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.
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.
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.
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.
1. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline–revision 2010. J Foot Ankle Surg. 2010; 49(Suppl3):S1-19.
2. League AC. Current concepts review: plantar fasciitis. Foot Ankle Int. 2008; 29(3):358-66.
3. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008; 16(6):338-46.
4. Healey K, Chen K. Plantar fasciitis: current diagnostic modalities and treatments. Clin Podiatr Med Surg. 2010; 27(3):369-80.
5. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003; 93(3):234-7.
6. Hendrix CL, Jolly GP, Garbalosa JC, Blume P, DosRemedios E. Entrapment neuropathy: the etiology of intractable chronic heel pain syndrome. J Foot Ankle Surg. 1998; 37(4):273-9.
7. Lehman TJ. Enthesitis, arthritis and heel pain. J Am Podiatr Med Assoc. 1999; 89(1):18-9.
8. Hall RL, Erickson SJ, Shereff MJ, Johnson JE, Kneeland JB. Magnetic resonance imaging in the evaluation of heel pain. Orthopedics. 1996; 19(3):225-9.
9. Sammarco GJ, Helfrey RB. Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle Int. 1996;17(9):520-6.
10. Cutts S, Obi N, Pasapula C, Chan W. Plantar fasciitis. Ann R Coll Surg Engl. 2012; 94(8):539-42.
11. Bader L, Park K, Gu Y, O’Malley MJ. Functional outcome of endoscopic plantar fasciotomy. Foot Ankle Int. 2012 Jan;33(1):37-43.
12. Fishco WD, Goecker RM, Schwartz RI.The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review. J Am Podiatr Med Assoc. 2000 Feb;90(2):66-9.
For a related article, see the November 2011 DPM Blog, “Resistant Plantar Fasciitis: Why We Should Opt For A Gastrocnemius Recession Before Even Considering A Plantar Fasciotomy,” by Patrick DeHeer, DPM, FACFAS at http://tinyurl.com/8wl5kuy  .
By Steven Shannon, DPM, FACFAS
Plantar fasciitis and plantar heel pain are very common problems in most of our practices. People who present with the symptoms vary widely in their activity levels, shoe gear, body type, age, gender and occupation.
In light of these variations, a wide variety of non-surgical treatments are available for plantar heel pain. As we all know, stretching exercises and arch support therapy are the first-line treatments for this very common ailment. In addition, many other modalities are not far behind if the patient does not respond. Rest, ice, immobilization, nonsteroidal anti-inflammatory drug (NSAID) therapy, cortisone injections, night splints, physical therapy, exercise modification, custom-molded orthotics and shoe changes can all be very appropriate therapies. In addition, modalities such as platelet-rich plasma (PRP) injections, prolotherapy and extracorporeal shockwave therapy (ESWT) have all entered the arena as non-surgical options to treat plantar heel pain.
Generally speaking, I have found the conservative approaches to plantar heel pain usually will yield at least a 90 percent success rate if not higher. This leaves a very small percentage of cases that become recalcitrant to conservative approaches. Even taking into account these recalcitrant cases, research has shown that other forms of treatment, including ESWT and PRP injections, have a beneficial effect and can relieve a significant number of these difficult cases.1,2 What this leaves is a very small percentage of people who do not respond to a non-surgical approach.
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.
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.
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.
As physicians, we need to be cognizant of the fact that other diagnoses may be involved and be sure to treat the correct pathology conservatively for an appropriate period of time prior to consideration of more invasive or surgical options.
Dr. Shannon is affiliated with the Division of Podiatric Surgery at Penn Presbyterian Medical Center in Philadelphia. He is a Fellow of the American College of Foot and Ankle Surgeons.
1. Speed C. A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. Br J Sports Med. 2013; epub ahead of print.
2. Kumar V, Millar T, Murphy PN, Clough T. The treatment of intractable plantar fasciitis with platelet-rich plasma injection. Foot (Edinb). 2013; epub ahead of print.
3. Leach RE, Seavey MS, Salter DK. Results of surgery in athletes with plantar fasciitis. Foot Ankle. 1986; 7(3):156–61.
4. Daly PJ, Kitaoka HB, Chao YS. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle. 1992; 13(4):188–95.
5. Benton-Weil W, Borrelli AH, Weil LS, Weil LS. Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis. J Foot Ankle Surg. 1998; 37(4):269–72.