By Michael S. Downey, DPM
Plantar heel pain remains one of the most frequently encountered complaints from patients seeking treatment for foot and ankle problems. Many of these patients will ultimately be diagnosed as having plantar heel spur syndrome or plantar fasciitis. The majority of them will be successfully treated by conservative means. A small percentage of these patients will not respond to conservative measures and will elect to undergo surgical intervention.
In 1991, Barrett and Day described the endoscopic plantar fasciotomy (EPF) procedure as one method of surgical management for patients with recalcitrant plantar fasciitis or plantar heel spur syndrome.1,2 Since its introduction, the EPF procedure has occupied the forefront of the debate as to when and how plantar heel pain should be managed surgically.
The EPF procedure should be judged like any other surgical approach for recalcitrant plantar fasciitis or plantar heel spur syndrome. Like other surgical approaches, the EPF procedure has inherent risks and potential long-term sequelae, including the possible loss of arch height and arch integrity. Although it is generally associated with a quicker postoperative recovery period compared to traditional surgical methods, this should not make a patient consider the procedure any earlier in the treatment course. Choices of conservative therapy vary widely and generally include both anti-inflammatory measures and attempts at biomechanical control. Common examples of anti-inflammatory choices are corticosteroid injections, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy modalities such as ice and ultrasound. Examples of biomechanical treatment include rest, activity or footwear changes, padding or strapping, heel cups or pads, orthoses, casting, plantar night rest splints, weight loss, and physical therapy modalities with function-improvement goals (e.g., stretching regimes).
Although many authors advocate a specific time period for which conservative treatment should be tried before surgery is considered, it would appear that the nature of the conservative therapy should be the stronger consideration. Poor conservative treatment provided indefinitely is likely to fail, whereas sound conservative measures are likely to resolve the patient’s symptoms within a reasonable time period. Several recent studies continue to discuss the success of conservative treatment for roughly 90% of the patients with diagnoses of plantar fasciitis or plantar heel spur syndrome who seek treatment.3,4 From these studies, it would appear that a minimum of six to 12 months of varied and quality conservative treatment should be tried before surgery is considered as an option.
Several of these reports have come from the founding surgeons. In 1991, Barrett and Day evaluated the results of the procedure in seven patients.2 In 1993, they reported the results of 65 EPF procedures in 62 of their own patients.5 Between 1991 and 1993, the authors altered and improved their surgical technique to include a two-portal approach and new instrumentation.6 Most recently, in 1995, Barrett et al discussed the results of 652 procedures performed by 25 different surgeons.7
The most recent study provides the most intriguing data. In it, the authors reported that the EPF procedure relieved the patient’s heel pain in 633 (97.1%) of the 652 cases. They also identified 62 postoperative complications, which occurred in 53 (8.1%) of the 652 cases. The authors divided observed complications into three categories; lateral column destabilization phenomena, medial column destabilization phenomena, and other complications. Lateral column destabilization problems included calcaneocuboid/midtarsal joint pain, fourth and/or fifth metatarsocuboid pain, peroneal tenosynovitis, and sinus tarsi syndrome. Additionally, Sammarco and Idusuyi have recently reported a stress fracture of the base of the third metatarsal following an EPF procedure, and have suggested that this pathology is related to lateral column destabilization.8 Medial column destabilization pathology included central arch pain and intrinsic myositis. Other complications included continued heel pain, postoperative infection, incisional pain, nerve entrapment, and plantar fibromatosis. The most common complications were calcaneocuboid/midtarsal joint pain which occurred in 25 cases (3.8%), and continued heel pain which occurred in 19 cases (2.9%). Approximately 52% (32 of 62) of the complications were categorized as lateral column destabilization phenomena. Based on these results, Barrett et al suggested that the EPF technique should be modified to release only the medial one-third of the plantar fascia.7
Other authors have also reported results of the EPF procedure. In 1993, Kinley et al reported a comparative study between EPF and a traditional type of open heel spur surgery.9 They reviewed 66 EPF procedures and compared them to 26 procedures where the plantar fascia was cut and any plantar heel spur present was removed through a 3 to 6-cm plantar-medial incision. These authors reported that in six (9.1%) of the 66 EPF cases the patients had a partial or complete return of their pain. This compared to a 19.2% incidence (five of 26) in the traditional open approach. In total, Kinley et al reported 27 complications in the 66 EPF procedures and 15 complications in the 26 traditional procedures.9 The EPF complications included the six cases with recurrent pain, three cases of neuritis (one sural nerve, two medial plantar nerve), two superficial infections, six cases of transferred pain, five cases of incisional pain, four cases of adhesions, and one case of pain along the course of the endoscope tract. Of the six cases of transfer pain, three were described as being in the arch, two in the sinus tarsi, and one in the forefoot. In comparing the two approaches, these authors concluded that patients undergoing the EPF procedure had a shorter surgical time, earlier recovery, less postoperative pain, and fewer complications.
