Plantar Fasciitis Surgery
Plantar fasciitis surgery is an option that lies at the end of a long road of alternatives for plantar fasciitis treatment. Some 90% of plantar fasciitis suffers resolve their problems through a menu of “conservative” treatments led by Stretching and improvements in Orthotics & Footwear. Then there are the additional options of Minimally Invasive Treatments.
“How long will it take to get better?” We keep asking ourselves and our doctors, physical therapists and any other sources we can find. “And what if it doesn’t?”
According to the University Foot & Ankle Institute, the need for plantar fasciitis related surgery is “exceptionally rare…Only 5% of our patients seen with plantar fasciitis require surgery to release the plantar fascia. In such cases, patients have had pain persist for many years, have severe scar formation and have had multiple conservative attempts.”
The American Foot & Ankle Society and the American College of Surgery have recommended a minimum of six months of non-operative management before considering surgery.
Some think it should be longer than that.
Dr. W. Hodges Davis, a Charlotte, North Carolina Foot and Ankle Surgeon and 2012-2013 President of the Outreach and Education Fund of the American Orthopaedic Foot & Ankle Society, requires 20 months of conservative treatment before doing surgery.
Surgery is a rare procedure for doctors treating plantar fasciitis, says Dr. Johnson. “The main reason is that we see some really significant complications from doing that, and we don’t have good solutions for those complications. When it’s such a high percentage of patients who can get better without surgery, then you really have to drag your feet as far as offering surgery to make sure you’re not dealing with somebody in that 90 percent.”
The plantar fascia has a real function and is not just some vestigial organ like the appendix, he says. “It provides quite a few different things. It primarily provides support to the longitudinal arch during mid-stance and terminal gate stance.” So why, he asks, would one want to cut this thing for a self-limiting problem, i.e. one which might be cured by more conservative approaches.
“Absolutely avoid surgery at all costs,” says one physical therapist. “Why would you want to weaken a structure that we use every time we push off? It supports the structure of the foot.”
But surgery works, says Dr. Davis, and significant weakening of the plantar fascia by surgery is not something he’s seen, he says.
“We’ve published a large series on disabling plantar fasciitis foot pain, and we’ve had 90% good results, and a lot of them were athletes. I’ve done it on 300-pound NFL players.”
Surgery is typically a “partial transection” of the plantar fascia, essentially making a controlled partial rupture so it will lengthen, and then giving it time to heal in that lengthened position. It appears to heal back to a strength similar to a healthy plantar fascia, a little thickened but fine from a structural standpoint, according to one doctor.
A partial transection video, unless you’re squeamish :
But surgery also involves the nerves.
“I do surgery on the plantar fascia when I believe there is some associated nerve entrapment problem going on,” says Dr. Johnson. “I release the nerves that go down onto that part of the heel, and I also release a little of the plantar fascia thinking the edge of the plantar fascia may be a source of compression to the nerve.”
“We release a nerve, the first branch of the lateral plantar nerve,” says Dr. Davis, “and do a partial transection of the plantar fascia. If partial, it will allow the plantar fascia to lengthen enough to provide the pain relief. But surgery does take six months to get back from”
Dr. Davis, like Dr. Johnson, describes limitations of the endoscopic approach to plantar fasciitis surgery. “You don’t know how much you’re releasing, and you also can’t address the nerve. That’s never become popular in the orthopedic community.”
Endoscopic surgery, of course, offers the option of being less surface cutting to get at the job:
“Almost all treatments people use,” says Dr. Johnson, “surgery or minimally invasive treatments like PRP injections or shock wave therapy, are trying to stimulate the body’s own healing response. That’s why partial transection works. All we’re trying to do is to stimulate the body to heal what we call an inflammation and often chronic kind of degenerative process in a ligament or tendon attached to bone.”