Plantar fasciitis: how successful is surgical intervention?

Forty-three patients (47 heels) underwent decompression of the nerve to abductor digiti minimi with partial plantar fascia release for intractable plantar fasciitis over a 4-year period. Forty-one patients (45 heels) were available for follow-up. All of the patients had failed to respond to nonoperative treatment. The mean duration of symptoms before surgery was 34.8 months (range, 12-132 months), and the mean follow-up was 31.4 months (range, 11-66 months). Seventy percent of the patients in the study were overweight or obese. Before surgery, 39 patients (43 heels) rated their heel pain as severe. At follow-up, 34 of 45 (75.6%) of the heels were pain-free or only mildly painful. The mean visual analogue pain score dropped from 8.5 of 10 preoperatively to 2.5 of 10 postoperatively. Only four patients failed to report an improvement in their activity restrictions, and only one patient had a walking distance of under 100 m after surgery; this patient had been affected by a reflex sympathetic dystrophy. Overall, however, only 20 of 41 patients were totally satisfied with the outcome (48.8%). We recommend that the small group of patients who fail to respond to nonoperative treatment be considered for surgical intervention. The results in terms of symptomatic relief are generally good but in terms of patient satisfaction can only be rated as moderate. The patients should be counseled about the likely outcome of surgery.     

A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint

Twelve patients were treated with the Ankle Dorsiflexion Dynasplint (Dynasplint Systems Inc, Severna, Md) for recalcitrant plantar fasciittis. Using a modified plantar fasciitis functional assessment scale and a visual analog pain assessment scale for evaluation, 75% of patients reported improvement ofsymptoms at 1-month follow-up. The average percentage of weekly sleeping hours spent in the splint was 95%. There was no tendency to deterioration of results by 6 months postsplinting. The Ankle Dorsiflexion Dynasplint is effective in the treatment of recalcitrant heel pain in a majority of patients. This study supports its use for the treatment of recalcitrant plantar fasciitis.     

Our experiences with the surgical treatment of plantar fasciitis

The authors present the results of surgical treatment of plantar fasciitis done at the University of Debrecen, Department of Orthopaedics, between 1996 and 2004 on 52 feet of 42 patients. The surgical indication was heel pain unresponsive to at least 6 months of conservative treatment with the exclusion of all differential diagnosis. During surgery, the partial detachment of the plantar aponeurosis origin was performed. The American Orthopaedic Foot and Ankle Society score was used for assessment. The average preoperative score of 43 increased to 85 postoperatively. Postoperatively 69% of the patients had excellent (86–100), 12% good (71–85), 4% average (61–70) and 15% had bad (fewer than 60) results. The patients 66% was very satisfied, 11% was satisfied, 12% was slightly satisfied, and 11% was unsatisfied with the surgical result. Based on our retrospective study, we recommend the surgical treatment of plantar fasciitis unresponsive to conservative treatment.     

Partial fasciectomy is a useful treatment option for symptomatic plantar fibromatosis

Plantar fibromatosis is a rare, benign fibroproliferative disorder of the plantar fascia. It is considered as a low-grade tumour and it can be locally aggressive. It can present as painful swelling with impairment of local function. Upon failure of non-operative management, surgical treatment options include total fasciectomy or partial fasciectomy. Although surgical excision is the mainstay of treatment, recurrence rate can be up to 60%. The aim of this study was to determine the recurrence and complication rates of surgically treated plantar fibromatosis.A retrospective study was conducted involving patients who had a confirmed diagnosis and excision of plantar fibromatosis treated in our institution between 2011 and 2016. Demographic data, follow-up duration, recurrence and complications were reviewed.Eighteen patients underwent 19 operations. Mean age was 41.3 years (20–57). There were 12 male patients. The main presenting features were pain, swelling and impairment of function. They were investigated by ultrasound scan (12 feet, 63%) and/or magnetic resonance imaging (8 feet, 42%). Two patients (11%) had prior surgery at other institutions whilst 3 patients (17%) had multiple nodules at presentation. All patients underwent partial fasciectomy of the plantar fibromatosis. At up to 5 years follow-up, one patient (6%) had a recurrence in our series whilst 3 patients (17%) had scar related problems (2 patients with scar pain and one patient had hypersensitive scar that resolved after 12 months).Symptomatic plantar fibromatosis can be effectively treated with partial plantar fasciectomy.     

