Chronic heel pain due to the entrapment of the first branch of the lateral plantar nerve: analysis of surgical treatment

This is a case series study that was conducted to report the outcome of surgical release of the first branch of the lateral plantar nerve in patients with chronic heel pain. Thirty-one patients with chronic heel pain underwent release of the first branch of the lateral plantar nerve. The setting was a public university hospital and a public university-affiliated hospital in the north of Jordan. Six patients were lost to follow-up. The average age of the remaining 25 patients was 43.8 years. The average duration of symptoms prior to surgery was 15 months. Radiography showed spur in 14 cases. All patients had conservative treatment for a minimum of 6 months before surgery, and all had one or two local cortisone injection. The average length for recovery was 3 months. All patients, except for 2, reported fair to excellent results. Level of post-operative satisfaction between fair and excellent was reported by 75% at 3 months, 96% at 6 months and 80% at 3–11 years (average 8 years). The diagnosis of entrapment of the first branch of the lateral plantar nerve can be clinical and could be confirmed by nerve block. Heel spurs should be removed when in very close proximity relation to the first branch of the lateral plantar nerve.     

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.     

Bilateral chronic proximal plantar fasciopathy: treatment with electrohydraulic orthotripsy

BACKGROUND: Patients presenting for treatment of chronic plantar fasciopathy often have bilateral involvement. When various nonoperative treatments fail, subsequent intervention may be problematic, especially since bilateral surgery (bilateral fascial release) may not be realistic because of variable, frequently restrictive postoperative weightbearing limitations. METHODS: Twenty-three patients (46 heels) were treated with electrohydraulic high-energy orthotripsy to the plantar entheses of both feet while under the same anesthesia (conscious sedation). Following orthotripsy, all patients immediately were fully weightbearing and resumed normal activities of daily living and work, usually within 24 hours. Progressive return to athletic activities was allowed. Patients were assessed by three outcome parameters: (1) pain measured objectively by a dolorimeter combined with the patient's subjective evaluation of the level of pain; (2) pain after 5 minutes of walking upon arising; and (3) pain with daily activities. All pain measurements were done by the visual analog scale. RESULTS: Patients initially experienced varied pain relief responses. This included earlier pain relief in one heel compared to the other, as well as better pain relief in one heel than the other at the 6- and 12-week evaluations, but with much less variance at the 1-year evaluation. By 3 months following orthotripsy, 28 heels (61%) had good or excellent results. These results were maintained or improved at 1 year. In 18 heels (39%), the outcome was fair or poor. Nineteen heels received a second orthotripsy application; one patient requested a second orthotripsy treatment of only one heel, while nine patients requested a second treatment of both heels. The outcome showed further improvement following the second application of orthotripsy. At 1 year after one or two orthotripsy applications, 19 patients (38 heels) were satisfied with the results in both heels (83%), while four patients (eight heels) still had an unsatisfactory outcome (17%). CONCLUSION: Electrohydraulic high-energy orthotripsy is a reasonable nonincisional method for treating patients with bilateral chronic proximal plantar fasciopathy under a single anesthetic without the prolonged nonweightbearing status often recommended for patients following unilateral open or endoscopic fascial release.     

跟痛症的针刀分型论治

目的:将跟痛症进行分型,针对不同分型运用小针刀给予不同的治疗以提高疗效。方法:2005年8月至2008年12月治疗200例266跟,门诊189例251跟,住院11例15跟;男83例,女117例;年龄26～72岁,平均46岁;病史3～36个月,平均6.8个月。按笔者分型标准,分为跖筋膜炎型67跟,跟骨下滑囊炎型61跟,足底脂肪垫炎型36跟,跟骨内压增高型6跟,神经卡压型21跟,混合型75跟。采用小针刀针对不同的分型运用不同的疗法进行治疗。结果:完成治疗后1个月跖筋膜炎型治愈31跟,显效36跟;跟骨下滑囊炎型治愈32跟,显效29跟;足底脂肪垫炎型治愈9跟,显效20跟,好转4跟,无效3跟;跟骨内压增高型治愈1跟,显效3跟,好转2跟;神经卡压型治愈11跟,显效8跟,好转1跟,无效1跟;混合型治愈16跟,显效46跟,好转5跟,无效8跟。完成治疗后6个月以上的电话随访,跖筋膜炎型治愈21跟,显效40跟,好转5跟,无效1跟;跟骨下滑囊炎型治愈30跟,显效28跟,好转3跟,无效0跟;足底脂肪垫炎型治愈15跟,显效18跟,好转2跟,无效1跟;跟骨内压增高型治愈0跟,显效3跟,好转3跟,无效0跟;神经卡压型治愈7跟,显效11跟,好转1跟,无效2跟;混合型治愈10跟,显效45跟,好转11跟,无效9跟。结论:在临床工作中不能用单一的发病机制来解释跟痛症的病因,更不能用单一的方法来治疗,应将跟痛症进行分型,并针对不同的分型给予不同的治疗,这样才能提高跟痛症的治愈率。     

