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Point-Counterpoint: Recalcitrant Plantar Fasciitis: Is Fasciotomy Ever Necessary?
This author says there is still a very important role for plantar fasciotomy in the treatment of recalcitrant plantar fasciopathy, citing high success rates and minimal complications.
By Stephen L. Barrett, DPM, MBA
First, let us get the nomenclature right. “Fasciitis” is incorrect as it is not an inflammatory condition but a degenerative one. Therefore, we should really call the condition either plantar fasciopathy or plantar fasciosis.1,2 It is well established that there is a certain subset of cases of plantar fasciopathy, perhaps higher than 10 percent, which simply does not respond to other treatments, either conservative or minimally invasive ones.
Since the introduction of the endoscopic plantar fasciotomy (EPF) procedure in 1990, surgeons have performed more than 1 million of these procedures worldwide.3 Even with the incredible advancements that have been made with extracorporeal shockwave therapy (ESWT), ultrasound guided partial plantar fasciectomy and other modalities, there are still thousands of patients who need a plantar fasciotomy. For the record and contrary to much outside opinion, I do not like to cut the plantar fascia and will do everything possible to avoid having to perform an EPF. However, when needed, the EPF is highly efficacious with minimal complication and postoperative morbidity.4-6
With today’s technology, especially high-resolution diagnostic ultrasound, not only can physicians make an assured diagnosis of plantar fasciopathy within minutes, they can also accurately measure the level of severity of the degeneration within the plantar fascia itself. Ultrasongraphy is definitive for the diagnosis of plantar fasciopathy. If normal or mildly affected fascia is present, this takes the consideration of plantar fasciotomy out of the debate.7-11 This technology allows for the institution of better treatment paradigms with faster and more beneficial outcomes for patients who suffer from this condition.
The fact of the matter is there are some patients — and with grading we know who they are — who will not get relief with lesser invasive or conservative techniques. For example, a patient who has a symptomatic plantar fascia, which measures greater than 7.5 mm in thickness with a severe hypoechoic signal intensity (Grade IV C), will not likely benefit from anything less than a fasciotomy.12 In my experience, this even includes treatments such as ultrasound guided partial plantar fasciectomy with autologous platelet concentrate (APC+) and ESWT. There is also a high level of association of nerve entrapment with plantar fasciopathy and the use of modalities such as the Pressure Specified Sensory Device (PSSD) proves extremely valuable in determining the true pain generators responsible for a patient’s heel pain.13-16
Certainly, much of the controversy over the use of plantar fasciotomy to treat recalcitrant plantar fasciosis (plantar fasciitis) stems from potential biomechanical consequences. Additionally, prior to the introduction of endoscopic and minimally invasive techniques, open heel “spur” surgery had significant postoperative morbidity, which made the use of fasciotomy a last-ditch attempt to treat the patient with plantar heel pain due to fasciosis. The severe postoperative morbidity also masked many of the biomechanical sequela, such as lateral column stress, simply because the surgery was associated with so much pain the patient, in many cases, could not walk for months. Accordingly, this eliminated signs of biomechanical breakdown.
Many foot specialists would advise folks that they were better off suffering from their condition as opposed to possibly developing a painful amputation neuroma of the medial calcaneal nerve or being off their feet for a year or more. I was certainly in that camp prior to developing the EPF because I had seen such horrific situations after open heel surgery in my residency training.
Historically, the Joe DiMaggio case is probably the most illustrative in this regard. Due to the type of incision used (Griffith’s), arguably the greatest baseball player of the time was relegated to the plastic surgery service at Johns Hopkins University for treatment of a chronic wound dehiscence with maggot therapy for more than a month. DiMaggio’s baseball career was never the same and he soon retired.
