It is a rare occasion in one’s professional career to experience a paradigm shift in philosophy, even if it is on just one topic. Plantar fasciitis is the most common condition I see on a daily basis. Up to 85 percent of the time, I am able to treat it conservatively. For the past 20 years, when it came to patients who did not respond to conservative treatment or did not have associated nerve entrapment, I have done a plantar fasciotomy.
Early in my career, I would perform a complete release for such patients. Over the past 15 years or so, I have simply done a medial band release from an in-step plantar approach. The procedure lasts approximately 10 minutes and it almost always improves the patient’s symptoms. Often, however, this relief came at a price of lateral column pain and instability. I have always debated internally whether the risk outweighed the reward for this procedure.
After doing extensive research on equinus and its role in plantar fasciitis, I am convinced that podiatrists should no longer utilize the plantar fasciotomy procedure unless the condition is associated with a nerve entrapment release.
Based on articles I will review in this blog, I now feel that one should use a gastrocnemius recession in place of a plantar fasciotomy. This approach eliminates the risk component of a plantar fascia release. Instead of weakening the arch structure, it improves foot biomechanics. Does this approach require a leap of faith? Absolutely but there is evidence-based medicine to support it. Does this approach require significant patient education? Absolutely but if you put in the time with patients, they will understand your treatment plan.
Maskill and colleagues looked at the effect of a gastrocnemius recession on patients with heel pain, metatarsalgia and arch pain who failed six months of conservative therapy.1 They used the visual analog scale (VAS) to take preoperative and postoperative recordings. The plantar fasciitis patient group consisted of 25 feet and an average preoperative VAS score of 8.1 out of 10. The postoperative VAS score averaged 1.9 at a follow-up of 19.5 months.
Cheung and colleagues further showed the correlative relationship between the plantar fasciitis and equinus.2 They were able to quantify the biomechanical effects of loading of the Achilles tendon on the plantar fascia in the standing foot. They found the plantar fascia to be an important arch supporting structure, raising further doubts about the questionable approach of cutting this structure. The study found the Achilles tendon loading to have twice the amount of straining effect on the plantar fascia than body weight. Finally, they concluded that lengthening or tension relief of the Achilles tendon may benefit stress relief on the plantar fascia.
Two separate studies from the Oakwood Dearborn Health System in Dearborn, Mich. examined the effects of lengthening the plantar fascia. A 2001 study recommended a 25 percent release of the width of the plantar fascia.3 The 2002 study recommended no more than a 50 percent release.4 Both studies spoke in detail of the biomechanical consequences of releasing the plantar fascia.
Where else in foot and ankle surgery do we accept such a poor risk versus reward? We continually hear the term “evidence-based medicine” when evaluating any type of treatment. The evidence is clearly against plantar fascia releases. Now with a better understanding of the relationship of equinus on plantar fasciitis, I believe we should evolve beyond this archaic procedure. I believe the approach we should take in resistant plantar fasciitis cases is gastrocnemius recession without release of the plantar fascia.
What is the risk of this approach? There is a chance the pain may not go away. In my opinion, that is the only true risk. If this does occur, then by all means proceed with cutting the plantar fascia. Realize that by doing a gastrocnemius recession initially, you will remove the primary pronatory deforming force of the leg onto the foot. Therefore, you further reduce the complication of lateral column instability when you perform a plantar fascia release.
The paradigm has shifted when it comes to resistant plantar fasciitis. It is time to leave the plantar fascia alone at all costs. Think before you cut.
1. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010; 31(1):19-23.
2. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon). 2006 Feb;21(2):194-203.
3. Anderson DJ, Fallat LM, Savoy-Moore RT. Computer-assisted assessment of lateral column movement following plantar fascial release: a cadaveric study. J Foot Ankle Surg. 2001; 40(2):62-70.
4. Brugh AM, Fallat LM, Savoy-Moore RT. Lateral column symptomatology following plantar fascial release: a prospective study. J Foot Ankle Surg. 2002; 41(6):365-71.