Endoscopic plantar fascia release: a case series

Plantar fasciitis is a common disabling condition that can be recalcitrant to treatment. Endoscopic Plantar Fascia Release (EPFR) has received greater attention in recent years as a viable, and possibly superior, alternative to established open procedures for the treatment of plantar fasciitis. In a series of 17 patients (17 feet) with follow-up over an average of 16 months, we report a two portal endoscopic technique of partial release of the plantar fascia, as a successful, safe and reliable procedure for the treatment of plantar fasciitis in the patient group selected. The surgical results of 17 EPFR's performed by the same surgeon were reviewed. All patients had preoperative symptoms of subcalcaneal heel pain for greater than 12 months, all having undergone nonsurgical measures for at least 12 months. Of 17 feet, all reported marked improvement of preoperative symptoms within two months. Patients' subjective assessment of the procedure was strongly supportive, 100% totally satisfied or satisfied with only minor restrictions. Postoperatively, 82.4% reported mild or no pain, and 100% had improvement in walking distance. Complications all resolved within two to six months; there were no re-operations and no infections.     

A Case of Bilateral Baxter's Neuropathy Secondary to Plantar Fasciitis

Heel pain is 1 of the most common presentations to the foot surgeon, and its causes are multifactorial. Baxter's neuropathy is caused by an impingement of the inferior calcaneal nerve and has been reported to be responsible for up to 20% of heel pain. The diagnostic imaging features are striking, with inflammation or atrophy of the abductor digiti minimi muscle. Multiple studies have found that the prevalence of this finding is much greater than initially thought. However, it is more unusual to find bilateral and symmetrical features. The possible causes of this condition lie along the course of the inferior calcaneal nerve. Management is focused on treating the underlying condition, with conservative therapy and steroid injection as the mainstay. Refractory cases may require surgical release. We present the case of a 56-year-old female presenting with bilateral foot pain. Imaging reveals symmetrical abductor digiti minimi atrophy associated with bilateral plantar fasciitis. These appearances are well demonstrated on both magnetic resonance imaging and ultrasound.     

Platelets rich plasma for treatment of chronic plantar fasciitis

Background

Plantar fasciitis is a common cause of heel pain in adults. Many treatment options exist. Platelets rich plasma (PRP) is derived from autologous blood and contains high concentration of growth factors necessary for tissue healing. The use of PRP in the treatment of plantar fasciitis is a fairly recent and evolving concept. The purpose of our work was to study the effectiveness of PRP treatment for chronic plantar fasciitis.

Materials and methods

Between February 2010 and June 2011, 25 patients with chronic plantar fasciitis with a mean age of 44?years were treated by PRP injection and included in this prospective study. All patients were assessed for the pain on Visual Analogue Scale (VAS) pre-injection and post-injection. Using ultrasound, the thickness of the plantar fascia was measured prior to the injection of PRP and at each visit of follow-up after injection. The mean follow-up was 10.3?months.

Results

Using a visual analog pain scale, the average pre-injection pain in patients of was 9.1 (range 8–10). Prior to injection, 72?% of patients had severe limitation of activities, and 28?% of patients had moderate limitation of activities. Average post-injection pain decreased to 1.6. Twenty-two patients (88?%) were completely satisfied, two patients (8?%) were satisfied with reservations, and one patient (4?%) was unsatisfied with using the visual analog scale. Fifteen patients (60?%) had no functional limitations post-injection and eight patients (32?%) had minimal functional limitations. Two patients (8?%) had moderate functional limitations post-injection. Twenty PRP injections. Ultrasonography, we noted significant changes not only in thickness but also in the signal intensity of the plantar fascia after PRP injection. None of our patients experienced any complications from PRP injection at the end of follow-up period.