Even if the numbers in the literature are accurate regarding the 80 to 90 percent efficacy of conservative, non-surgical care for the treatment of plantar fasciopathy, then an epidemiological analysis quickly reveals that there are thousands of patients every year who will require some type of surgical intervention to relieve their heel pain. It is rare for a week to go by without someone presenting to my clinic who has been treated for years with conservative measures for “plantar fasciitis.” In fact, many have a perfect fascia as determined by ultrasound and have another etiology causing their pain. For those who have such severe fasciopathy, none of their eight different conservative care modalities, including several pairs of orthoses, could ameliorate the symptoms.
Examining The Efficacy Of EPF
Endoscopic plantar fasciotomy is a well established technique. It has been documented in the seminal podiatric and orthopedic textbooks, and has an extremely high efficacy (nearly 99 percent in our experience.).4,6,17-19 Additionally, the technique results in less pain and a faster return to normal recovery in comparison to open fasciotomy.18 With accurate diagnosis and grading, as well as judicious postoperative management, the complication rate is extremely low at approximately 3 percent.12 Most complications are biomechanical sequelae of the lateral column, which one can effectively and quickly manage with biomechanical support.
In my opinion, many of those on the side of believing that fasciotomy should never occur are erroneously grounded in their beliefs regarding the potential biomechanical consequences of cutting part of the plantar fascia. I respect that philosophy and have already stated that I really hate having to partially and sometimes totally cut the plantar fascia. However, physicians have to realize that in patients for whom we are forced to make that decision, there are already severely altered biomechanics. (Sometimes, the compensation is so bad that patients break down their forefoot trying to offload the heel.) Therefore, the risk to benefit tradeoff is stacked in favor of fasciotomy.
Another consideration to discuss is that surgeons can prevent most of the complications of EPF with accurate diagnosis, excellent intraoperative technique and stringent postoperative management. There really can be no credible academic debate about whether fasciotomy is effective and efficacious, especially with EPF, as there is an abundance of literature from various authors confirming a very high success rate with fewer complications than open surgery.20
The only counterpoint that one can take, with any academic credibility, is from a complication perspective and that is weak. Would anyone not consider a technique with a manageable complication that occurs 3 percent of the time when there is greater than a 97 percent success rate?12 All surgical techniques have complications and there is little value in the attempt to discredit a procedure on this myopic basis alone.
Additionally, techniques that are not effective and fraught with unmanageable complications are not continually implemented more than a million times throughout the world by more than 5,000 surgeons since the inception of the technique, and to the order of 15,000 to 20,000 times this past year in the United States.12
In Summary
Endoscopic plantar fasciotomy is a valid, well-established and documented method to treat recalcitrant plantar fasciosis with high inter-surgeon reliability. We should focus on developing a better paradigm for the grading of plantar fasciosis. This will allow for more accurate and faster diagnosis with subsequent interventions that are based on pathology rather than outdated dogma.
Dr. Barrett is an Adjunct Professor within the Arizona Podiatric Medicine Program at the Midwestern University College of Health Sciences. He is a Fellow of the American College of Foot and Ankle Surgeons.
References
1. Barrett SL, Erredge SE. Growth factors for chronic plantar fasciitis. Podiatry Today. 2004; 17(11):37-42.
2. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003; 93(3):234-237.
3. Barrett SL, Woolley M. Partial plantar fasciectomy with autologous platelet concentrate. Practical Pain Management. November/December 2010. Available at https://bit.ly/nnLrUp .
4. Barrett SL, Day SV. Endoscopic plantar fasciotomy vs. traditional heel spur surgery. J Foot Ankle Surg. 1994; 33(2):214-216.
5. Barrett SL, Day SV, Brown MG. Endoscopic plantar fasciotomy: preliminary study with cadaveric specimens. J Foot Surg. 1991; 30(2):170-172.
6. Barrett SL, Day SV, Pignetti TT, Robinson LB. Endoscopic plantar fasciotomy: a multi-surgeon prospective analysis of 652 cases. J Foot Ankle Surg. 1995; 34(4):400-406.
7. Cardinal E, Chhem RK, Beauregard CG, Aubin B, Pelletier M. Plantar fasciitis: sonographic evaluation. Radiology. 1996; 201(1):257-259.
8. Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiol. 1999; 28(1):21-26.
