Results of endoscopic plantar fascia release

Use of 3D printing technology for custom bolus fabrication in the management of palmar or plantar fibromatosis with radiotherapy: A retrospective case series

PURPOSE

Palmar or plantar fibromatosis is a benign fibroproliferative disorder affecting the fascia of the hands or feet. Management involves surgery, typically reserved for cases where progression limits function. Retrospective series demonstrate that radiation therapy (RT) can stabilize the disease course in many patients and improve symptoms in some cases. RT techniques vary between the use of electrons and superficial or orthovoltage photons and often require lead cutouts or custom boluses. We present a new approach demonstrating the implementation and effectiveness of three-dimensional (3D)-printed bolus material in patients receiving RT for fibromatosis.

MATERIALS AND METHODS

A total of 3 patients, one with plantar and two with palmar fibromatosis, were treated with radiation using 3D-printed boluses over the past year. Bolus's design was based on computed tomography (CT) imaging data. Palmar patients were treated with a single en-face electron field, with a two-part accessory as a bolus and an immobilization device encasing the hand. The plantar case required 6MV photons delivered with a Volumetric Modulated Arc Therapy (VMAT) technique to cover the deeper target volume adequately. Dose and fractionation were based on guidelines from the Royal College of Radiologists in the United Kingdom. CT was used to assess printed shape and density accuracy.

RESULTS

The mean deviations in shape between the printed bolus pieces and their designs were all less than 0.4 mm. The differences in mean Hounsefield units (HU) between the printed boluses and their expected values were between 7 and 44 HU. No significant issues were encountered when applying the bolus to patients. The thermoluminescent dosimeters (TLD) used demonstrated dose accuracy to within TLD precision (5 %).

CONCLUSIONS

3D printing bolus technology represents a novel approach to treating fibromatosis with radiation. It offers superior dosimetry through the reduction of air gaps and by permitting custom bolus thickness. Also, it simplifies clinical set-up by acting as an immobilization device and a visual aid for daily field placement.

Outcomes of Endoscopic Treatment for Plantar Fasciitis: A Systematic Review

BACKGROUND

Endoscopic plantar fascia release (EPFR) is an established operative treatment for recalcitrant plantar fasciitis. The purpose of this systematic review is to provide a comprehensive review on the outcomes of EPFR in the treatment of plantar fasciitis at mid-term and long-term follow-up.

METHODS

A systematic review was performed using, MEDLINE, EMBASE, and Cochrane library databases in May 2020 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were evaluated regarding level of evidence (LOE) and quality of evidence (QOE) using the modified Coleman methodological score. Clinical outcomes and complications were also evaluated.

RESULTS

Twenty-six studies including 978 feet were included in this systematic review with a weighted mean follow-up of 25.6 ± 21.0 months. Eighteen papers used the American Orthopaedic Foot and Ankle Society (AOFAS) score. The weighted mean preoperative AOFAS score was 55.66 ± 10.3, and the postoperative score was 89.6 ± 5.2 out of 100. The total number of patients who had complications was 88 of 994 (8.9%). The most common complication was recurrence of pain experienced by 41 patients (4.2%).

CONCLUSION

Endoscopic plantar fascia release provides good clinical and functional outcomes in patients with refractory plantar fasciitis. However, this procedure is associated with a moderately high complication rate (8.9%) and should only be considered following failure of conservative management. Future prospective studies comparing the various endoscopic and open techniques with nonoperative treatment are required to elucidate the most effective management for recalcitrant plantar fasciitis.

LEVELS OF EVIDENCE

Level I: Systematic review of level IV studies.

Endoscopic Plantar Fascia Release Combined With Calcaneal Spur Resection: A Case Series of 40 Patients

PURPOSE

To review the cases of patients treated using endoscopic plantar fascia release (PFR) with calcaneal spur resection (CSR) and examine why the combined procedures cause complications.

METHODS

The medical records of patients treated with endoscopic PFR with CSR from November 2017 to December 2019 with a follow-up of >2 years were reviewed.

RESULTS

A total of 40 feet in 40 patients (22 females, 18 males) were enrolled. The mean age and body mass index were 51.1 years and 24.7 kg/m2, respectively. The mean follow-up duration was 5.7 years. The visual analog scale for pain improved from 80.7 to 8.8 mm, and the Japanese Society for Surgery of the Foot score improved from 44.7 to 95.6 points (Wilcoxon signed rank test, P < .001 for both). Complications occurred in 8 patients (20%): 3 had flatfoot, 3 had an injury to the first branch of the lateral plantar nerve, 1 had scar pain, and 1 had a wound infection.