Tomczak and Haverstock also compared the EPF technique to an open plantar fasciotomy with heel spur resection.10 These authors compared 34 patients who had an EPF procedure to 34 patients who had the open approach. They concluded that the group undergoing the EPF procedure returned to work much faster (an average of 55 days sooner) than the group undergoing the open fasciotomy with heel spur resection. These authors did not specifically discuss their complications, but did conclude that the two surgical approaches were equally effective in relieving plantar heel pain.
In 1996, Stone and Davies reported the results of a retrospective survey conducted on 40 patients.11 These 40 patients responded to a written questionnaire and were not objectively examined or evaluated. Despite this limitation, the study did yield some interesting findings. Seventy percent of the patients responded “yes” when queried as to whether they would recommend the procedure to others or undergo the procedure again. However, 100% of the patients responding (40 of 75 questionnaires mailed out were returned) reported at least one postoperative complication. The most common complications were arch strain (63%), continued heel pain (45%), fatigue and stiffness (45%), cuboid and lateral pain (33%), and ball and toe pain (28%). The authors suggested releasing only the medial 50% of the plantar fascia, and managing patients postoperatively in a weight-bearing short leg cast for the first four to six weeks.
Even more recently, Brekke and Green have compared the results of a minimal incision plantar fasciotomy, an open procedure with either plantar fasciotomy or fasciectomy and heel spur resection, and endoscopic plantar fasciotomy.12,13 These authors reviewed 54 procedures in 44 patients. Seven patients (eight cases) had the minimal incision approach, 13 patients (17 cases) underwent the EPF procedure, and 24 patients (29 cases) had an open procedure. They found that on average, the EPF patients returned to normal activities more quickly: at just under seven weeks (6.91) compared to 12.14 and 12.09 weeks, respectively, for the minimal incision and open groups. They also found that the average rate of satisfaction and the average reduction of pain (postoperative versus preoperative) were lowest in the EPF group, although the results in all three groups were similar. The mean satisfaction rates were 67.7% for the EPF group, 71.4% for the minimal incision group, and 78.8% for the open group. The average reduction in pain was 71.5% for the EPF group, 75.8% for the open group, and 78.6% for the minimal incision group. The study’s authors felt that the lower success rate with the EPF technique in their study might have been due to surgeons’ inexperience with the technique, lack of preoperative incision planning, and variations in surgical technique. Of the 13 patients undergoing the EPF procedure, seven patients reported a postoperative concern or complication, and these included one case of plantar-lateral numbness, two cases of intermittent plantar fascial pain that was aggravated by increased sports activities, and one case of medial incisional tenderness in high heel shoes.
An unusual complication following plantar fasciotomy that was not reported in the larger retrospective studies is pseudoaneurysm formation. Two cases of traumatic pseudoaneurysm development following plantar fasciotomy have now been reported. In one case, the pseudoaneurysm occurred immediately following the procedure, and in the other case it developed almost two years after the procedure. Both of these reports reinforce the need to be aware of the potential for injury to vascular structures when performing an EPF procedure.14,15
Probably the greatest long-term concern for most surgeons performing the EPF procedure is the potential for significant loss of arch height with accompanying chronic pain in any patient undergoing a plantar fasciotomy procedure. Experimental evidence certainly supports the conclusion that arch height and foot length can be adversely affected by a plantar fasciotomy.16-18 This evidence suggests that a complete plantar fasciotomy is the most detrimental solution and that plantar fasciotomy in feet with preexisting arch instability should be approached with caution. Future studies need to assess the long-term sequelae of the EPF and other plantar fasciotomy techniques on arch height and foot function. Until more is known, it would appear to be prudent to limit the plantar fasciotomy to the medial portion of the fascia, and to manage patients undergoing these techniques with orthoses or other mechanical means of arch support postoperatively.