9. Kamel M, Kotob H. High frequency ultrasonographic findings in plantar fasciitis and assessment of local steroid injection. J Rheumatol. 2000; 27(9):2139-2141.
10. Kane D, FitzGerald O. Re: The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology (Oxford). 2003; 42(3):486.
11. Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan B, Gibney R, FitzGerald O. The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology (Oxford). 2001; 40(9):1002-1008.
12. Barrett SL. Endoscopic plantar fasciotomy--surgical technique. Tech Foot Ankle Surg. 2011; 10(2):56-64.
13. Rose JD, Malay DS, Sorrento DL. Neurosensory testing of the medial calcaneal and medial plantar nerves in patients with plantar heel pain. J Foot Ankle Surg. 2003; 42(4):173-177.
14. Chang CW, Wang YC, Hou WH, Lee XX, Chang KF. Medial calcaneal neuropathy is associated with plantar fasciitis. Clin Neurophysiol. 2007; 118(1):119-123.
15. Dellon AL. Deciding when heel pain is of neural origin. J Foot Ankle Surg. 2001; 40(5):341-345.
16. Dellon AL. Technique for determining when plantar heel pain can be neural in origin. Microsurgery. 2008; 28(6):403-406.
17. Barrett SL, Day SV, Brown MG. Endoscopic plantar fasciotomy: preliminary study with cadaveric specimens. 1991. J Foot Ankle Surg. 2011; 50(4):439-440.
18. Kinley S, Frascone S, Calderone D, Wertheimer SJ, Squire MA, Wiseman FA. Endoscopic plantar fasciotomy versus traditional heel spur surgery: a prospective study. J Foot Ankle Surg. 1993; 32(6):595-603.
19. Urovitz EP, Birk-Urovitz A, Birk-Urovitz E. Endoscopic plantar fasciotomy in the treatment of chronic heel pain. Can J Surg. 2008; 51(4):281-283.
20. Tomczak RL, Haverstock BD. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg. 1995; 34(3):305-311.
For further reading, see “Should You Change Your Approach To Plantar Fasciosis?” in the November 2006 issue of Podiatry Today.
Dr. Barrett also writes a blog for Podiatry Today. For recent blogs, visit https://bit.ly/oAfxza .
Although fasciotomy can be successful in treating patients with chronic plantar fasciitis who have failed conservative therapy, this author says podiatric surgeons should exercise caution and consider the possible biomechanical implications of cutting the central component of the plantar aponeurosis.
Plantar fasciitis is one of the most common disorders presenting to podiatric practices today. The mechanical forces that occur during all weightbearing activities cause the chronic plantar heel pain from plantar fasciitis. These forces act directly on the plantar calcaneus and on one of the most important supporting structures of the plantar foot, the central component of the plantar aponeurosis.1
The central component is the most important of the three components of the plantar aponeurosis. The medial component acts as the thin covering of the abductor hallucis muscle. The lateral component inserts upon the base of the fifth metatarsal but is only present in 92 percent of the population.2 From its origin on the plantar aspect of the medial calcaneal tubercle, the central component of the plantar aponeurosis fans out distally to insert onto the sesamoids and plantar plates of the metatarsophalangeal joints (MPJs), which attach by ligaments to the plantar bases of the proximal phalanges of all five digits.
In effect, the central component of the plantar aponeurosis is the longest and strongest plantar ligament of the longitudinal arch. It provides structural support to the foot from the plantar heel to the plantar digits by helping to prevent lengthening and flattening of the longitudinal arch of the foot.3
The majority of cases of plantar fasciitis result from the combination of the tensile force from the central component of the plantar aponeurosis and the compression force from ground reaction force (GRF) acting on the origin of the central component of the plantar aponeurosis at the plantar calcaneus.1 The combination of these forces pulls and pushes on the same small area of the plantar calcaneus with every step.