Conclusion

Injection of PRP is safe and doesn’t affect the biomechanical function of the foot. Our successful early findings with injection of PRP indicate that this may become a very commonly used modality in treating this difficult condition.     

Vascular anatomy of plantar muscles

Many reports on the plantar arteries and the deep plantar arch exist, but none of them focus on the arterial pedicles of the plantar muscles. They mainly discuss the deep plantar arch, its variations, and location. This study plans to determine the location and origin of arterial pedicles of all the plantar muscles as a preliminary study for designing new flaps. The study was carried out on 20 feet from 10 cadavers aged from 35 to 67 years. After an injection of latex via popliteal arteries, dissection of the arteries was carried out under a microscope. Abductor hallucis and flexor hallucis brevis muscles receive their main blood supply from the medial plantar artery; abductor digiti minimi and flexor digiti minimi brevis muscles receive their main blood supply from the lateral plantar artery. The flexor digitorum brevis muscle receives branches from both arteries. Adductor hallucis and plantar interosseous muscles receive branches from plantar metatarsal arteries. Quadratus plantae is directly nourished from a branch of the posterior tibial artery. No distal anastomoses between the medial and lateral plantar arteries were identified, except 1 specimen in which the medial plantar artery made anastomosis with the deep plantar arch. As a result, the arterial pedicles of all the plantar muscles were defined, and based on these findings, new flaps can be planned or existing flaps can be modified.     

Endoscopic plantar fascia release

BACKGROUND: Endoscopic release of the plantar fascia is becoming an increasingly popular alternative to open procedures for the treatment of chronic plantar fasciitis. Although most patients can be successfully treated with Achilles tendon stretching, orthoses, physical therapy and corticosteroid injections, a small percentage of patients will have symptoms that are refractory to such treatments. METHODS: This is a retrospective review, analyzing the clinical outcome of 22 consecutive patients treated for chronic plantar fasciitis with endoscopic plantar fascia release by a single orthopaedic foot and ankle surgeon. RESULTS: These patients complained of symptoms for an average of 7.43 months before referral to the senior author (MS); 11 patients had chronic symptoms for 12 months or more. The ages at surgery ranged from 30 to 73 years. Followup averaged 8.48 (range 6 to 20) months. Satisfaction rate with this procedure was 97.7% and all patients reported at least a 50% improvement in pain after surgery. Twenty-two patients completed a modified Mayo Foot and Ankle Score: 15 of 22 (68%) were judged to have good or excellent results. Bilateral symptoms and prior ankle trauma or surgery were significantly correlated with less favorable results. CONCLUSIONS: Patients who had no previous foot trauma and had unilateral symptoms obtained the best results from this procedure. Even patients who had some residual pain in their foot were satisfied with the procedure and with the level of pain relief that had been achieved. Endoscopic plantar fascia release does appear to benefit selected patients who fail to respond to conservative therapy.     

Electromyographic assessment of neuromuscular block at the gastrocnemius muscle

We have assessed neuromuscular block electromyographically at the gastrocnemius muscle and compared it with that at the abductor digiti minimi muscle in 60 adult patients undergoing cervical spine surgery under general anaesthesia. All patients were in the prone position. After vecuronium 0.2 mg kg-1, times to onset of neuromuscular block at the gastrocnemius and abductor digiti minimi muscles were mean 147 (SD 24) and 145 (14) s, respectively (ns). Times to return of the first response of the post-tetanic count (PTC1) at the gastrocnemius and abductor digiti minimi muscles were 27.7 (5.6) and 37.0 (5.9) min, respectively (P = 0.0001). Times to return of the first response of the train-of-four (TOF) at the gastrocnemius and abductor digiti minimi muscles were 41.0 (9.1) and 49.9 (8.7) min, respectively (P = 0.01). Recovery of PTC, T1/T0 and TOF ratio at the gastrocnemius muscle were significantly faster than at the abductor digiti minimi muscle.      