Nerve entrapment in painful heel syndrome

Subcalcaneal heel pain is one of the most common foot ailments, yet the exact etiology is still controversial. Nerve entrapment has been suggested as one of the possible causes of this painful condition in recalcitrant cases. The purpose of this study is to determine the role of nerve entrapment in painful heels. Twenty patients with heel pain (25 heels) were compared with an age and body mass index-matched control population using electrodiagnostic methods. The results of the study revealed 22 heels (88%) with heel pain had lateral plantar nerve entrapment signs with or without medial plantar nerve findings on EMG. There were no abnormal values in the control group. Nerve entrapment syndrome has previously been considered only in cases with intractable heel pain, but this study suggests that it may play a role the early phases of painful heel syndrome.     

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.     

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.     

Distal tarsal tunnel release with partial plantar fasciotomy for chronic heel pain: an outcome analysis

This study evaluated the effectiveness of distal tarsal tunnel release with a partial plantar fasciotomy for chronic subcalcaneal pain syndrome in patients who failed nonoperative management through a retrospective review of all patients undergoing this procedure between 1994 and 1999. Distal tarsal tunnel release and a partial plantar fasciotomy were offered only to those patients with disabling heel pain and were performed under general anesthesia or ankle block. Seventy-five patients (80 heels), averaging 20 months of nonoperative treatment, were identified (group I). Postoperative outcome questionnaires (SF-36 and Foot Function Index [FFI]) were sent to these patients and 44 (46 heels) responded (group II). In group I, 88% of patients had a good to excellent result. Many continued with mild to moderate residual symptoms, which typically did not limit their activity. In group II, 91% of patients were somewhat to very satisfied with their outcome. Visual analogue scale scores for pain were reduced by a mean of 55. SF-36 scores, matched against a control group of patients receiving just nonoperative treatment, showed a statistically significant improvement in all pain and functioning subcategories. We conclude that a distal tarsal tunnel release with a partial plantar fasciotomy may successfully increase function and decrease pain in patients who fail nonoperative treatment.     

Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis

The aim of this study was to compare the effect of extracorporeal shockwave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, heel cup, orthoses and/or shoe modifications, local steroid injections and electrotherapy. Forty-seven patients (49 feet) with a previously unsuccessful conservative treatment of at least six months were randomized to two groups. Treatment of Group 1 (25 heels) started immediately with three sessions of ESWT (3000 shockwaves/session of 0.2 mJ/mm2) at weekly intervals. In the patients of Group 2 (24 heels) treatment was continued for 12 weeks. After this period they were treated using the protocol of Group 1. No significant difference of pain and walking time after further non-ESWT treatment (three months) was seen. Six months after ESWT pain decreased by 64% to 88% on the visual analog scale (VAS) and the comfortable walking time had increased significantly in both groups.     

Preliminary experience of a single session of low-energy extracorporeal shock wave treatment for chronic plantar fasciitis

BACKGROUND: The purpose of the present study was to evaluate the effect of a single session of ultrasound- and biofeedback-assisted extracorporeal shock wave treatment (ESWT) in patients with chronic plantar fasciitis. MATERIALS AND METHODS: 20 patients (22 heels) with symptomatic plantar fasciitis that did not respond to conservative treatment for at least 6 months were studied. Patients received a single session of low-energy, ultrasound- and patient feedback-guided ESWT. Visual analog scale (VAS) was used to compare pain intensity before treatment and at followup (72 +/- 15 days after treatment). RESULTS: There was a significant decrease in overall pain (VAS 5.5 +/- 1.8 vs. 3.3 +/- 2.7, p = 0.001), maximum pain (7.7 +/- 2.1 vs. 4.0 +/- 3.9, p = 0.008) and pain at activities of daily living (5.3 +/- 2.1 vs. 2.5 +/- 2.6, p = 0.018). Night pain decreased to a lesser extent (2.4 +/- 2.5 vs. 1.3 +/- 2.1, p = 0.317). ESWT improved symptoms in 16 heels, of which six were completely symptom-free at followup 2.4 months after treatment. Six patients experienced no change. Fourteen patients with pain localized to the heel and all male patients benefited from ESWT. No difference was noted for age, body mass index, duration, and severity of symptoms or previous treatment. CONCLUSION: Low-energy ESWT proved to be an effective treatment option for the majority of patients with chronic plantar fasciitis that failed to respond to conservative treatment. Predictive parameters for successful outcome are male gender and an easily detectable pain center at the heel.     

