How To Perform An In-Step Plantar Fasciotomy

    Heel pain is obviously one of the most common complaints we see in podiatric office. The causes of heel pain are varied and include tarsal tunnel syndrome, Baxter’s neuritis, calcaneal stress fracture and spondyloarthropathies, just to name a few. For the majority of these patients, the diagnosis is plantar fasciitis.     Many of these patients will get better with conservative care, which includes stretching, orthotic devices and steroid injections. Those who still have pain may find relief with extracorporeal shockwave therapy. Patients who still do not respond to these treatments are left with the option of surgical cutting of the plantar fascia. However, research has shown that a total release of the fascia causes an increased incidence of lateral column instability.     In 1957, DuVries described the classic surgery for plantar fasciitis or heel spur syndrome.1 He performed the surgery through a medial incision in which he removed the fascia from its insertion and subsequently removed the heel spur. Others have used a minimal incision technique with just a stab incision on the plantar or medial aspect of the foot. According to current podiatric thought, it is the inflamed/degenerative fascia rather than the heel spur itself that is the source of the heel pain.     With the medial DuVries incision, Gormley showed in his study that 84 of the 94 patients had postoperative numbness along the incision and 36 had numbness after six months.2     Some physicians have used an endoscopic approach to release the plantar fascia. In an anatomic study, Reeve, et. al., showed the inability to transect the most medial band of the plantar fascia using the endoscopic plantar fasciotomy double portal technique that Barrett and Day described.3 Kim, et. al., showed in their study that using the traditional endoscopic approach can lead to the formation of a neuroma of the calcaneal nerve.4     Foot and ankle surgeons also have used the plantar transverse in-step approach to release the fascia. Woelffer, et. al., showed a 91 percent excellent or good result up to 6.5 years after surgery.5 Fishco, et. al., showed a 93.6 percent success rate with 95.7 percent of the patients recommending the procedure.6     The main complications reported with this surgery are scarring, medial arch pain, cramping in the arch, lateral column pain, pain across the dorsum of the foot, and burning or tingling in the ball of the foot.6 These complications occurred infrequently in patients.     Accordingly, let us take a closer look at the plantar in-step fasciotomy and our experience with it over the past 12 years.

Detailing The Advantages Of In-Step Plantar Fasciotomies

    We feel this procedure has several advantages over the traditional medial approach, endoscopic plantar fasciotomy (EPF) and minimal incision technique. This procedure allows direct visualization of the plantar fascia in an area that is at low risk for nerve entrapment. This procedure also equivocally allows the surgeon to transect the appropriate percentage of the plantar fascia due to this direct visualization. As reported previously by Reeve, surgeons are often unable to release the abductor hallucis fascia with the endoscopic plantar release.4 The in-step plantar fasciotomy avoids direct transection of the medial calcaneal nerve branches, which is common with the traditional DuVries medial approach.     Even after the EPF procedure, medial calcaneal nerve damage has been reported in up to 10 percent of feet. The in-step plantar fasciotomy also has the advantage of allowing early weightbearing if the surgeon desires. As mentioned by previous authors, the EPF as well as the DuVries incision puts “cutaneous innervation of the medial heel region at risk to injury.”4

How To Combat Potential Complications

    Potential complications can occur with the in-step procedure as with any surgical approach to the plantar fascia. Our experience with this procedure over the last 12 years has included some minimal but noteworthy complications. We have noticed very little lateral column instability symptoms with this procedure despite releasing the entire medial and the entire central band of the plantar fascia. This may be due to the fact that our post-op course is rather guarded and patients do not return to any shoe until about three weeks after surgery. Also, since we have direct visualization, we can avoid any inadvertent cutting of the lateral band of the fascia, which may occur with the other techniques.     One complication that we have seen occasionally, probably about 5 to 8 percent of the time, is a tender plantar scar. The scar itself heals nicely and without any hypertrophy or keloid due to its location parallel to the relaxed skin tension lines on the plantar aspect of the foot. However, some patients will develop deep thickened scar tissue at the site where the plantar fascia underwent transection. If we note this early on in the postoperative course, we refer these patients to physical therapy immediately for aggressive deep friction massage and physical therapy modalities. Occasionally, we have had to inject the scar in the postoperative period to lessen some of its symptoms.     Proper incision placement is important. If one places the incision too distally, subdermal scarring can occur. We have had a few cases of regrowth/reattachment of the plantar fascia in this area confirmed by postoperative MRI. These patients went on to further resection and subsequent removal of a larger portion of the plantar fascia and scar tissue. With any repeat procedure, casting these patients at 90 degrees afterward avoids further reattachment.

