Surgery for Plantar Fasciitis
A plantar fasciotomy or fasciectomy is a surgical procedure that involves cutting or releasing the fascia in order to reduce mechanical tension going through the fascia that travels into the heel bone. Some regard this technique as a drastic and outdated treatment method based on an outdated understanding of plantar fasciitis.
Most experts now agree plantar fasciitis or heel pain is actually a syndrome with many different causes of the pain. The treatment therefore should be cause specific and not one operation for all causes.
A fasciotomy will only help a small number of these causes of heel pain. Furthermore, studies suggest that at least 1/10 having a fasciotomy will go to develop a serious side effect known as lateral column instability that can cause lifelong pain and disability.
The plantar fascia forms an important aspect of the normal ‘locking mechanism’ of the calcaneocuboid , cutting the plantar fascia can allow for this important join to open up and the foot to spread.
Lateral column instability produces a myriad of symptoms involving the joints and bones and soft tissue structures of the lateral column. The lateral column is comprised of the calcaneus, the cuboid and the fourth and fifth metatarsals as well as their respective joints, the calcaneocuboid, the cuboidometatarsal and the intermetatarsal joints.
Symptoms of lateral column instability can include:
- Sinus tarsiitis. A type of joint irritation, causing pain felt on the outer ankle
- Arch pain and fatigue
- Metatarsalgia- pain in the forefoot at the metatarsal head level.
- Lesser tarsal joint strain – pain in the mid foot
- Lesser tarsal joint fracture
- Increased pressure under the metatarsal heads.
- Increased loading of the 2ndmetatarsal sometimes resulting in stress fracture.
- Calacaneal stress fracture
Causes of heel pain that do not respond to fasciotomy:
- Neuritis- inflammation of the nerves around the heel.
- Nerve entrapment, the most commonly affected nerve in the heel to become entrapped is Baxter’s nerve.
- Undiagnosed Stress fracture of the calcaneus. The heel bone has an unusual honeycomb like structure that can hide the appearance of heel bone fractures on x ray.
- Fat pad syndrome- a degradation of the protective pad of fat that cushions the heel bone.
- There are also several underlying inflammatory autoimmune diseases and conditions that trigger plantar fasciitis that will also not be helped by a fasciotomy, some of these include:
- Systemic lupus erythematosus(SLE)
- Rheumatoid arthritis
- Psoriatic arthritis
- Ankylosing spondylitis
- Inflammatory bowel disease
Cryosurgery by contrast has a broader range of causes of heel pain that it can treat and caries an almost non-existent risk of lateral column instability. Anyone considering a fasciotomy should consider cryosurgery first.