Lateral column symptomatology following plantar fascial release: A prospective study

Plantar fasciitis or heel spur syndrome usually resolves with conservative management, but for patients with continued pain, surgical intervention is often pursued. In some cases, plantar fasciitis is relieved, but pain in the lateral column area appears postoperatively. This lateral column pain may be debilitating for the patient and often overlooked by the foot and ankle surgeon. The goal of the study was to identify the maximum amount of plantar fascia that can be surgically released to treat recalcitrant heel pain effectively while preventing the development of lateral column symptoms. All patients undergoing plantar fasciotomy after failing conservative treatment were eligible to participate. Patients rated their pain with an 11-point (0-10) visual analog scale (VAS) and described its location prior to and at monthly intervals after their surgery. Surgeons recorded whether 25, 50, or 66% of the plantar fascia was released during surgery. Open procedures were performed 72% of the time, and endoscopically in 28% of the patients. Key outcome variables included degree of fascial release and foot structure. Patients (n = 47) with lateral column pain after surgery (n = 15 feet) had a mean +/- S.E. of 60.6 +/- 3.0% of their plantar fascia released while those without pain (n = 35 feet) had only 48.7 +/- 1.9% of this fascia released during surgery (ANOVA, p = .019). Age, weight, body mass index, gender, smoking status, comorbidities, general health, surgical procedure, postoperative care, calcaneal inclination angle, and talar declination angle did not differ for these groups (p > .146). For this patient population, regardless of surgical technique (endoscopic or open release), lateral column symptoms were more likely to result when more than 50% of the plantar fascia was released. The report proposes that a maximum of 50% of the plantar fascia be released during surgery.     

A Retrospective Comparison of Percutaneous Plantar Fasciotomy and Open Plantar Fasciotomy with Heel Spur Resection

Minimally invasive surgery for the treatment of recalcitrant heel pain is a relatively new approach. To compare the 2 approaches, a retrospective chart review was conducted of 53 patients (55 feet) who had undergone surgical treatment of plantar fasciitis by either open fasciotomy with heel spur resection or percutaneous medial fascial release. The outcomes measures included perioperative pain and the interval to return to full activity. Pain was measured on a subjective 10-point visual analog scale. Of the 55 fasciotomies performed, 23 were percutaneous and 32 were open, with adjunctive heel spur resection. The percutaneous group experienced a mean pain reduction of 5.69 points at the first postoperative visit, whereas open fasciotomy group experienced a mean pain reduction of 3.53 points. At 12 months postoperatively, no statistically significant difference was found in the pain levels between the 2 groups. The results also showed that the percutaneous group returned to normal activity an average of 2.82 weeks (p < .001) faster than the open group. In the patient cohorts studied, percutaneous medial fascial release was as effective at resolving recalcitrant plantar fasciitis pain as the open procedure and involved less postoperative pain and a faster return to full activity.     

Cryosurgery: An Innovative Technique for the Treatment of Plantar Fasciitis

A prospective study testing the efficacy of cryosurgery on painful plantar fasciitis of the heel was performed. Cryosurgery, a minimally invasive, percutaneous, office-based technique, was used to treat 59 consecutive patients (61 heels), who had failed prior conservative therapy and were considered surgical candidates. Patients were evaluated on an 11-point visual analog scale administered preoperatively and up to 1 year of follow-up. The mean pain rating (8.38) before cryosurgery (day 0) is statistically significant to the mean pain rating (1.26) at day 365 postoperatively. Pain decreased significantly after the procedure (analysis of variance, P < .0001). These results suggest cryosurgery is significantly effective in treating patients with recalcitrant plantar fasciitis. Cryosurgery offers a highly effective treatment modality after failed conservative treatment without resorting to open invasive outpatient surgery.     