Plantar fascia release through a transverse plantar incision.

A transverse plantar incision for plantar fascial release was assessed for pain relief, numbness, and subsequent heel pad symptoms. Twenty-seven feet in 26 patients who underwent plantar fascia release were reviewed with a minimum follow-up of 2 years after surgery (average, 37.6 months). Comprehensive data were obtained on 25 feet (24 patients) (93% response rate). The plantar fascia origin was completely transected in all cases. This led to complete resolution of symptoms in 19 feet and residual minor symptoms in six feet. After 2 years, four patients had developed recurrent symptoms, two in the area of surgery and two on the dorsum of the foot, in association with a pes planus foot. Two patients had some continued persistence of heel pain after surgery, although significantly less pain than preoperatively.Thus, 76% of patients had complete relieve of there symptoms, 12% of patients had mild symptoms not affecting daily activities, and 12% of patients had moderate symptoms that limited some activities. No patient suffered heel pad symptoms or numbness after surgery. It is concluded that plantar fascia release through a transverse plantar incision is a successful procedure for long-term relief of symptoms which avoids unnecessary heel pad numbness and scar morbidity. The benefits of a transverse incision include greater intraoperative vision, to ensure adequate release and spur excision, and an incision parallel to the medial calcaneal branches of the tibial nerve.     

Percutaneous fenestration of the anteromedial aspect of the calcaneus for resistant heel pain syndrome

IntroductionThe failure of conservative treatment of chronic heel pain might cause prolonged disability from continued discomfort and pain, which mandates a further treatment modality.Aim of studyThe presentation of the results of percutaneous fenestration of the anteromedial aspect of the calcaneus for symptomatic relief of resistant heel pain syndrome.Material and methodsBetween September 2001 and August 2006, 34 patients (38 feet) with chronic heel pain syndrome reported an unacceptable level of pain despite intensive conservative treatment. There were 23 females and 11 males with an average age of 41 years (25–59 years). The average follow-up was 46 months (range, 14–84 months). Clinical evaluation of the intensity of pain (VAS score system), walking distance, standing duration, fascial tenderness, and ankle and subtalar joint motion were evaluated preoperatively and at regular follow-up.ResultsThe preoperative pain score level was 8.4 (range, 6–10). The mean postoperative VAS for pain at 4 weeks was 5.89 (range, 3–9), at 8 weeks the value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at 8 months 1.7 (range, 0–3) and at 12 months zero. A clinical improvement was seen in all patients irrespective of the duration of symptoms (p = 0.0041). Three heels (7.9%) had partial relief of pain, but after 43 weeks had complete subsidence of pain. Complications include three transient paraesthesias at the distribution of the medial calcaneal nerve that resolved spontaneously after 8 weeks post-surgery.ConclusionThe results suggest the technique of percutaneous fenestration is a significantly effective treatment modality for patients with recalcitrant heel pain syndrome after failed conservative treatment.The described technique may provide a useful method for treating refractory heel spur syndrome without resorting to invasive surgical techniques and warrants further study.     

Endoscopic decompression of the first branch of the lateral plantar nerve

Entrapment of the first branch of the lateral plantar nerve is one the cause of plantar heel pain. It is easily overlooked. Surgical treatment classically utilizes a long medial incision with release of both the superficial and deep fascia of the abductor hallucis muscle. We decompress the nerve by release of the deep abductor hallucis fascia under arthroscopic visualization. By this approach, the soft tissue trauma and risk of wound complications can be minimized.     

Reconstruction of plantar heel defect using reinnervated, skin-grafted flexor digitorum brevis flap

Two cases with extensive plantar avulsion injuries had their heel defects resurfaced initially with full thickness skin grafts. Two months later, reinnervation presented in areas of grafted skin innervated by medial and lateral plantar nerves. No reinnervation was found in the plantar heel region originally innervated by the medial calcaneal nerve. Heel ulceration in the non-sensate, grafted skin occurred in the first case. Reinnervated, skin-grafted flexor digitorum brevis muscle flaps were then used for reconstructing the non-sensate plantar heels. There was no breakdown of skin during the follow-up period of 8 months and 6 months respectively. This method provides sensate and durable cover for extensive plantar heel defects.     