CONCLUSION

The 40 patients treated with endoscopic PFR with CSR for plantar fasciitis had good outcomes with a high complication rate; the invasiveness of creating the working space for the combined procedures was thought to be responsible.

LEVELS OF EVIDENCE

Level IV: Case series.

What is the evidence for efficacy, effectiveness and safety of surgical interventions for plantar fasciopathy? A systematic review

Aims

To systematically review randomised control trials (RCT’s) assessing the effectiveness and safety of surgical interventions in adults with plantar fasciopathy (PF).

Materials and methods

We searched MEDLINE, EMBASE, Web of Science, Google Scholar, the Cochrane Central Register of Controlled Trials, trial registries and references lists. RCT’s comparing surgical interventions with non-surgical or surgical comparisons in adults with PF were included. Primary outcomes were changes in first step pain severity/intensity, and incidence/nature of adverse events. Secondary outcomes included foot and ankle related disability/function, health related quality of life, cost effectiveness, changes in other reported measures of pain and medication use. Data were extracted at short-term (≤3 months post-intervention), medium-term (>3months—≤6 months post-intervention) or long-term (>6 months—≤2 years post-treatment). Certainty of evidence was evaluated using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

From 3620 screened records, we included 8 studies comprising 345 patients. Substantial variation across trials precluded meta-analysis, hence a narrative synthesis was conducted. We judged all studies to have high risk of bias. For all outcome comparisons our GRADE judgement for the certainty of the evidence was very low. Three studies compared one type of surgery with another largely showing little to no difference in outcomes for pain, function or quality of life. Five studies compared surgery with non-surgical interventions—three providing very low certainty evidence that surgery may improve pain and function at long-term follow-up compared to non-surgical comparisons, whereas two studies provided no long-term between-group differences. Reporting of adverse events were inadequate, inconsistent or absent across all studies.

Conclusion

There is a paucity of high certainty evidence to support or refute the effectiveness and safety of surgical interventions in the management of PF. We make recommendations for improving the evidence base in this field.

Comparison of the Isolated Plantar Fascia Release Versus Plantar Fascia Release Combined With Calcaneal Decompression in Management of the Patients With Resistant Heel Pain

We aimed to compare isolated percutaneous plantar fascia release by using a needle versus percutaneous plantar fascia release combined with calcaneal decompression in treatment of the patients with resistant heel pain. We reviewed the prospectively recorded data of patients who treated and follow-up for resistant heel pain (treated more than 6 months with other treatment modalities) with a minimum 1-year follow-up. Twenty patients were treated with plantar fascia release using a needle (group 1) and 21 patients were treated with a similar percutaneous release combined with calcaneal decompression (group 2). Functional outcomes were evaluated using visual analog scale (VAS) and Foot Function Index (FFI) pre- and postoperatively. No significant differences were observed between both groups in terms of age (44.3 years in group 1 vs 46.8 years in group 2), gender (18 females and 2 males in group 1 vs 19 females and 3 males in group 2), body mass index (25.1 in group 1 vs 26.3 in group 2), and follow-up (14.6 months in group 1 vs 15.7 months in group 2). The decrease in postoperative FFI and VAS scores compared with preoperative VAS scores was statistically significant in both groups. However, improvement of FFI and VAS score was significantly higher in group 2 than group 1. Although both methods are very effective in the treatment of persistent heel pain, the group 2 has a better improvement in functional scores than group 1 with a mean 15 months following the procedure.

Fluoroscopic and Endoscopic Calcaneal Spur Resection Without Plantar Fascial Release for Recalcitrant Plantar Fasciitis

Background

Studies on endoscopic calcaneal spur resection (CSR) without plantar fascial release (PFR) are limited. This study aimed to review the data of patients who underwent fluoroscopic and endoscopic CSR without PFR for plantar fasciitis with a calcaneal spur to assess the effectiveness of CSR.

Methods

Medical records of consecutive patients with plantar fasciitis with ≥2 mm calcaneal spur who underwent endoscopic CSR without PFR from November 2017 to December 2019 were reviewed. Patients with ≥2 years of follow-up were included, whereas those who underwent another surgery on the operated foot were excluded. Age, body mass index (BMI), follow-up duration, calcaneal spur length, duration to full weightbearing postoperatively, Japanese Society for Surgery of the Foot (JSSF) score, visual analog scale (VAS) score for pain, and complications were assessed.