Endoscopic plantar fasciotomy versus extracorporeal shock wave therapy for treatment of chronic plantar fasciitis

Background

Planter fasciitis is a common cause of heel pain in adults. Many treatment options exist. Most of patients resolve with conservative management. Approximately 10% of patients develop persistent and often disabling symptoms.

Patients and methods

This prospective study includes 37 patients with an established diagnosis of chronic plantar fasciitis, aiming to compare two different techniques of treatment. First group includes 17 patients with a mean age of 42 years treated by endoscopic plantar fasciotomy (EPF); the mean follow-up was 11 months. Second group includes 20 patients with a mean age of 45 years treated by extracorporeal shock Wave Therapy (ESWT); the mean follow-up was 7.6 months.

Results

In the first group (EPF), using the visual analog scale the average post-operative pain was improved from 9.1 to 1.6. Post-operatively, 58.8% had no limitation of functional activities, 35.3% had minimal limitation of activities and 5.9% had moderate limitation of activities. Concerning patient satisfaction, 82.3% of patients were completely satisfied, 11.8% of patients were satisfied with reservation and 5.9% of patients were unsatisfied. For the second group (ESWT), using the visual analog scale the average post-operative pain was improved from 9 to 2.1. Post-operatively, 50% had no functional limitation of activities, 35% had minimal limitation of activities, 10% had moderate limitation of activities, and 5% had severe limitation of activities. Concerning patient satisfaction, 75% of patients were completely satisfied and 25% were satisfied with reservation or unsatisfied.

Conclusion

Because of better results with endoscopic release versus the benefits of no complications, no immobilization, and early resumption of full activities with ESWT, we conclude that ESWT is a reasonable earlier line of treatment of chronic plantar fasciitis before EPF.     

Gastrocnemius Recession in Recalcitrant Plantar Fasciitis: A Systematic Review

Plantar fasciitis is a common cause of heel pain. Recalcitrant plantar fasciitis can be difficult to manage. Medial gastrocnemius recession is increasingly being used to treat recalcitrant plantar fasciitis, with advocates describing fewer complications and quicker recovery time than other surgical options. This systematic review aimed to determine the effectiveness of gastrocnemius recession for the treatment of patients with recalcitrant plantar fasciitis. Multiple databases were searched using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The level of evidence of each study was assessed according to the American Academy of Orthopaedic Surgeons Levels of Evidence. The level of bias for each study was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Seven studies were retrieved: 3 retrospective case series, 1 retrospective study that compared gastrocnemius recession to open plantar fasciotomy, 1 prospective cohort study (pre-post study with no control group), and 2 randomized controlled trials. All 6 studies that assessed pre- and postoperative pain using the Visual Analogue Scale showed a large reduction in pain postoperatively. Four studies that assessed pain at 12 months postoperatively showed a weighted mean of 76.06 ± 10.65% reduction in pain. No major complications were reported. Minor complications included sural neuritis. This review found a consistent reduction in pain following gastrocnemius release in patients with recalcitrant plantar fasciitis, suggesting it is a very promising treatment. However, the included studies are limited by low quality study designs and inherent biases, limiting the strength of recommendation. Further definitive, well-designed trials are required.     

Pre- and postoperative motor conduction times, measured using magnetic stimulation, in patients with cervical spondylosis

Motor conduction time (MCT) between head and neck in pathways to abductor digiti minimi was measured pre- and postoperatively in 15 patients. There was a significant improvement in MCTs in patients with myelopathy who improved clinically, but preoperative MCTs provided no clear, predictive information. Magnetic stimulation may be of value in quantifying motor function before and after surgery in patients with cervical spondylosis.     

