Is The Plantar Fasciotomy An Outdated Treatment Option?

Over the past eight years, I have found the foot and ankle community's reluctance to adapt to the evidence-based paradigm shift in treating chronic refractory plantar fasciitis (CRPF) perplexing. Fortunately, we generally see that most plantar fasciitis patients do not require surgery. Thus, the limited number of surgical procedures for this condition provides some context to the continued use of plantar fasciotomies.¹

The amount of literature on gastrocnemius recession (GR) to treat CRPF is substantial.^2-15 There are fourteen articles in peer-reviewed journals and counting, if you missed the references in the prior sentence. Procedures that gain popularity in foot and ankle surgery with nowhere near the level of evidence of GR to treat CRPF is something I will never understand.

One recent article on the topic by Ginés-Cespedosa and colleagues provided new insight on the role of GR for CRPF.¹² The study examined changes in the plantar fascia preoperatively and one-year postoperatively in patients with CRPF treated by a proximal GR. The mean plantar fascia thickness was 6.59 mm preoperatively and 6.37 mm postoperatively (P=.972). The qualitative variables (hyperintensity in the plantar fascia, insertional calcaneus bone edema, a plantar fascia tear, and the presence of perifascial collections) demonstrated no statistical change in preoperative and postoperative evaluations.

The study utilized both anatomical specific (American Orthopaedic Foot and Ankle Society) and generalized (Visual Analog Scale and Short Form-36) patient-reported outcome measurements. Improved clinical results at one-year postoperatively for pain, quality of life, and function with a patient satisfaction rate above 85 percent. Postoperative SF-36 showed statistically significant improvement compared to preoperative scores for physical functioning, physical role functioning, bodily pain categories. AOFAS scores increased from 65.25±10.4 preoperative to 89±9.9 postoperatively, while VAS scores decreased from 68.1±18.8 preoperative to 15.1±18.3 postoperatively.

The authors concluded, "Quantitative and qualitative variables assessed for the plantar fascia on MRI did not show any significant change after medial gastrocnemius release despite clear clinical improvement." These outcomes demonstrate the role of the gastrocnemius on the plantar fascia and that the symptoms associated with plantar fasciitis have little to do with the inflammatory and ultimately the degenerative changes within the plantar fascia.¹²

Cheung and colleagues' definitive article on the relationship between the Achilles tendon and the plantar fascia established, that as the tension of the Achilles increased, one could note a reciprocal increase in tension on the plantar fascia.¹⁶ Additionally, increased strain on the Achilles tendon resulted in arch deformation. Both findings underscore the linkage of equinus to plantar fasciitis. Understanding this linkage clarifies the reasoning in using a GR to treat CRPF surgically.

In my opinion, and based on the evidence, plantar fasciotomies should go the way of video rental stores and disappear for good. The way I look at it, GR is the Netflix for CRPF. You can invest in “Netflix” stock on your patients' behalf or be a star in a forthcoming documentary about the last “Blockbuster” (aka plantar fasciotomy).

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.

1. Crawford, F., D. Atkins, and J. Edwards. "Interventions for treating plantar heel pain." The Foot 11.4 (2001): 228-250.
2. Abbassian, Ali, Julie Kohls-Gatzoulis, and Matthew C. Solan. "Proximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis." Foot & ankle international 33.1 (2012): 14-19.
3. Maskill, John D., Donald R. Bohay, and John G. Anderson. "Gastrocnemius recession to treat isolated foot pain." Foot & ankle international 31.1 (2010): 19-23.
4. Molund, Marius, et al. "Results after gastrocnemius recession in 73 patients." Foot and Ankle Surgery 20.4 (2014): 272-275.
5. Hoefnagels, E., et al. "Chronic therapy resistant plantar fasciitis, the effect of lengthening the gastrocnemius muscle." Foot and Ankle Surgery 2.22 (2016): 58.
6. Avila, A., et al. "Medial gastrocnemius proximal release in chronic plantar fasciitis. Prospective study of 75 cases." Foot and Ankle Surgery 2.22 (2016): 24-25.
7. Ficke, Brooks, et al. "Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients." Foot and Ankle Surgery 24.6 (2018): 471-473.
8. Molund, Marius, et al. "Proximal medial gastrocnemius recession and stretching versus stretching as treatment of chronic plantar heel pain." Foot & ankle international 39.12 (2018): 1423-1431.
9. Monteagudo, Manuel, et al. "Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession." International orthopaedics 37.9 (2013): 1845-1850.
10. Gamba, Carlo, et al. "Proximal medial gastrocnemius release versus open plantar fasciotomy for the surgical treatment in recalcitrant plantar fasciitis." Foot & ankle international 41.3 (2020): 267-274.
11. Hoefnagels, Eva M., et al. "The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis." Foot and Ankle Surgery 27.5 (2021): 543-549.
12. Ginés-Cespedosa, Alberto, et al. "Clinical And Plantar Fascial Morphologic Changes After Proximal Medial Gastrocnemius Release Treatment of Recalcitrant Plantar Fasciitis." Foot & Ankle Orthopaedics 6.3 (2021): 24730114211027323.
13. Cheney, Nicholas, et al. "Controversies in Surgical Treatment of Recalcitrant Plantar Fasciitis." Techniques in Foot & Ankle Surgery 20.2 (2021): 86-102.
14. Cheney, Nicholas, et al. "Isolated Gastrocnemius Recession for Plantar Fasciitis." Foot & Ankle Orthopaedics 3.3 (2018): 2473011418S00186.
15. Latt, L. Daniel, et al. "Evaluation and treatment of chronic plantar fasciitis." Foot & Ankle Orthopaedics 5.1 (2020): 2473011419896763.
16. Cheung, Jason Tak-Man, Ming Zhang, and Kai-Nan An. "Effect of Achilles tendon loading on plantar fascia tension in the standing foot." Clinical Biomechanics 21.2 (2006): 194-203.