The consensus of current evidence appears to support the EPF procedure as a viable surgical option for the management of plantar fasciitis or plantar heel spur syndrome that is recalcitrant to conservative treatment. Patients appear to recover more quickly with less postoperative pain than patients undergoing more traditional surgical approaches for the same condition.
One of the concerns regarding the EPF procedure is the possible damage a surgeon might inadvertently cause to a local nerve in the heel. Several nerves are potentially subject to nerve injury with any surgical approach to the heel, including the medial and lateral plantar nerve; the medial calcaneal nerve; the first branch of the lateral plantar nerve (i.e., the nerve to the abductor digiti quinti, or Baxter’s nerve); and the sural nerve along with its terminal branch, the lateral dorsal cutaneous nerve. In early 1995, several clinicians reported anecdotal accounts of nerve injuries in an article on the EPF procedure in this publication.19 More recently, three cadaver studies have directly addressed and evaluated this clinical concern.
Hawkins et al evaluated the EPF procedure and its reproducibility in 18 fresh-frozen cadaver specimens.20 They attempted to release 75% of the plantar fascia in each specimen via an endoscopic surgical approach. They then dissected the specimens to expose the plantar heel and evaluated several parameters, including the actual amount of the plantar fascia cut, the width of the plantar fascia, and its thickness. The authors also evaluated each specimen for any damage to neural structures. When measured, the actual cuts they created in the plantar fascia through the endoscope (the original goal was 75% of the width) varied from 53% to 100%, but averaged 82%. The average medial to lateral width of the plantar fascia was 17.4 mm and the average thickness of the fascia was 3.5 mm. No damage to neural structures was identified in any of the cadaver specimens. The authors found the average distance from the plantar fascia to the nerve to the abductor digiti quinti to be 11 mm.
Hofmeister et al conducted a similar study on 13 fresh-frozen cadaver feet.21 They attempted to release the plantar fascia completely through the endoscope, but found on more extensive dissection that, on average, only 81% of the fascia had been released. They also assessed the average distance from the plantar fasciotomy to the lateral plantar nerve and from the nerve to the abductor digiti quinti. They found the average distances to be 10.5 mm and 12.3 mm, respectively. None of their specimens demonstrated any injury to neural structures. The authors concluded that with good technique, the risk to neural and vascular components appeared to be minimal.
Reeve et al22 did a cross-sectional analysis of 10 fresh-frozen cadaver specimens. They performed an EPF procedure on five of the specimens, and attempted to release 100% of the fascia. After performing the procedures, they did transverse, coronal, and sagittal plane sectioning of the specimens. Of the remaining five specimens, none had an EPF performed, but one underwent cross-sectional analysis and four underwent gross dissection. The authors assessed the amount of the plantar fascia actually released and the relationship of the plantar fascia to the nerve to the abductor digiti quinti. They found that the average amount of plantar fascia released was 90% (despite their trying to release 100%) with consistent failure to release the fascia from the abductor hallucis. The first branch of the lateral plantar nerve was not damaged in any of their specimens, and the average distance from the cannula margin to the nerve was 6 mm at the medial border of the plantar fascia. Although the proximity of the EPF cannula to the nerve to the abductor digiti quinti was less than that found in the other cadaveric studies, the authors still concluded that the risk of a properly done EPF procedure to neural structures was minimal.
