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Plantar fascia release

    Overview

    Learn the Plantar fascia release surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Plantar fascia release surgical procedure.
    The vast majority of patients do not require operative treatment for this condition. For those with the severest and most resistant of symptoms however it is indicated and improves symptoms in 80% of patients.
    The operations poor reputation is ill founded if the technique and post-operative management are carefully adhered to.
    The key factors are to avoid damaging the cutaneous nerves during the approach, adequate release of the fascial layers encountered and careful haemostasis. Appropriate post-operative pain management, splintage, shoewear advice and wound care are also critical.
    There are alternatives to the open release through a medial, non-plantar approach, described here. In particular a proximal and medial release of the gastrocsoleus, a direct approach through the sole of the foot and endoscopic release of the plantar fascia.
    Readers will also find of use Kartik Hariharans OrthOracle technique Gastrocnemius recession.



    Indications

    INDICATIONS.
    -Plantar fasicitis that has failed conservative management.
    SYMPTOMS AND EXAMINATION.
    The vast majority of patients settle with conservative management (see below and also results section).
    For those with either the severest of symptoms (i.e. frequent night pain and severe daytime restriction ) or most resistant of symptoms a decompression of the Plantar fascia is indicated. Most patients will have been symptomatic for at least 12 months. This is an observation rather a requirement.
    The classical symptoms are those of pain effecting the plantar medial heel in particular after periods of non-weight-bearing, easing with increased weight-bearing. More severe cases do not improve with weight-bearing and on occasion symptoms will also be present at
    A proportion of patients will present with intermittent paresthesia effecting the foot as part of the plantar fascitis. This most commonly is due to compression of the superficial branches of the Calcaneal nerve and a branch of the lateral Plantar nerve (which are released during the medial approach plantar fascia decompression as described here). There are also a cohort of patients with far more extensive sensory symptoms effecting the plantar surface of the foot. It is recognised (see results section) that Tarsal tunnel and Plantar fascitis can co-exist and on occasion both may require decompression. These patients will have very clearly delineated symptoms effecting the Plantar nerve territories of the sole of the foot.
    On examination there is usually localising tenderness to the plantar medial aspect of the plantar fascia. If the tenderness is more distally located to the region of the medial longitudinal arch (but still within the plantar fascia) then the alternate diagnosis of Plantar Fibromatosis should be considered. Bony tenderness (as shown by pain on medio-lateral compression of the Calcaneus above the level of the Plantar fascia ) should raise the possibility of associated bone oedema or even this as an alternate diagnosis.
    In most there will be little effect upon the medial arch profile of the foot with plantar fascitis though it will on some occasions be lower post release. A patient with an unstable midfoot or flat foot is one to be slightly wary of in the context of a complete release of the plantar fascia, which may destabilise the situation further and produce lateral column midfoot pain.
    There are concerns raised in the literature about effect upon forefoot loading, arch profile and foot stability of completely dividing the plantar fascia which have resulted in recommendations on partial release of the fascia only. Historically a complete release was the standard technique, with many published papers reporting good results over many years (Kitaoka 1997).
    INVESTIGATION.
    Plain X-Ray: Not required. If a spur is present this should be regarded as a marker of inflammatory change in the structure at some stage but is unlikely relevant to the presence of symptoms.
    MRI Hindfoot: Will demonstrate most objectively the extent of soft tissue change as well as any bony pathology (such as bone oedema ). Alternate diagnoses such as Plantar Fibromatosis(which is rare)can also be made.
    Ultrasound: A way of both diagnosing the condition and targeting an injection and as a result the most commonly performed investigation.
    Nerve conduction studies: Very occasionally plantar Fascitis can co-exist with a tarsal tunnel syndrome and the symptoms will suggest this, with fairly comprehrensive sensory symptoms in the distribution of one or both of the plantar nerves. This investigation is required under these circumstances but in approximately 30% of patients will be negative even if the compression exists.
    NON OPERATIVE ALTERNATIVES.
    Physiotherapy: The mainstay of treatment , combining active and passive modalities. Works in 2/3rds of patients.
    Orthotic Management: This ranges from appropriate shoe-wear such as Fit-Flops(which benefit most) to rigid custom-made Functional Foot Orhotics which are tolerated and work well in 50% or so of patients. Night splints that hold the foot in a neutral position can assist but often interfere with sleep.
    Injection: Works in 70-80% of patients, but rarely after a single injection . May be performed without guidance equally effectively. Has a small risk of rupture associated which if it occurs will be inconvenient for 8-10 weeks but will cure the condition also.
    Shockwave therapy: There are robust published results to suggest that this is highly effective and yields long-lived results as long as enough impulses are used. It is associated with a small risk of rupture.
    OPERATIVE ALTERNATIVES
    Endoscopic plantar fascia release.
    Du Vries technique (using a medial, longitudinal and Plantar incision).
    Gastrocnemius release.
    CONTRAINDICATIONS.
    The usual ones of poor vascularity, poor soft tissue cover and poor compliance .
    Kitaoka HB , Luo ZP , An KN . Mechanical behaviour of the foot and ankle after plantar fascia release in the unstable foot. Foot Ankle Int 1997;18:1–15.