Endoscopic Plantar Fasciotomy Through Two Medial Portals for the Treatment of Recalcitrant Plantar Fasciopathy

Plantar fasciopathy is a common cause of heel pain. Endoscopic plantar fasciotomy has the advantage of less surgical trauma and rapid recovery. The aim of the present prospective study was to delineate the results of endoscopic plantar fascia release through 2 medial portals. The present study included 2 groups. The first group included 27 feet in 25 patients that had undergone endoscopic plantar fascia release followed up for 19.7 (range 12 to 33) months. The second group, the control group, included 20 feet in 16 patients treated conservatively and followed up for 16.4 (range 12 to 24) months. The results of endoscopic plantar fascia release were superior to the conservative methods. The surgically treated group experienced significantly less pain, activity limitations, and gait abnormality. The presence of a calcaneal spur had no effect on the final postoperative score. In conclusion, endoscopic plantar fascia release through 2 medial portals is an effective procedure for treatment of resistant plantar fasciopathy that fails to respond to conservative management options.     

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.     

Endoscopic treatment of calcaneal spur syndrome: A comprehensive technique

We describe a comprehensive approach to the endoscopic treatment of calcaneal spur syndrome developed by the Arthroscopic Group of the Orthopedic Service of Hospital Hermanos Ameijeiras in Havana, Cuba. The surgical technique involves treatment of the heel spur and plantar fasciitis commonly found in calcaneal spur syndrome, but it also addresses adjacent calcaneal periostitis and allows decompression of the nerve to the abductor digiti quinti. Medial endoscopy and lateral instrumentation are used in a sequential approach with exposure and debridement of the posterior roof of the calcaneal arch, followed by removal of the calcaneal spur, lateral to medial release of the medial 75% of the plantar fascia, and if necessary, debridement of the calcaneal tuberosity periosteum. This technique was used in a prospective case series from June 1997 to May 1998 to treat a select group of 38 feet in 30 patients who reported unacceptable levels of pain despite 5 months of conservative treatment, which included an aggressive 8-week physical therapy program prescribed by the treating physician. Good to excellent results were obtained at 3 months postoperatively in all patients with regard to pain relief and return to normal activity, although 5 patients required a short course of physical therapy to resolve symptoms brought on by sports, trauma, or impact loading before 1-year follow-up, at which time all patients reported good to excellent results. Complications included 3 superficial wound infections cured by oral antibiotics and 2 transient lateral paresthesias that resolved with rest and nonsteroidal inflammatory medications. The described technique may provide a useful method for treating refractory heel spur syndrome and warrants further study.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 517–522     

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.     

Neuromas of the calcaneal nerves.

A neuroma of a calcaneal nerve has never been reported. A series of 15 patients with heel pain due to a neuroma of a calcaneal nerve are reviewed. These patients previously had either a plantar fasciotomy (n = 4), calcaneal spur removal (n = 2), ankle fusion (n = 2), or tarsal tunnel decompression (n = 7). Neuromas occurred on calcaneal branches that arose from either the posterior tibial nerve (n = 1), lateral plantar nerve (n = 1), the medial plantar nerve (n = 9), or more than one of these nerves (n = 4). Operative approach was through an extended tarsal tunnel incision to permit identification of all calcaneal nerves. The neuroma was resected and implanted into the flexor hallucis longus muscle. Excellent relief of pain occurred in 60%, and good relief in 33%. One patient (17%) had no improvement and required resection of the lateral plantar nerve. Awareness that the heel may be innervated by multiple calcaneal branches suggests that surgery for heel pain of neural origin employ a surgical approach that permits identification of all possible calcaneal branches.     

Extracorporal shock wave therapy in patients with tennis elbow and painful heel

The aim of this study was to evaluate the effect of extracorporal shock wave therapy (ESWT) in tennis elbow and painful heel. Nineteen patients with tennis elbow and 44 patients with painful heel in which conservative treatment had failed underwent ESWT. Both groups received 3000 shock waves of 0.12 mJ/mm2 three times at weekly intervals. After a follow-up of 5 and 6 months respectively, pain measured on a visual analogue scale (VAS) decreased significantly in both groups. The success rate (excellent and good results) was 63% in tennis elbows and 70% in painful heels. ESWT seems to be a useful conservative alternative in the treatment of both conditions.