The follow-up studies on the EPF procedure appear to support the evidence supplied by these cadaver studies. In their study of 652 cases, Barrett et al described only one postoperative nerve entrapment.7 Kinley et al described three cases of postoperative neuritis in their 66 cases.9 Of these, the sural nerve was involved in one case, suggesting the injury occurred with the creation of the lateral portal, and two cases involved the medial plantar nerve. No injuries to the lateral plantar nerve or its first branch were reported. Although injury to the sural nerve and lateral dorsal cutaneous nerve have rarely been reported, Jeran et al23 have suggested returning to a one-portal technique, with newer, specialized instruments inserted through a medial portal, to lessen the likelihood of lateral nerve injury.
In two of the three cadaver studies, the nerve to the abductor digiti quinti was found to be more than 1 cm (on average) away from the plantar fascia, and in the third study, the nerve was never closer than 6 mm to the plantar fascia.20-22 This distance would appear to offer a significant “buffer zone” between the fascia and nerve when the proper instrumentation and technique are utilized. Therefore, concern about possible nerve injury would not appear to be a reason for abandoning the EPF technique.24,25
When the EPF technique was initially described, Barrett and Day1,2 advocated a complete transection of the plantar fascia. Two years later, when they were discussing their results in 65 cases, Barrett and Day5 recommended that only the medial two-thirds of the plantar fascia be cut. In early 1995, Barrett, Day, and associates26 published a cadaver study in which they recommended release of the medial band of the plantar fascia, which their study determined was just less than 50% of the total width of the plantar fascia. Now, with their most recent report of 652 cases, they recommend performing a release of only the medial one-third of the plantar fascia.7
The reason for the change in the amount of plantar fascia to be cut is to reduce the common complication of lateral column destabilization. It is hoped that by keeping intact the lateral fibers of the plantar fascia, the locking mechanism of the calcaneocuboid joint will not be disrupted, thereby avoiding excessive strain on the plantar calcaneocuboid joint capsule and ligament. Murphy et al recently evaluated the biomechanical consequences of partial and complete release of the plantar fascia.27 In six fresh cadaver specimens, they sequentially released a third of the plantar fascia at a time from medial to lateral. With release of the medial one-third of the plantar fascia, an 18% drop in the medial longitudinal arch height occurred, along with an 8% drop in the height of the lateral longitudinal arch. Not surprisingly, complete release of the plantar fascia caused a 29% drop in the height of the medial longitudinal arch and an 18% drop in the lateral longitudinal arch. Thus, complete sectioning of the plantar fascia caused a 62% and 100% greater drop in the medial and lateral columns, respectively, than did release of the medial one-third of the plantar fascia. After completing their study, these authors felt that their data supported the hypothesis that “a strain of the plantar calcaneocuboid joint capsule and ligament is a cause of the lateral midfoot pain some patients experience after complete plantar fascia release.”
A future study evaluating the clinical results with only a one-third medial plantar fasciotomy is needed to see if the actual results support this theoretical hypothesis. Until then, a release of the medial one-third to one-half of the plantar fascia is probably advisable with the exception being a more lateral release in revisional cases or in cases where the patient’s pain is associated with the lateral band of the plantar fascia.
When the problem of calcaneocuboid syndrome does occur, it should be managed in an aggressive but conservative fashion. Barrett et al7 recommended that initial treatment consist of decreased ambulation and standing, stretching exercises, NSAIDs, orthoses, and physical therapy. If this regimen fails to alleviate the problem, they recommend a removable cast boot or referral to another surgeon experienced in the EPF technique, a pain management specialist, or a neurologist. In certain cases, where nerve entrapment or a potential chronic pain problem are possibilities, referral might be considered. However, in most cases, diligent continuation of conservative measures oriented towards the amelioration of inflammation and mechanical control of the calcaneocuboid joint will lessen or resolve the patient’s symptomatology. I recommend orthotic management with a cuboid pad to help lock the calcaneocuboid joint, or a course of nonweight-bearing in a short leg cast for four to six weeks. Corticosteroid injections, NSAIDs, and physical therapy are used as adjunctive measures. As a last resort, in cases unresponsive to conservative treatment, calcaneocuboid joint arthrodesis or midtarsal joint arthrodesis may be necessary.25
Michael S. Downey, DPM, is professor and chairman of surgery at Temple University School of Podiatric Medicine in Philadelphia.
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