    Setup

    Plantar Fascia release is easiest carried out with the patient supine
    The incision used is postero-medial & positioned at the level of the Fascias’ origin , running from the medial skin and just skirting onto the plantar surface.
    One or two side supports should be placed on the operated side , at thigh and trunk level , whilst several sandbags are placed under the opposite buttock , thus turning the operated leg into external rotation
    The further addition of rolled up sterile towels allow an extra element of helpful rotation and access .
    GA or Regional anaesthesia
    Laminar flow theatre if available
    Popliteal block for post operative pain relief.
    Thigh tourniquet to be used and Flowtron on non-operated calf.
    Prophylactic antibiotics and LMW-Heparin peri-operatively & post-operatively
    Bipolar diathermy

    Operation

    Both thickening and considerable increased signal is seen in the calcaneal attachment of the plantar fascia (1). Such florid change is not often seen (nor is it required to be seen for cases needing surgery).

    The coronal sequence shows considerable associated calcaneal oedema(1) , not an uncommon finding in more severe cases.
    It is perhaps related to the altered gait pattern often displayed in such patients with a shortened stance phase and proportionately increased heel loading.

    It is important to place the skin incision in exactly the correct position, or an east operation becomes more difficult.
    The most anterior and plantar aspect of the calcaneus is palapated and a skin incision of 3 cm or so made, located obliquely and just above the plantar skin.

    The oblique skin incision for plantar fascia release is made at the level of the anterior border of the weight bearing surface of the calcaneum .It should extend distally to the edge of the plantar skin but not far onto it if possible. Once through the skin scissors dissection is used.

    A Wests retractor is usefully used to place the fat layer under tension during plantar fascia release and allows easier identification of the superficial branch of the Calcaneal nerve if present in the operative plane.
    Dissection through this layer should be with fine tenotomy scissors.

    The superficial branch of the calcaneal nerve(1) is not always encountered in the fat layer and as long as it is not in the immediate operative field need not be sought. It is well demonstrated however in this image.
    This is a right foot & the sole is located inferiorly.

    The superficial fascia overlying the abductor hallucis muscle is next identified(1). Beneath this as as separate structure is seen the plantar fascia(2). More often the plantar fascia is not so well delineated at this stage, due to adherent fat .

    The superficial abductor fascia is released by careful sharp dissection(2) onto a McDonalds(1).

    The superficial fascia over the adbuctor should be released fully along its length. This layer is usually a visibly tight structure which yields once incised.

    The abductor muscle belly is now visible. Its superior and inferior margins are identified by gentle blunt dissection as the next stage in plantar fascia release.
    It should be recalled that both the medial and lateral plantar nerves are in close proximity to the superior aspect of the abductor hallucis (see Tarsal tunnel decompression for a dissection of this area), so dissection here should be under direct vision only using fine ended tenotomy scissors. It need not, and should not, be extended proximally.

