Plantar Fascia Release Surgery

Introduction

Plantar fascia is the connective tissue band that runs from the heel bone to the base of the toes in the plantar surface of the foot. The inflammation of the plantar fascia is known as plantar fasciitis. Plantar fasciitis occurs due to an overuse injury of the plantar foot surface and is characterized by heel pain. The condition is commonly seen in young runners and middle-aged individuals who are overweight.

Conservative treatment options like over-the-counter medications, cold and heat packs, activity modifications, orthotics, footwear changes, night splints, etc., are the gold standard for plantar fasciitis management options. But in about 5 percent of cases, surgical correction may be needed. The prognosis for such procedures is about 70 to 90 percent.

Plantar fascia release surgery relieves the tension in the plantar fascia. This is done by detaching a part of the ligament or the entire ligament from the heel bone. Relieving the tightness lowers the plantar fascia friction, thus reducing inflammation and foot pain.

The different techniques for plantar fascia release include open, percutaneous, and endoscopic release techniques.

What Are the Indications?

Plantar fascia release surgery is indicated in those cases of plantar fasciitis:

• Plantar fascitis cases in which conservative management options like physiotherapy and medications fail.

• In cases where plantar fascia pain persists for more than six to twelve months.

• In cases where there is functional restriction despite conservative management.

• Affects the affected person’s working ability adversely.

• Adversely impacts the individual’s sports performance.

Surgery is mostly performed as a last resort in cases where other options fail.

How to Prepare for the Procedure?

Initially, the physician thoroughly examines the affected foot, testing the sensitivity, nerve impairment, and mobility. Diagnostic tests, including radiological examinations, evaluate anatomical issues like bone spurs and other foot conditions. The physician describes the procedure to the patient, including the possible risks.

How Is the Procedure Performed?

Though the open surgical procedure is the most commonly performed, it has a lot of associated complications compared to endoscopic plantar fascia release. These complications include a longer recovery period, leads to larger painful scars, require more dissection, and may lead to nerve entrapment. The endoscopic procedure has a comparatively higher success rate.

The steps involved in the percutaneous release procedure are:

• General or local anesthesia is administered.

• The patient is placed in a supine position, and the foot is prepared.

• Newer surgical techniques use fluoroscopy techniques to identify the calcaneal tuberosity (heel bone) and the origin of the plantar fascia.

• A stab incision is made over the calcaneus.

• The plantar fascia is partially or fully detached to relieve tension.

• In the case of a calcaneal spur, cylindrical burs are used to remove it.

• The area is washed out using Normosaline.

• The wound is closed with a non-absorbable suture.

• As per new surgical techniques, weight-bearing starts on the day of surgery; the foot is protected by a bulky bandage for two weeks.

• After bandage removal, rehabilitation starts.

The steps involved in the endoscopic plantar fascia release technique are:

• Administration of anesthesia and foot preparation.

• A vertical incision is placed on the medial aspect of the heel.

• A blunt dissection is made to the level of the fascia, and using a facial elevator, a channel is created.

• A cannula system is introduced through the channel, and a vertical incision is made for the exit.

• The endoscope is introduced medially.

• The medial band of fibers is severed, and two-thirds of lateral fibers are released.

• The underlying musculature should be visible.

• After the procedure, the area is irrigated, and sutures are placed.

• Weight-bearing starts on the same day.

What Are the Associated Risks?

• Long Recovery Period - the recovery and rehabilitation period after the surgery is comparatively longer. Resuming normal activities may take more than six weeks following the procedure.

• Decreased Patient Satisfaction - studies suggest less than 50 percent of patient satisfaction after the surgical procedure.

• Post-Surgical Scarring - scarring of the plantar fascia is a common complication of plantar fascia release surgery. Appropriate incision placement (with minimal skin tension) and surgical execution help reduce this complication. Painful scarring mostly resolves spontaneously, but scar release surgery may sometimes be needed.

• Nerve Entrapment or Neuritis - nerve pain can occur due to neuritis following abnormal scar formation. Nerve release procedures or nerve excision may be needed in such cases.

• Instability - instability is one of the most common complications of surgery. This is because muscles, ligaments, and other foot-supporting structures get damaged. This instability is temporary and resolves as other supporting structures adapt to the new role.

• Plantar Fascia Tear - a complete plantar fascia tear can occur in some patients.

• Fibrosis - persistent pain may follow the procedure in some cases; one of the reasons for this is the reattachment of fibers. This can occur if insufficient plantar fascia is not relieved and tight fibers remain. It may also occur if the opening of the fibers is not maintained. Different surgeons take different measures to avoid this complication. Some suggest immediate weight-bearing post-operatively, and some suggest casts and splints to separate the fibers.

• Other Complications - other uncommon complications include:

• Flattening of the longitudinal arch.

• Transient heel swelling.

• Damage to the posterior tibial nerve.

• Pain concerning the metatarsal region.

• Numbness of the heel.

What Are the Benefits of Surgery?

The benefits associated with plantar fascia release surgery are:

• Pain reduction or pain elimination.

• Restoration of normal gait.

• Return to sports.

• Restoring normal function.

• Increase in overall well-being.

The benefits of the surgery are enhanced with rehabilitation post-surgery. Physiotherapy rehabilitation is essential to ensuring that one gains maximum benefits from the surgery. The weight-bearing ability depends on the surgical technique (open or endoscopic). In open surgery, casts or non-weight-bearing braces are used for a few weeks after surgery. On the other hand, in the case of endoscopic technique, partial weight bearing is started immediately due to the less soft tissue damage associated.

Conclusions

Plantar fascia release surgery is indicated only in cases where the conservative options fail or where there is persistent pain. Before starting the procedure, other possible causes of heel pain should be ruled out. As with any surgery, plantar fascia release procedures have associated risks and complications. Open surgical procedures result in larger, more painful scars, more recovery time, etc., and an overall low success rate compared to endoscopic and percutaneous procedures. Proper patient selection and surgical technique can minimize the ill effects and maximize the benefits of the plantar fascia release procedure.