Heel pain is most common reason for visits to podiatrists and it is increasing in incidence according to the American Academy of Podiatric Sports Medicine. Being female, overweight or obese, or over 40 years of age increases the odds that a person will develop plantar fasciitis. When the initial treatments of medication, icing, shoe orthotics and therapy fail, surgery is performed.
Anatomy
The plantar fascia is a thick fibrous band that extends from the calcaneus, or heel bone, to insert at the base of toes. It maintains the arch of the foot. As weight is placed on the foot, the fascia stretches. With increased activity, increased body weight or arthritis, the plantar fascia develops irritation on the inside of the foot where it attaches to the calcaneus. The irritation is called plantar fasciitis. It is worse when weight bearing occurs after rest, such as getting out of bed in the morning.
History
Multiple medical procedures for treating plantar fasciitis have evolved. For years, physicians believed plantar fasciitis pain was due to heel spurs. The treatment was directed at removing the bone spur using large incisions. Dr. Rodney Tomczak, wrote in the "Journal of Foot and Ankle Surgery" that a major shift occurred in 1983 when a study showed heel spurs present in 13 percent of adults, but only 39 percent of those were symptomatic. Dr. Charles Cole reports in "American Family Physician" that heel spurs are found in 50 percent of patients with plantar fasciitis and in 19 percent of adults without symptoms. Magnetic resonance imaging of plantar fasciitis shows thickened fascia, and edema. Bone spurs may be present. Treatment now is directed at the plantar fascia or the nerves to it.
Open Surgical Procedures
In open surgical procedures, an incision is typically made from the inside of the foot, which is called the medial side. Patients are given anesthetic to numb the leg. So the surgeon can see the plantar fascia, a small incision is made. The painful plantar fascia is cut from the heel bone. Most of the plantar fascia is left intact. The surgeon may remove a heel spur.
Instead of an open procedure, the surgeons may do a minimally invasive release of the plantar fascia or a percutaneous plantar fasciotomy. Patients are given a local anesthetic. A small surgical blade is inserted into the medial foot. As she feels the foot, the surgeon cuts the medial part of plantar fascia by moving the blade.
Endoscopic
Small medial and lateral incisions are made by the heel for endoscopic plantar release. A camera is used to see the plantar fascia. Using special small instruments, the surgeon cuts a portion of the plantar ligament from its insertion on the heel bone. Tomczak felt his patients returned to work faster after this procedure than after an open plantar fascia surgery.
Cryosurgery
Brian Allen in "Journal of Foot and Ankle Surgery" explains his preference for using cryosurgery as a modern method of using cold properties the way Hippocrates used snow and ice to heal. A small probe inserted in the foot is cooled to minus 70 degrees C. The cold kills the inner portion of nerves, but the outer portion of the nerve remains intact, so painful abnormal nerve tissue does not develop as the body heals. Connective tissue, such as fascia and tendons, is not affected.
Extracorporeal Shock Wave
Instead of surgery, some doctors started using sound waves transmitted through fluid to treat plantar fasciitis. This procedure, extracorporeal shock wave therapy is done with local or no anesthetic. One theory is that the sound waves create a local injury which stimulates a healing response. Another theory is that the sound waves alter the pain response. Scot Malay reported in "Journal of Foot and Ankle Surgery" that this significantly reduced plantar fasciitis pain in his patients. Cole cites studies that extracorporeal shock wave treatment was only shown to be effective in runners.
References
- "The Journal of Foot and Ankle Surgery": A Retrospective Comparison of Endoscopic Plantar Fasciotomy to Open Plantar Fasciotomy with Heel Spur Resection for Chronic Plantar Fasciitis Heel Spur Syndrome; Rodney L. Tomczak,, Brent D. Haverstock; 1995
- "American Family Physician"; Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy; Charles Cole, Craig Seto, John Gazewood; 2005
- "The Journal of Foot and Ankle Surgery": Extracorporeal Shockwave Therapy Versus Placebo for the Treatment of Chronic Proximal Plantar Fasciitis: Results of a Randomized, Placebo-Controlled, Double-Blinded, Multicenter Intervention Trial; D. Scot Malay, et al; 2006
- "The Journal of Foot and Ankle Surgery": Cryosurgery: An Innovative Technique for the Treatment of Plantar Fasciitis; Brian H. Allen, Lawrence M. Fallat, and Steve M. Schwartz; 2007
- American Academy of Podiatric Sports Medicine: Plantar Fasciitis