A Step-By-Step Guide To Surgical Technique

    In performing the in-step plantar fasciotomy, surgeons will generally have the patient under IV sedation with a posterior tibial nerve block and a local infiltrative block. We usually perform this under ankle pneumatic tourniquet hemostasis. When first performing this technique, one should avoid infiltration of any local anesthesia directly into the surgical site as this may obliterate the natural soft tissue dissection plane. Although dissection is relatively simple, there is an advantage to avoiding excessive injection of local anesthetic into the surgical site itself to help in anatomic dissection.     We perform the procedure approximately 1.5 to 2.5 cm distal to the plantar heel pad. This incision is directly plantar on the foot but leading toward the medial side. Utilize an incision of approximately 1.5 inches. The surgeon should make the incision in a plantar transverse direction with the relaxed skin tension lines. Usually, one would cauterize two to three small bleeders after the initial skin incision. Perform gentle dissection through the subcutaneous fat. Sometimes the surgeon will note small septae bands within the subcutaneous tissue and should release these with a sharp #15 blade. At this point, maximally dorsiflex the toes to elicit the windlass mechanism and then use the back of a scalpel handle or a malleable retractor to try to push away the subcutaneous tissue off the plantar fascia.     Proceed to place a Weitlaner retractor directly down onto the plantar fascia and open it up for direct visualization of the fascia. While maintaining the windlass mechanism and starting from the most medial side of the foot with a #15 blade, release the entire medial and central bands of the plantar fascia. We do not resect the spur if it is present or even visualize it.     The surgeon will usually encounter a natural delve between the central plantar fascia band and the lateral band. One can protect the lateral band by using the deep end of the Senn retractor. With this atraumatic technique, the plantar fascia separates slowly and this enables direct visualization of underlying muscle bellies. We will usually take a small portion of the plantar fascia at this point and send it for pathological examination.     We have performed somewhat large resections of the plantar fascia in the past but currently do not. We have not noted much difference in the surgical outcomes. If regrowth of the plantar fascia is a concern for the surgeon, then he or she may resect a larger section of the fascia at this time.     It is important to recheck the most medial aspect of the incision to make sure one has released the entire medial band. This medial band is nothing more than thickening of the abductor hallucis fascia and we think it is important to release this entire medial fascia. Sometimes with the tip of a curved hemostat, we can “pluck” the medial fascia to ensure we have adequately released it. Flush the wound with standard amounts of saline and proceed to closure. One would traditionally perform closure with minimal sutures. Over the past 12 years, we have tried to minimize many deep tender scar formations by varying our techniques. This includes applying two or three 4.0 absorbable deep sutures as opposed to no deep sutures at all. We have not found much difference between the two techniques. We close the skin with 4.0 nylon horizontal mattress type sutures. Place the patient in a posterior splint at 90 degrees.     Others have reported this technique with variations including Woelffer, et. al., who reported release of just the central portion of the plantar fascia through this technique.5 Fishco has reported success with this technique while sectioning the medial “one-third of the fascia.”6 The controversy remains as to what percentage of the fascia one needs to transect. We have traditionally cut the entire medial and the entire central band, which may be more aggressive than others have reported. Despite this, we have had minimal lateral column instability symptoms.

What Does The Post-Op Course Entail?

    Our postoperative course includes a short period of non-weightbearing for only four to five days and then we follow this with guarded weightbearing in a fracture type boot. Boberg and Dauphinee have described early weightbearing with this technique.7 We traditionally allow the patient to return to a tennis shoe gradually with an orthotic about three weeks postoperatively. We routinely remove the plantar sutures between 10 and 14 days, and have had minimal complications with wound dehiscence.     With this approach, we have found that patients have much less post-op pain compared to the traditional procedures, and will sometimes not even need to use narcotics in the postoperative course.

In Conclusion

    The in-step fasciotomy is just another technique for the podiatric surgeon to utilize when addressing a patient with chronic recurrent plantar fasciitis. This procedure allows direct visualization of the plantar fascia and one can do this at an aneural site. Patients usually tolerate the postoperative course well. In comparison to some of the traditional procedures as well as the endoscopic release of the plantar fascia, the in-step plantar fasciotomy is beneficial for the patients as well as the surgeon.     Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is a Clinical Instructor of the Western Reserve Podiatric Residency Program in Youngstown, Ohio. Dr. Karlock is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.     Dr. Kirk is the Chief Resident at the Western Reserve Podiatric Residency Program in Youngstown, Ohio.     Editor’s note: For a related article, see “A Closer Look At Endoscopic Plantar Fasciotomy” in the May 2002 issue or visit the archives at www.podiatrytoday.com.
 

References:

1. DuVries HL. Heel Spur (Calcaneal Spur). Arch Surg. 1957:74:536-542.
2. Gormley J, Kuwada G. Retrospective Analysis of Calcaneal Spur Removal and Complete Fascial Release for the Treatment of Chronic Heel Pain. The Journal of Foot Surgery, 31(2):166-69, 1992.
3. Kim J, Dellon L. Neuromas of the Calcaneal Nerves. Foot and Ankle International 22(11):890-94, November 2001.
4. Reeve F, Laughlin RT, Wright DG. Endoscopic Plantar Fascia Release: A Cross-sectional Anatomic Study. Foot and Ankle International, 18(7):398-401, 1997.
5. Woelffer KE, Figura MA, Sandberg NS, Snyder NS. Five-Year Follow-up Results of Instep Plantar Fasciotomy for Chronic Heel Pain. The Journal of Foot and Ankle Surgery, 39(4):218-23, July/August 2000.
6. Fishco WD, Goecker RM, Schwartz RI. The Instep Plantar Fasciotomy for Chronic Plantar Fasciitis. Journal of the American Podiatric Medical Association, 90(2):66-69, February 2000.
7. Bobery J, Dauphinee D. McGlamrys Comprehensive Textbook of Foot and Ankle Surgery. Vol. 1, Third Edition. Chapter 12. Lippincott Williams-Wilkins 2001.