Surgical treatment of plantar fasciitis
Any discussion of surgery should begin with a careful review of the indications for the surgery. Why are we doing the surgery? What do we stand to gain? What are the risks of the surgery? As a podiatrist, I'll occasionally perform a surgery for cosmetic reasons, but those procedures are few and far between. The primary indication for foot surgery is pain that has not responded to conservative care or restoration of function (broken bone). How do we define pain and how long do we provide conservative care prior to suggesting surgery? As a community, doctors often speak about the decision making in medicine and surgery being based on what is called the community standard. Think of the community standard as what might be the average of decision making. Where one surgeon might be quick to go to surgery with a plantar fasciitis patient following two months of conservative care, there will be others who would wait longer and go to surgery at 6 months. In the literature, I think you'll find the community standard for moving from conservative care of plantar fasciitis to surgical care will be about four months of conservative care. Simply put, you need to complete about four months of conservative care prior to initiating a discussion on surgical care of plantar fasciitis. I think you can see that there's a lot of leeway here for give and take. As an example, I've been in practice long enough to see patients who come back to have a second case of plantar fasciitis treated. In their first case, they completed four months of conservative care and then had to have surgery. Most of these patients say, "Doc, do I really have to go through all that stretching and shots? It didn't work last time. Can't we just do the surgery?" I need to stress with these patients that conservative care really does work. They still need to go through at least a trial period of three months. And if I start to see a lack of response to conservative care, will I lower the threshold to 3 months before going to surgery? Probably.
Indications for plantar fasciotomy
When you fail to respond to the conservative treatment of plantar fasciitis and you're considering your remaining options for care there's actually a lot of options to choose from. In my next blog post I'll discuss what I call the 'other choices', but for this blog post, I'd like to focus on a surgical procedure called a fasciotomy. The term fasciotomy describes a cut made in the fascia. And in this case, since we are discussing the plantar fascia, this procedure is called a plantar fasciotomy. This cut or release of the plantar fascia is made at the insertion of the fascia on the bottom of the heel. The choice of this location for the fasciotomy is logical in two respects. First, the plantar heel is the primary location of pain found in most cases of plantar fasciitis. But another reason that the fasciotomy is performed here is that there is a lot of tissue to work with. The plantar fat pad of the heel is thick enough to accommodate the surgical equipment used to complete the fasciotomy.
I trained in the early eighties and during those years I can honestly say that I did some terrible things to patients with plantar fasciitis. When you read my prior post on the history of the treatment of plantar fasciitis, you'll see that the thinking among docs in the '80s was still that the spur was the primary surgical objective. Heel spur surgery was all about hammers and chisels. It was pretty rough. An in those days, you really didn't recommend surgery until you had 6-12 months of conservative care knowing that the surgery was so tough on patients. But I was fortunate to be one of the early adopters of endoscopic plantar fasciotomy surgery. I honestly think that this transition from open to the endoscopic technique was the single biggest advance in foot care during my career.
Endoscopic plantar fasciotomy - surgical technique
A plantar fasciotomy can be performed in a number of ways. My preferred technique is a two-incision approach. A 1cm incision is made on the medial aspect of the heel. The location of the incision is away from the weight-bearing portion of the foot and adjacent to the location where the fascia attaches to the medial tubercle of the heel bone. I'll always measure 2cm up from the plantar aspect of the foot and 5cm from the posterior heel. Another rule of thumb is 2 fingers up and 5 fingers in from the posterior heel. The incision is bluntly dissected with a hemostat and an obturator and cannula inserted. The cannula is about the size of a large drinking stray (5mm). The cannula is a large tube that is used to create a space for the camera. But to get the cannula in the correct space, a tool called an obturator is inserted in the cannula. The obturator is a blunt rod that fits within the cannula. Both the obturator and cannula are inserted into the incision and used to bluntly dissect a path on the plantar heel superficial to the fascia. When the obturator reaches the lateral wall of the heel, a second 1cm incision is placed on the lateral wall of the heel, 2cm up from the plantar surface. The obturator is removed and suction used to remove any residual fat from within the cannula. The cannula has an open slot running along one side so that when the obturator is removed and the 4mm endoscope (camera) is inserted, you can visualize the fascia through the slot in the cannula. And to make viewing even easier, the tip of the camera is angled by 30 degrees. Face the 30-degree angle towards the slot and you are able to see the fascia. The fascia is made of three segments, a medial, central and lateral segment. Although you cannot really differentiate these segments, the inside of the cannula is marked and helps to guide the portion of fascia on which you are going to perform your fasciotomy. Another trick that I use is to place my thumb on the edge of the blade handle and measure the depth of the blade on the outside of the heel. I'll hold my thumb in that place and then re-insert the blade into the cannula. My objective is to perform a fasciotomy on only the medial 50% of the fascia. So by measuring the depth of the blade on the outside of the heel and then re-inserting the blade into the cannula, I'm somewhat guaranteed to know how much of the fascia that I'm releasing.
As you complete the fasciotomy you'll see the muscle belly of the flexor hallucis brevis (FHB) muscle. The fascia is very white and the muscle a deep red. It is very obvious when the cut is compete. Once you see the FHB and you've released 50% of the fascia, your job is done. The endoscope is removed and sterile saline solution is used to flush the site, removing any loose tissue or debris from the surgery. The obturator is re-inserted and the obturator and cannula are removed. A single suture of 4-0 nylon is used to reappose skin edges at the incision site. A dry dressing is applied.
Endoscopic plantar fasciotomy - post-op care
My post-op course of treatment is to keep the original bandage in place for 3 days. At three days I see the patient in the office for follow-up at which time the patient can wear a normal, loose-fitting shoe. Simple Band-Aids are used to cover the incisions. Showers are OK but no swimming or hot tubs until the sutures come out.
There are a number of variations of this procedure. Some doctors use a 1 incision approach. Others use a direct plantar approach with a plantar incision. Some use a larger medial incision and use scissors to cut the fascia. And other doctors refuse to perform the procedure saying that it is unnecessary. Like so many other aspects of medicine, you need to have an honest discussion with your doctor about what works best in his or her hands. For me, endoscopic plantar fasciotomy is a very useful part of my toolbox for treating cases of plantar fasciitis that fail to respond to conservative care. In your case, talk to your doctor and see what he or she thinks may work best for you.
Additional topics in the blog series include -
Plantar fasciitis | History
Plantar fasciitis | Causes and contributing factors
Plantar fasciitis | Differential diagnosis of heel pain
Plantar fasciitis | Conservative methods of care
Plantar fasciitis | Additional treatment methods
Plantar fasciitis | Surgical complications