, Reiter’s syndrome, gout, psoriatic arthritis, ankylosing spondylitis and inflammatory bowel disease.
Continued inflammation following a plantar fasciotomy may also be a source of continued pain. Once the plantar fascia can adequately stretch and the tension has been released along the insertion at the calcaneus, the inflammatory process usually starts to subside. However, this can be a slow process and one can employ anti-inflammatory measures, including rest, ice, NSAIDs and corticosteroid injections, postoperatively if needed.
How To Address Scarring And Complications Due To Surgical Technique
Besides complications resulting from altered biomechanics, scarring is one of the more common complications with a plantar fasciotomy regardless of procedure selection.
Again, the key to avoid painful, thickened scarring is good surgical execution and incision placement. Surgeons can minimize scarring by making incisions within relaxed skin tension lines, making them parallel to the course of nerves to avoid neuritis or nerve entrapments, and keeping incisions on non-weightbearing areas. When painful scars occur, one can employ conservative treatments such as topical medications and massage, gel (silicone) sheeting and corticosteroid injections.
Many of the painful scars do resolve with time. For scars with persistent pain, one can attempt scar excision. Also, if the scar is painful secondary to neuritis or nerve entrapment, one must address this. The use of NSAIDs and corticosteroid injections is often helpful for neuritis although nerve release and/or excision may be necessary to relieve the symptoms of nerve entrapment.
Persistent pain may also result if one did not release enough of the plantar fascia and tight fibers remain. It is also possible that although the plantar fascia was released, if the opening of the fibers is not maintained, they can fibrose and reattach.
Some surgeons take a small portion of the plantar fascia and perform a plantar fasciectomy to avoid this possible complication. Some surgeons employ immediate weightbearing postoperatively while others utilize splinting and casting to help keep the fibers of the plantar fascia separated. Stretching of the plantar fascia postoperatively may also be helpful to avoid this complication but take care not to be overaggressive as this can lead to plantar fascia rupture.
Also, if the surgeon releases too much of the plantar fascia and employs an active postoperative course with weightbearing and stretching, one should be cautious of complete rupture. If not enough of the plantar fascia has been released or there is scarring along the plantar fasciotomy site, revisional surgery with possible plantar fasciectomy may be warranted for relief of pain.
Can ESWT Be An Alternative To Plantar Fasciotomy?
Although plantar fasciotomy can be a successful technique with few complications, extracorporeal shockwave therapy is a non-invasive alternative for the treatment of chronic plantar fasciitis and research has shown good results.30,31
Surgeons should be aware of this technique and familiarize themselves with the risks and benefits in comparison to a plantar fasciotomy.
Plantar fasciotomy can be a successful technique for recalcitrant heel pain. Few complications have been reported and typically resolve with conservative therapies. Most complications are due to temporary instability in the foot from altered biomechanics resulting from the release of the plantar fascia.
Proper patient selection, accurate diagnosis and good surgical technique can minimize complications, and result in a high rate of patient satisfaction. For persistent pain, revisional surgery may be needed and the patient may need to make lifestyle changes including possible weight loss, change in athletic routines, or even changes in employment.
Dr. Butterworth is a Fellow and is on the Board of Directors as Treasurer/Secretary of the American College of Foot and Ankle Surgeons. She is in private practice in Kingstree, S.C.
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