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Plantar Fasciitis Surgery: Are We Going Full Circle?

We have seen quite an evolution over the years in regard to surgical procedures for plantar fasciitis. In the 1980s, the standard procedure was open heel spur resection for patients that had failed conservative treatment. Podiatrists released the fascia to gain access to the spur. Little consideration was given to the amount of fascia that was released. Frequently, the entire fascia was released in the open procedure.

Patients often would develop pain on the dorsal lateral aspect of their foot and we assumed it was because they were shifting their weight to avoid walking on the surgical site.

This pain could be even more severe than the original heel pain. It seemed resistant to injections and supportive measures but fortunately appeared to be self-limiting and would eventually resolve.

Occasionally a patient did not have hospital coverage with his or her health insurance, or could not take the time off for the postoperative period of the open procedure. For these patients, we would perform a percutaneous medial fascial release in the office. We did this with a local anesthetic and released the fascia with a Beaver blade. The blade was not very long so you could not release too much of the fascia. The surgical site would heal in about two weeks and shortly after that, all heel pain had subsided.

Even though this little office procedure worked well, the procedure of choice remained the open heel spur resection.

In the early 1990s, percutaneous endoscopic plantar fasciotomy was introduced to our profession. We could use a scope to see the fascia and release exactly the desired amount. This was pretty high tech. The results were excellent although it could take the novice 30 to 60 minutes to perform the procedure. With experience, the procedure usually only took 15-20 minutes.

With the percutaneous approach, one was less likely to cut the branches of the medial calcaneal nerve in comparison to the open procedure. Healing was also much faster and there was less postoperative pain.

Perhaps the greatest contribution to the endoscopic procedure for our profession was the realization that we did not have to remove the heel spur to get good results.

Over the years, I gradually resorted back to the open heel spur resection. I just came across a number of patients who wanted the spur removed and I started performing the open spur resection routinely.

Getting Back To The Percutaneous Fascial Release

Last year, I performed several procedures using the percutaneous fascial release on patients who had no heel spurs. I performed these procedures as outpatient procedures. As we saw in the 1980s, these patients all did very well and after several weeks, all of the heel pain resolved.

I have been performing this procedure more frequently. I make a small 3 to 4 mm incision distal to the heel and release the medial band of the fascia. The patients have almost no postoperative pain since I did not perform the procedure on the weightbearing surface of the heel.

Lateral column pain? It does not occur with this procedure since we only release the medial band. We no longer use the endoscopic equipment.

Will this simple procedure become popular with our profession? I do not know but I do know that it is fast, has little postoperative pain and our patients love it.



"As we saw in the 1980s, these patients ALL did very well and after several weeks, ALL of the heel pain had resolved" There is a bit of a disconnect here for me. If the procedure worked so well, could be done under local anesthetic, and was associated with little risk... why did you possibly make a switch away from performing this procedure?

I also performed the MIS plantar release in the office in the late 1970's. The results were excellent but there were some patients down the road who developed neuromas, hammer toes, tarsal DJD etc. I repaired the additional pathology and the patients were happy. So what caused these additional podiatric problems. Chance?? Understanding the effects of a MIS release or any kind of release still has me performing ESWT and still being a strong advocate of not doing a release if at all possible due to the damge short and long term to the windlass effects. We must go back to the podiatric biomechanics that we studied in podiatry school All plantar fasciotomies have some effect on the biomechanics of the human foot and chain of motion. ESWT has no effects that could alter the windlass. We first must not be harm and we must educate our patients regardless of whether ESWT is an insurance covered procedure.

I had a facia release as an outpatient procedure and all is still well. I did develope tarsel tunnel in the other foot and my orth told me that is a common issue with tendon release. What is you take on this and how often do you see this after surgery. de RN

I find it interesting that you stated that you returned to the open procedure because "a number of patients wanted the spur removed". Did you return to the open procedure and remove the "spur" because the patients wanted it removed or because you really felt it was contributing to the pain? Although I believe a patient should be involved with the decision making process, I also believe that a patient shouldn't dictate a treatment if I don't believe that treatment is indicated. I personally do not believe that the actual "spur" contributes to the pain, therefore I would simply educate these patients rather than perform what I consider an unnecessary bone procedure just to make them "happy". I do agree that the simple fasciotomy described accomplishes the same end result as the EPF without all the bells and whistles. In addition to a Beaver blade, I have found a Smylie knife (sp) to be very useful. The curved blade allows me to place in along the calcaneus and just "push" it across to release part of the fascia. This has been described in the literature and works very well.

Calcaneal spurs plantarly and the tight plantar fascia can yield increased bursal sac fluid presure under the medial or lateral calcaneal nerve branches.Increased pronation may also stretch the plantar fascia during weight bearing.In large spurs plantarly, I tend to resect the whole spur as long as the patient has the TIME to heal.Cryosurgery works well for patients with heel pain /facsitis and is effective long term if the procedure is done properly.I also follow the patient in a custom made orthoses to reduce stress off the plantar facsia during weight bearing.
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