Plantar Fasciotomy is an Option in Only 5% of Plantar Fasciitis Patients
Over the last several weeks we have been discussing Plantar Fasciitis and treatment options for alleviating symptoms. The reason so much time has been spent discussing this topic is because plantar fasciitis is extremely common, seen in about 50% of new patients presenting to a Podiatrist’s office. The upside to the high prevalence of plantar fasciitis is that in 95% of patients who have “heel pain,” conservative treatment methods will result in success!
To recap, plantar fasciitis is an irritation of a band of tissue on the bottom of your foot extending from the heel into the toes. When this band of tissue is stretched in the wrong direction, or is too short to stretch correctly, it becomes irritated and inflamed causing heel pain. The most clinically indicative symptom of plantar fasciitis is pain in the morning, with the first step out of bed that lessens during the day with activity. The reason patients experience this “first step” pain is because as they were sleeping the plantar fascia started to repair itself, essentially shortening, and with that first step, it is stretched again and micro-tears in the tissue occur.
A few of the conservative options we touched on included: stretching exercises, supportive and constantly worn shoes, injection therapy to help break the chronic inflammatory cycle, and oral anti-inflammatory medications. Last week we discussed Acoustic Shock Wave Therapy for treatment of chronic plantar fasciitis after a 6-month period of failure with treatment using other conservative options. Shock Wave Therapy is a conservative method of treatment in that there are no surgical incisions, but it is slightly more aggressive than other conservative options and is thus reserved for specific patients.
With failure of all conservative options, including Shock Wave Therapy, in patients with long-standing plantar fasciitis/heel pain, it is likely that surgery will be discussed as an option. Keep in mind that the conversation of surgical intervention will only occur in 5% of patients with plantar fasciitis, so surgical intervention is rarely required! The goal of surgery is to relieve the plantar fascia of the tension that is residing within it, providing relief to the patient. There are surgical options that are in favor at this time, each achieving that goal in a slightly different way.
One option, called an Open Plantar Fasciotomy, is simply what it sounds like. Your Podiatric Surgeon will make a small incision along the heel, visualize the plantar fascia and release it near its origin in the heel bone. A calcaneal spur, should one be present, may also be removed during the procedure. The decision as to whether or not to remove a calcaneal spur (an area of extra bone growth along the heel bone from plantar fascial pull) will be made prior to surgery by your Podiatrist using x-ray evaluation. The procedure is done in an outpatient setting, meaning you will be able to go home and relax immediately following surgery. You will be restricted from placing pressure on the heel for at least a week and you should expect some normal pain and swelling in and around the heel. Ice and pain medication prescribed to you will help to alleviate some of these symptoms. As your body heels from surgery, the area where the plantar fascia was released will fill in with new tissue growth, essentially lengthening the plantar fascia and relieving tension in the tissue. With the added length, the fascia is no longer too short to accommodate for the stretch it was meant to achieve!
An Endoscopic Plantar Fasciotomy is a slightly less invasive procedure than the Open Plantar Fasciotomy, but it also aims to relieve tension on the plantar fascia and allow your body to fill in with new tissue, lengthening the fascia. This procedure utilizes a small camera for visualization of the plantar fascia, with two small incisions rather than one larger incision. The procedure is completed in an outpatient setting with the post-operative instructions being the same as with the “open” procedure, although slightly less recovery time is needed.
Finally, one less available and infrequently performed procedure utilizes “Autologous Platelet Concentration.” Essentially, what that concentration is made up of, is cells and healing factors from your own blood that have been spun down into a syringe. The concentration will be injected into the heel under ultrasound visualization of the plantar fascia, with the goal of the procedure to stimulate healing to decrease thickness of the plantar fascia tissue, essentially alleviating the symptoms of fasciitis. You will be casted for several days to eliminate any chance of pressure on the heel, and once those few days have elapsed you will be transitioned back into a sneaker.
Remember that no surgical procedure is without its risks; therefore both benefits and risks of the surgery should be discussed with your Podiatrist prior to consenting to a procedure. For these specific procedures you must understand that recurrence of pain to the plantar heel is possible as well as a very low possibility of infection, destabilization of the lateral foot, neve entrapment and heel bone fracture. In addition, you will still need to implement conservative and preventative treatment measures such as proper and supportive shoes and stretching of the musculature to maintain your surgical results!
Enjoy Running? Stay tuned as next week we will tackle the topic!