Since it is these tension and compression forces that damage the tissues of the plantar calcaneus and cause the pain from plantar fasciitis, it is mechanically reasonable that podiatric physicians should design their treatments for plantar fasciitis around reducing these pathological tension and compression forces. Doing so will allow the plantar calcaneus to heal itself and thereby resolve the patient’s chronic plantar heel pain.
Therefore, the goal of treatment for plantar fasciitis should be to reduce both the tensile force from the plantar fascia and the compression force from ground reaction force acting on the plantar calcaneus.1 Most of the standard accepted treatments for plantar fasciitis focus on accomplishing these mechanical goals.
Reducing weightbearing activities, using immobilization bracing or casting, avoiding barefoot walking, and using prefab or custom foot orthoses all reduce these forces acting on the plantar heel.4-6 Calf stretching reduces the tensile stiffness within the Achilles tendon and gastrocnemius-soleus muscles, which will in turn reduce the tension force within the central component of the plantar aponeurosis.7-9 Plantar strapping reduces the length of the medial longitudinal arch, which helps unload the central component of the plantar aponeurosis.10 Plantar arch massage and night splints likely reduce plantar fascial tension by temporarily lengthening the plantar fascia.
Other common therapeutic modalities such as icing, nonsteroidal anti-inflammatory drugs, iontophoresis and cortisone injections are all also in common use to reduce the discomfort associated with plantar fasciitis.11
Why The Plantar Fasciotomy May Lead To Negative Biomechanical Effects
The majority of patients respond well to these therapeutic measures so the pain from plantar fasciitis gradually resolves. However, a small percentage of patients with plantar fasciitis may show little to no response with standard conservative therapeutic measures for their chronic plantar heel pain. When it comes to these patients, who have chronic plantar heel pain despite a long course of conservative treatment, the podiatric surgeon may consider partial plantar fasciotomy as a surgical approach. The fasciotomy could reduce one of the major pathologic forces acting on the plantar calcaneus, the tensile force from the central component of the plantar aponeurosis.
Many surgeons, including myself, have noted very encouraging results with partial plantar fasciotomy.12,13 However, before one contemplates cutting the central component of the plantar aponeurosis in an attempt to relieve a patient’s chronic plantar heel pain, the podiatric surgeon must first carefully consider the multiple biomechanical functions of the central component of the plantar aponeurosis that may be negatively altered or completely eliminated by cutting this vital structure of the plantar foot.
Hicks first described the important mechanical functions of the plantar aponeurosis, which included his classic concept of the windlass effect.14 He noted that dorsiflexion of the hallux produced longitudinal arch raising, subtalar joint supination and external rotation of the tibia in weightbearing cadaver limbs, which was completely eliminated with surgical transection of the plantar fascia. Carlson and colleagues found that increasing tension within the Achilles tendon caused an increase in plantar fascia tension at four different angles of MPJ dorsiflexion.8
Erdemir and co-workers found that tension within the plantar fascia was directly proportional to Achilles tendon tension in cadavers in a dynamic gait simulator and that plantar fascia tension peaked at heel-off at 0.96 times body weight.9 Cadaver studies have shown that plantar fasciotomy decreases arch height, lengthens the arch and dorsiflexes the first metatarsal.15,16
Other important biomechanical functions of the central component of the plantar aponeurosis include: facilitating normal resupination of the subtalar joint during propulsion; assisting the deep posterior compartment muscles at resisting pronation; assisting the plantar intrinsic muscles at resisting longitudinal arch flattening; and reducing the tension strain within the plantar ligaments.3,17,18 The central component of the plantar aponeurosis also helps reduce the interosseous compression forces within the dorsal joints of the midfoot and helps prevent excessive bending strains on the metatarsals during weightbearing activities.3,19,20
The central component of the plantar aponeurosis passively maintains digital purchase force on the ground by increasing the digital plantarflexion moment. This in turn helps reduce metatarsal head plantar pressures.3,14,19 Lastly, the central component of the plantar aponeurosis, along with the other plantar ligaments, help to store sufficient strain energy with the longitudinal arch. This helps make running activities more energy efficient.21
In Conclusion
Even though plantar fasciotomy can be a useful surgical alternative to treat the pain and disability from chronic plantar fasciitis, the cutting of this important supporting structure of the plantar longitudinal arch, the central component of the plantar aponeurosis, may lead to negative biomechanical consequences for the patient.
