Key Considerations With The Instep Plantar Fasciotomy

Plantar fasciitis is one of the common pathologies that we treat as podiatrists. I am fortunate enough to spend time with a large number of attendings who have a variety of treatment opinions. In the end, almost all of their conservative measures are very similar. Icing, stretching, arch supports, good shoes, and anti-inflammatory medications are all the basics of beginning conservative care. The differences come in the surgical treatment.

For this discussion, let us assume that we are talking about a patient with classic plantar fasciitis with pain at the medial tubercle, pain with the first step out of bed, a tight medial facial band on exam with pain persistent for greater than six months despite aggressive conservative therapy.

The success rate of the instep planar fasciotomy has been confirmed in may podiatric studies. Fishco and colleagues reported a 93.6 percent success rate with 95.7 percent of patients stating they would recommend the procedure to another patient.¹ When conservative therapy fails, the instep plantar fasciotomy is a very viable solution for those patients. This procedure is quick, relatively minimally invasive and can be performed in the office.

The approaches I have seen from my attendings have been mostly the direct plantar approach but there is also the medial approach. The direct plantar approach has been the classic procedure described in the McGlamry textbook with a plantar incision 2 cm anterior to the weightbearing surface of the calcaneus, staying within the resting skin tension lines.² The authors used the medial incision when performing resection of the plantar calcaneal spur. The plantar incision offers great direct visualization of the plantar fascia. The spur resection is a polarizing topic as not all attendings agree that it needs to be resected.

The main difference is the postoperative protocol. For the majority of in-office procedures as well as simple instep plantar fasciotomies in the hospital operating room, surgeons have their patients bandaged and have them be weightbearing as tolerated in a surgical shoe. Some attendings place their patients in a posterior splint or slipper cast. Their reasoning for these post-operative casts and splints is to keep the foot at 90 degrees in order to keep the plantar fascia from reattaching. This is confusing to me.

The plantar fascia is inelastic. As a taught structure, which is a given being this is a procedure for plantar fasciitis, the plantar fascia will not readily retract to a position where it will re-appose. I also feel that weightbearing will stretch out the plantar tissues, again forcing the resected edges apart. I feel that if re-apposition of the plantar fascia is a legitimate concern to the surgeon, then one should perform a plantar fasciectomy. This is especially easy to perform when the surgeon uses the plantar approach. When one uses a self-retaining retractor in the incision, it is easy to visualize the plantar fascia. One can slip a hemostat under the natural septum and make an incision on either side of the hemostat, allowing for the fasciectomy.

I am not a fan of the medial approach. I never feel comfortable cutting something I cannot fully visualize. I also do not feel that resection of the heel spur is necessary. This spur is not the cause of the patient’s symptoms, rather it is an indication tight plantar tissues and musculature. Radiographs are often a part of the patients work up for heel pain. The patient can be educated as to the nature of this spur as this is not a direct cause of the problem. Therefore, he or she does not need to have this spur resected. The term heel spur syndrome often conveys that the spur is the cause of the problem but a quick explanation in my experience leaves patients content and understanding of their condition.

In regard to the plantar fasciotomy/fasciectomy, I do understand the feeling of necessity for taking these patients to the operating room but I feel that this should primarily be an in-office procedure. This saves both you and the patient time. The patient does not need to undergo pre-operative testing, remain NPO for the morning or spend four hours at the hospital for the 15-minute procedure. Other benefits include not undergoing the risks of anesthesia and not incurring the substantial hospital bill.

In the office, one can perform this procedure at the end of the morning or the end of the afternoon, allowing for the physician to still maintain a full day of seeing patients as well as being able to perform the procedure. For this soft tissue procedure, the global period is 10 days, typically requires only one to two post-op visits and suture removal. A surgical shoe is approximately $15 for the patient and he or she can wear it until suture removal. During this time, the patient may transition to regular shoes with orthoses that were likely already dispensed during the conservative care regimen. I do not feel that casting or splinting is necessary. I keep the patient ambulatory as this procedure should not require a substantial change in lifestyle for the postoperative period.

The instep plantar fasciotomy is a very successful treatment for recalcitrant plantar fasciitis. One can perform the procedure quickly in the office and there is no need for a long, limiting, postoperative period. Patients respond well to this procedure and are often welcoming it when longstanding plantar fasciitis has been present.

References

1.    Fischo WD, Goecker RM, Schwartz RI. The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review. J Am Podiatr Med Assoc. 2000;90(2):66-69.

2.    Boberg JS, Dauphinee DM, Malay DS, Harris IV W. Chapter 39: Plantar heel. In: Southerland JT, Boberg JS, Downey MS, Nakra A, Rabjohn LV, eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 4th ed. Philadelphia: Lippincott, Williams and Wilkins; 2012.