    The abductor muscle belly(1) is retracted to reveal the underlying deep fascia(3) once the superficial fascia (2) has been divided.

    The abductor(2) needs to be retracted both superiorly and inferiorly (1, as here) to visualise the complete depth of the deep fascia(3) during plantar fascia release.

    A better view of the deep fascia beneath the Abductor Hallucis , prior to its sectioning.

    The deep fascia is released with careful sharp dissection. Beneath it(at some level) lies a branch of the lateral plantar nerve with its vessels. This should not be sought out. It is important that its whole breadth is released during plantar fascia release.

    Finally the plantar fascia itself is released and excised(2). A section needs to be excised of sufficient size to avoid the possibility of post operative fibrosis closing the defect.
    If its location is not obvious then identifying it can be assisted by the insertion of an index finger into the depth of the wound and dorsiflexing the toes to place it under immediate tension.
    There is legitimate debate about the size of this excision. Historically complete division has been performed, with reported fairly standard results of 80% or so of patients improved(see the paper referenced in results by Wheeler in the Journal of Orthopaedic Sports Medicine or Kitaokas review paper from Foot and Ankle International). Certainly in patients with an unstable midfoot complete release is best avoided. More commonly the medial one to two thirds on the fascia is divided
    If there is a significant plantar bone spur this is when to remove it, but only if in the immediate field.
    Closure must be with deep 2.0 Vicryl sutures to the fat to de-tension the skin and a subcuticular 3.0 Vicryl suture which will provide longer term support to the wound (which will be swollen and under tension for 6 weeks ) compared to a removable suture.

    There is a recognised cohort of patients who suffer concurrently with both plantar fascitis as well as tarsal tunnel syndrome. In these rare cases, with appropriately clear and delineated symptoms both areas are compressed at the same time.
    Here the medial plantar nerve (1) is being identified with the McDonald and the lateral plantar nerve is seen posteriorly(2).

    Extensile decompression of the proximal and distal tarsal tunnel combined with a partial plantar fascia release in the treatment of chronic plantar heel pain.
    Foot Ankle Spec. 2013 February; 6 (1): 27-35.
    Mwok W R, Gay T, Parekh S G
    Distal tarsal tunnel release with partial plantar fasciotomy for chronic heel pain: an outcome analysis. Foot Ankle Int. 2002 June; 23 (6): 530-7.
    Watson TS, Anderson RB, Davis WH, Kiebzak GM.

    After the tarsal tunnel decompression has been completed the exposure makes it very clear how close the lateral plantar nerve(1) sits to the superior edge of the abductor hallucis muscle belly(2), and therefore how little it would take to injure it if care (and limited dissection proximally) is not observed during a standard plantar fascia release.

    This MRI shows a fairly “full house” of signs that may be present
    As well as high signal within the plantar fascia there is a significant plantar bony spur and an unusual amount of associated calcaneal oedema ( bordering on an associated stress response of the calcaneus).

    Post Operative

    The first two weeks are spent in a lightweight cast, limited weight bearing
    After two weeks into long post-operative boot and commence weight bearing. This will be realistically required for 3-4 weeks.
    Beyond this a Fit-Flop shoe is very comfortable for a month or so. A semi-rigid off the shelf orthotic will also be of use in less structured shoes.
    Once out of cast , active and passive ankle and subtalar range of movement exercises are started as well as balance and proprioceptive rehabilitation. This should be under physiotherapy supervision.
    In terms of activity levels avoid impact for 3 months. A static bike and pool are fine from 4 weeks onwards, cross-training from 8 weeks and light (treadmill) jogging from 10-12 weeks.
    Of up-most importance through-out the post-operative period is that the wound is looked after . Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoe-wear.
    Any exudate from the wound which is allowed prolonged contact with the wound will further exacerbate any skin breakdown. Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed
    Showering & bathing is from when out of cast