Foot orthoses for the treatment of plantar fasciitis

BACKGROUND: The literature suggests mechanical interventions such as foot orthoses and night splints are effective in reducing pain from plantar fasciitis. There is, however, a lack of controlled trials. We studied the effects of foot orthoses and night splints, alone or combined, in a prospective, randomized trial with 1-year followup. METHODS: Forty-three patients (34 women and nine men with a mean age of 46 years) with plantar fasciitis were randomized to receive foot orthoses (n = 13), foot orthoses and night splints (n = 15), or night splints alone (n = 15). Data were available for 34 (79%) patients after treatment (12 weeks), and for 38 (88%) at 1-year followup. Pain, functional limitations, and quality of life were evaluated with the Foot and Ankle Outcome Score. RESULTS: All groups improved significantly in all outcomes evaluated across all times (p < 0.04). At 12 weeks, pain reduction of 30% to 50% compared to baseline were seen (p < 0.03). At 52 weeks, pain reduction of 62% was seen in the two groups using foot orthoses compared to 48% in the night splint only group (p < 0.01). Better compliance and fewer side effects were reported for orthosis use. At 12 months, 19 of 23 patients reported still using foot orthoses compared to 1 of 28 still using the night splint. CONCLUSIONS: Foot orthoses and anterior night splints were effective both short-term and long-term in treating pain from plantar fasciitis. Parallel improvements in function, foot-related quality of life, and a better compliance suggest that a foot orthosis is the best choice for initial treatment plantar fasciitis.     

Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve.

Sixty-nine heels (53 patients) with chronic heel pain had a surgical release of the first branch of the lateral plantar nerve. The average duration of heel-pain symptoms was 23 months (range, six months to eight years). No patient had less than six months of conservative treatment before surgery. The average duration of preoperative conservative treatment was 14 months. Forty-four patients (83%) had taken nonsteroidal antiinflammatory agents. Sixty-three heels (91%) had used heel cups and/or orthoses. Fifty-nine heels (86%) had received one or more injections of a steroid preparation. Thirty-four heels had developed pain initially during a sports activity. Postoperatively, 61 heels (89%) had excellent or good results; 57 heels (83%) had complete resolution of pain. The average follow-up period was 49 months. In general, heel pain resolves with conservative treatment. In recalcitrant cases, however, entrapment of the first branch lateral plantar nerve should be suspected. Surgical release of this nerve can be expected to provide excellent relief of pain and facilitate return to normal activity.     

Surgical treatment of plantar fasciitis

Ten patients were operated on for plantar fasciitis (12 heels) by stripping the plantar fascia and superficial plantar muscles from the calcaneus. All patients were refractory to conservative treatment for an average of 12.4 months prior to operation and were followed up for a minimum of 24 months after operation. Complete symptomatic relief was obtained in all patients despite the presence of massive obesity in six. Hypoesthesia of the heel, which was present in five feet after operation, may have enhanced pain relief. Three patients who were receiving workmen's compensation returned to work within 16 weeks of surgery. One deep wound infection occurred and required surgical debridement before healing could occur. Surgical treatment is efficacious in selected cases of plantar fasciitis that are refractory to conservative measures.     

Clinical outcome of surgical intervention for recalcitrant infero-medial heel pain

A retrospective review was conducted in 28 patients (31 feet) with recalcitrant infero-medial heel pain, to assess the clinical outcome of a combined release of the first branch of the lateral plantar nerve and the plantar fascia. All patients were questioned by telephone interview on their pre- versus post-operative level of pain and function (based on the Kitaoka mid-foot scale and the visual analog scale), and their satisfaction with the result of the intervention. Limitations of functional activity decreased, maximum walking distance increased and the level of pain decreased from 8.9 to 1.4 on the visual analog scale. The majority of patients was satisfied with the surgery (90.3%) and would undergo the same procedure again or would recommend it (92.9%). While conservative management remains the gold standard for treatment of infero-medial heel pain and/or plantar fasciitis, patients with recalcitrant disease usually can be effectively treated surgically with a combined release of the plantar fascia and the first branch of the lateral plantar nerve.