Therefore, before performing this surgical procedure, podiatric surgeons must carefully weigh its positive benefits along with its possible negative biomechanical alterations in foot structure and function for their patients with chronic plantar fasciitis.
Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is in private practice in Sacramento, Calif.
References
1. Kirby KA. Foot and lower extremity biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast Inc., Payson, AZ, pp. 187-188.
2. Sarrafian SK. Anatomy of the foot and ankle. JB Lippincott Co., Philadelphia, 1983.
3. Kirby KA. Foot and lower extremity biomechanics: a ten-year collection of Precision Intricast Newsletters. Precision Intricast Inc., Payson, AZ, 1997, pp. 45-46.
4. Redmond A, Lumb PSB, Landorf K. Effect of cast and noncast foot orthoses on plantar pressure and force during normal gait. J Am Podiatr Med Assoc. 2000; 90(9):441-449.
5. Wertsch JJ, Frank LW, Zhu H, Price MB, Harris GF, Alba HM. Plantar pressures with total contact casting. J Rehab Res Dev. 1995; 32(3):205-209.
6. Armstrong DG, Stacpoole-Shea S. Total contact casts and removable cast walkers. Mitigation of plantar heel pressure. J Am Podiatr Med Assoc. 1999; 89(1):50-53.
7. Morse CI, Degens H, Seyennes OR, Magnaris CN, Jones DA. The acute effect of stretching on the passive stiffness of the human gastrocnemius muscle tendon unit. J Physiol. 2008; 586(1):97-106.
8. Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendo-Achilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Int. 2000; 21(1):18-25.
9. Erdimir A, Hamel AJ, Fauth AR, Piazza SJ, Sharkey NA. Dynamic loading of the plantar aponeurosis in walking. J Bone Joint Surg. 2004; 86A(3):546-552.
10. Vicenzino B, Franettovich M, McPoil T, Russell T, Skardoon G. Initial effects of anti-pronation tape on the medial longitudinal arch during walking and running. Br J Sports Med. 2005; 39(12):939-43.
11. Gudeman SD, Eisele SA, Heidt RS, Colosimo AJ, Stroupe AL. Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. Am J Sports Med. 1997; 25(3):312-16.
12. Fishco WD, Goecker RM, Schwartz RI. The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review. J Am Podiatr Med Assoc. 2000; 90(2):66-69.
13. Stone PA, McClure LP. Retrospective review of endoscopic plantar fasciotomy: 1994 through 1997. J Am Podiatr Med Assoc. 1999; 89(2):89-93.
14. Hicks JH. The mechanics of the foot II: the plantar aponeurosis and the arch. J Anat. 1954; 88(1):24-31.
15. Sharkey NA, Ferris L, Donahue SW. Biomechanical consequences of plantar fascial release or rupture during gait part 1: disruptions in longitudinal arch conformation. Foot Ankle Int. 1998; 19(12):812-20.
16. Murphy GA, Pneumaticos SG, Kamaric E, Noble PC, Trevino SG, Baxter DE. Biomechanical consequences of sequential plantar fascia release. Foot Ankle Int. 1998; 19(3):149-52.
17. Ward ED, Smith KM, Cocheba JR, Patterson PE, Phillips RD. In vivo forces in plantar fascia during stance phase of gait. J Am Podiatr Med Assoc. 2003; 93(6):429-442.
18. Crary JL, Hollis M, Manoli A. The effect of plantar fascia release on strain in spring and long plantar ligaments. Foot Ankle. 2003; 24(3):245-50.
19. Sharkey NA, Donahie SW, Ferris L. Biomechanical consequences of plantar fascial release or rupture during gait part II: alterations in foot loading. Foot Ankle Int. 1999; 20(2):86-96.