    Recommended Reading

    Surgical treatment of recalcitrant plantar fasciitis.
    Foot & Ankle.1996.17(9);520-532
    G.J.Sammarco , R.B.Helfrey.
    35 feet in a total cohort of 780 patients treated with plantar fascitis required surgical decompression.
    Non weight bearing was for 1-2 weeks , following this “protected weight-bearing on the heel in a post-operative shoe”, then “full-weightbearing and regular shoewear as permitted.
    Average return to normal daily activity and some work was 5.7 weeks .
    92% of patients were satisfied and 8% were not.
    Approximately 30% had some heel pain despite operation.
    Plantar fascitis:How successful is surgical intervention
    Foot Ankle Int.1999: 20(12):803-7.
    45 patients who had failed non-operative treatment were followed up for a mean of 31 months. 75% of heels were pain free or had only minimal pain and the mean VAS scores had decreased significantly from 8.5 to 2.5. That said only 48% of patients were entirely satisfied with the outcome of surgery.
    Surgery for patients with recalcitrant plantar fascitis
    Orthop J Sports Med.2014.March 20 :2(3)
    P Wheeler, K Boyd ,M Shipton
    68 patients responded to a questionaire a mean of 7 years following surgical decompression
    An average reduction in VAS pain score was 79% and 84% classified themselves as happy with the results of treatment. There appeared to be no reduction in the results of the operation over time.
    Mechanical behaviour of the foot and ankle after plantar fascia release in the unstable foot.
    Foot Ankle Int 1997;18:1–15.
    Kitaoka HB , Luo ZP , An KN .
    Plantar fasciopathy: a current concepts review
    Manuel Monteagudo, Pilar Martínez de Albornoz, Borja Gutierrez, José Tabuenca, Ignacio Álvarez
    EFFORT open reviews. Vol 3. Number 8.
    29 Aug 2018https://doi.org/10.1302/2058-5241.3.170080
    An excellent review of the interventions and well referenced ( & open access).
    Surgery for Patients with Recalcitrant Plantar Fasciitis Good Results at Short, Medium, and Long-term Follow-up
    Patrick Wheeler MBChB, MSc(SEM), MSc(PA&PH), FFSEM(UK), FFSEM(I), MRCGP, Kevin Boyd, MBBS, FRCS(Tr&Orth), FFSEM(UK), and Mary Shipton, BA, RGN
    The Orthopaedic Journal of Sports Medicine, 2(3), 2014.
    Results of a single surgeon series following complete release of the plantar fascia reporting 80% satisfied patients in a group of 68 respondents.
    Evaluation of low-energy extracorporeal shock-wave application for treatment of Chronic plantar fascitis.
    J Bone Joint Surg 2002.84-A .335-341.
    JD Rompe, C Schoellner ,B Nafe
    Prospective , randomised trial comparing 3 applications/treatment sessions of low energy shockwave in 2 groups (total sample size 112 patients). In one group the applications were 100o impulses each session and in the other 10. All patients had been symptomatic for a minimum of 6 months.
    25 of 49 patients in the group receiving 1000 impulses had maintained ability to walk pain free at 6 months whereas none of the 48 in the 10 impulse group were able to. At 5 year follow up 13% of the remaining patients in the 1000 impulse group had required surgery whereas 58% in other group had.
    Painful heel syndrome:results of non-operative treatment.
    Foot Ankle Int.1994:15;531-5
    Davis PF, Severud E, Baxter DE
    90% of patients symptoms resolve within 10 months
    Extensile decompression of the proximal and distal tarsal tunnel combined with a partial plantar fascia release in the treatment of chronic plantar heel pain.
    Foot Ankle Spec. 2013 February; 6 (1): 27-35.
    Mwok W R, Gay T, Parekh S G
    Distal tarsal tunnel release with partial plantar fasciotomy for chronic heel pain: an outcome analysis. Foot Ankle Int. 2002 June; 23 (6): 530-7.
    Watson TS, Anderson RB, Davis WH, Kiebzak GM.
    The above 2 papers document that plantar fascitis is recognised to co-exist with Tarsal tunnel syndrome. If both are treated concurrently success rates in the region of 80-90% are reported.

    Reference

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