Heel pain

Last evidence check Marc 2011

Surgery is rarely necessary for plantar fascitis. Sammarco and Helfrey (1996) found that only 3% of 870 patients with plantar fascitis required surgery. In Blackburn we have operated on four of 400 patients.

The usual indication for surgery is typical plantar fascitis unresolved after adequate conservative treatment. Most papers which express a view suggest that 6 months' conservative treatment is the minimum before embarking on surgery, although it may also be considered in a few patients with very severe symptoms at an earlier stage. We also require patients to be an appropriate weight for their height.

Plantar fascial release

Most recent articles have described release or resection of the plantar fascial insertion from the calcaneum with removal of any spur that may be present. In view of biomechanical studies (Sharkey 1999), showing that partial plantar fascial release has less effect on arch stability than complete release, some surgeons have emphasised partial preservation of the attachment (Sammarco and Helfrey 1996, Davies et al 1999, Conflitti and Tarquinnio 2004); others carry out a full release (Brown et al 1999) or do not specify the extent of release (Daly et al 1992, Schepsis et al 1991). Spurs are often resected but no study has demonstrated that this makes a difference to the result. Indeed, 8 of 16 spurs excised by Tountas and Fornasier reformed without affecting outcome.

Most studies describe open surgical approaches, usually medial. Brown et al described a transverse plantar approach which they claim reduces post-operative scar problems. Series of endoscopic plantar fasciotomy have been reported with increasing frequency. This is claimed to have a lower morbidity and shorter recovery time. A number of series of endoscopic release have been published (Ogilvie-Harris + Lobo 2000, Blanc et al 2001, Saxena 2004) which seem to be reporting similar results to open procedures. Saxena found that athletic activity and low BMI predicted a better result.

In what is perhaps the most realistic report of the results of surgery, Davies et al (1999) found that a combined 50% plantar fascial release and neurolysis of the first branch of the lateral plantar nerve reduced mean visual analogue pain score from 8.5 to 2.5/10, but half still had noticeable pain and restriction of activities at 1-5y follow-up. It took a mean of 8 months to reach the final outcome.

Plantar fascial release leads to slight flattening of the arch (Sharkey et al 1998, Jarde et al 2003, Tweed 2009) and may produce pain in the lateral column of the foot, which is commoner after a release of over 50% of the fascia (Brugh et al 2002).

Nerve release

Baxter has claimed that much "plantar fascitis" is actually due to entrapment of the nerve to quadratus plantae, which arises from the lateral plantar nerve in or just below the tarsal tunnel. We agree that this is sometimes discernible as a distinct clinical entity. Baxter recommends nerve decompression alone or with fasciotomy and/or spur resection, reporting complete relief of pain in 83% of patients with a 3-month recovery period. Several series (Davies et al 1999, Conflitti and Tarquinnio 2004) report a similar combined procedure with varied results.

Other techniques

Historical papers also describe other techniques:

Although the papers describing these procedures are of little use in assessing the value of the operations, it is possible that further study of the biology of plantar fascitis may re-awaken interest in them and it is as well to be aware of their existence.

Post-operative care

Post-operatively most surgeons appear to have advised non-weightbearing for up to three weeks. However, Tountas and Fornasier allowed free weightbearing from the beginning and produced results comparable to other studies.

Unfortunately, there are no meaningful studies comparing surgical techniques or post-op management protocols. It would be particularly useful to compare: