If Conservative Care Does Not Work, What Next?

Milton J. Stern, DPM

    We know that 90% of all patients with plantar fasciitis will get better with conservative care.  We also know that only 75% of patients get better with conservative care if they have heel bursitis, 60% with retrocalcaneal bursitis and only 40% with heel neuritis.  What can we offer for those who do not respond to conservative care?   

    In this section, we will discuss some of the other treatments for plantar fasciitis.  In the near future we will include surgical options for the other heel pain syndromes.

    Plantar Fasciitis

     Before we think of surgical approaches there is one other modality out there for chronic, proximal plantar fasciitis.  This is called ESWT.  This stands for Extra Corporal Shock Wave Therapy.  This is when the plantar fascia at its insertion is subjected to 1500-2000 pulses from a machine similar to a lithotripsy machine for gall stones and kidney stones.  This is usually done in a hospital setting with some kind of anesthesia because one can feel the shocks going up the leg and this can be very uncomfortable.  The literature from the company suggests that this is 62% successful.  That same literature states that the placebo success rate is 48%.  That means that 48% of the patients got better even if the machine was never turned on.  Some of the local insurances have stopped paying for this treatment.   

    There have been many different surgical treatments for releasing the plantar fascia.  Some of them include removing the heel spur but most do not.  The majority of time the spur does not cause any problems if it is left alone.  If the surgeon measures the x-rays and can determine the exact location of the spur and makes his/her incision accordingly, the spur is easy to find and remove.

     The traditional heel spur surgery has been a good treatment choice for many years.  It involves making approximately a 2.5-3.0cm incision on the inside of the foot.  Through this incision the plantar fascial is identified and transected.  If the plantar fascia cut is made close to the bone then the boney heel spur can also be identified and resected.  For many years we let patients walk in a surgical shoe in 3-4 days.  The only real problem is that the incision would break down due to the location and the fact that the circulation to that area was diminished.  Now routinely we place the patient in a non-weight bearing cast for three weeks.  The patients will have some kind of post operative discomfort for 10-12 weeks, but then the pain usually goes away.  This has always been a very reliable surgery but does have a longer post operative recovery time.

    Endoscopic plantar fasciotomy started to be performed in about 1989.  This usually has to be done in a hospital setting because of the equipment.  This is when a small 1/2cm incision is placed on both sides of your heel.  A small tube called a cannula is placed through to heel from the inside to the outside.  An endoscope with a camera is placed in the cannula and a very small but sharp instrument is observed as it cuts through the fascia.  One stitch is placed on each side.  What makes this popular is that the healing time is much shorter that with the traditional surgery.   The patients were allowed to full weight bear the next day.  It was discovered that when the full fascia is cut through and next day ambulation was allowed that some of these patients developed some fore foot problems.  These included lateral column pain on the top middle of the outside of one's foot.  Patients also developed a fore foot condition called Morton's neuroma.  These both can be very painful conditions that cal last for a long period of time.  Because of this the surgery was changed.  Instead of cutting through the entire plantar fascia most surgeons only cut the medial band of the plantar fascia.  This has change the success rate of this procedure.  We like this procedure and still cut through the entire plantar fascia but do not let the patients bear weight for two weeks.  This has drastically reduced the post operative problems.

    In-step partial plantar fasciotomy is another small incision surgical release.  A small incision is placed on the plantar medial aspect of the foot.  From this incision the medial fibers of the plantar fascia are transected.  One or two stitches are placed in the arch and the patient can bear weight in one or two days.   This procedure can be performed in an office or outpatient center. 

    Minimally-invasive Plantar Fasciotomy by Koby  is another newer way to transect the plantar fascia.  A small medial incision is made and the top and bottom of the plantar fascia is identified.  A special instrument is inserted so as to isolate the plantar fascia and a sharp blade attached to the instrument is pushed through the plantar fascia.  Usually only one to two sutures are required to close the skin.  Some of the same post operative concerns exist as with the endoscopic plantar fasciotomy.  If the whole plantar fascia is cut then some form of  immobilization should be done.

    Laser guided plantar fasciotomy is closely related to the traditional heel spur surgery.  Everything is done the same except instead of cutting the plantar fascia a laser is used to cut the fascia.  In my opinion this is not a good option.  Visualization of the entire plantar fascia is virtually impossible.  If the laser comes in contact with bone then there is a severe periostitis (inflammation of bone) that can be very painful for a very long time.  Using a laser can decrease the amount of bleeding but the plantar fascia does not bleed routinely.

    Cryo surgery is starting to be used to treat plantar fasciitis.  This is where a small incision is made on the medial side of the foot.  A very cold probe is inserted and placed on the beginning of the plantar fascia.  This is supposed to freeze the plantar fascia and help with chronic plantar fasciitis.  This is a very new technique and there is evidence of some post operative problems.  This procedure can produce chronic tissue necrosis that can cause the foot to hurt for an extended amount of time and drain from the incision for months after the surgery.  

    These are the most commonly used treatments if conservative care does not render the patient pain free.

    In the near future I will add the other heel pain syndromes and their treatment when conservative treatment fails.

Family Footcare, PC

Milton J. Stern, DPM

30055 Northwestern Hwy.     Suite L40  

Farmington Hills, Mi 48334     

 (248) 851-4900    Fax:  (248) 851-4901

Send mail to drstern@badheel.com with questions or comments about this web site.
Last modified: January 08, 2006