Results

The mean follow-up duration was 2.7 years. A total of 47 patients (31 female, 16 male; mean age, 56.4 years; mean BMI, 25.5) were included. The mean calcaneal spur length was 5.7 mm. The VAS score improved from 79.6 ± 12.9 mm preoperatively to 5.3 ± 7.3 mm postoperatively. The JSSF score improved from 54.0 ± 19.1 points preoperatively to 97.5 ± 5.7 points postoperatively (Wilcoxon signed-rank test, P < .001, respectively). The mean duration to full weightbearing postoperatively was 4.4 ± 4.2 days. Two patients presented with tenderness, and one presented with hypesthesia at the portal site.

Conclusion

Endoscopic CSR without PFR resulted in good outcomes, early return to full weightbearing, and few complications in patients with plantar fasciitis with ≥2 mm calcaneal spur. The results suggested that CSR was sufficient to relieve symtoms and improve function. PFR may not be necessary for treating plantar fasciitis with calcaneal spur.

Level of Evidence

Level IV, retrospective case series.

[Plantar fascia release and decompression of the first branch of the lateral plantar nerve (Baxter's nerve)]

OBJECTIVE

Treatment of chronic plantar fasciitis and release of the first calcaneal branch of the lateral plantar nerve (Baxter's nerve).

INDICATIONS

Chronic plantar fasciitis, compression of the first calcaneal branch of the lateral plantar nerve (Baxter's nerve).

CONTRAINDICATIONS

General medical contraindications to surgical interventions, infection.

SURGICAL TECHNIQUE

Longitudinal incision at the medial heel. Exposure of the plantar fascia at its origin on the medial plantar calcaneus. Medial incision of the plantar fascia preserving the lateral portion. Resection of a heel spur, if present. Exposure of the abductor hallucis muscle. Incision of the superficial fascia of the muscle. Retraction of the muscle belly und incision of the deep portion of the fascia, decompression of the nerve.

POSTOPERATIVE MANAGEMENT

Two weeks partial weight bearing 20 kg in a healing shoe. Progressively weight bearing using a shoe with a stiff sole for another 4 weeks.

RESULTS

A total of 32 feet of 27 patients with chronic plantar fasciitis and compression of the first branch of the lateral plantar nerve were treated with medial incision of the fascia and a nerve decompression. In 24 feet a calcaneal spur was resected. Mean follow-up was 25.6 months (12-35 months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 52.5 (±9.0), postoperative MOXFQ score was 31.3 (±4.1). Six (18,8%) patients had same or more pain 6 weeks postoperatively.;8 (25%) patients stated minor complications like swelling, delayed wound healing, temporary hypoesthesia or pain while walking.

The Clinical Efficacy of Two Endoscopic Surgical Approaches for Intractable Plantar Fasciitis

In this randomized retrospective study, 2 different endoscopic approaches were used to treat intractable plantar fasciitis with the aim to reduce complications and improve therapeutic effects. The lateral double incisions group included 23 feet in 22 patients, and the medial and lateral incisions group included 21 feet in 19 patients. Both groups were treated with endoscopy through the suprafascial approach. Patients were evaluated using the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale (AOFAS-AHS) and visual analog scale (VAS) preoperatively and 3, 6, 12, and 24 months postoperatively. At the final follow-up, the Roles-Maudsley (R-M) score was used to determine patient satisfaction. The AOFAS-AHS scores of the lateral double incisions group were 54.54 ± 7.02 preoperatively and 97.71 ± 3.67 postoperatively. Similarly, AOFAS-AHS scores in the medial and lateral incisions group were 55.52 ± 6.41 preoperatively and 96.64 ± 3.18 postoperatively. There was no significant difference in AOFAS-AHS scores between groups before and after surgery. The time to full weightbearing after surgery and the time to return to full athletic activities in the 2 groups showed no significant difference. The postoperative VAS scores were significantly lower than the preoperative values for both groups. However, no differences were noted in VAS scores or R-M scores postoperatively between the 2 groups. In the medial and lateral incisions group, 3 cases of injury of the first branch of the lateral plantar nerve occurred postoperatively. In conclusion, both endoscopic approaches are effective in the treatment of intractable plantar fasciitis. The lateral double incisions approach showed a lower incidence of nerve injury.

Endoscopic Plantar Fascia Release versus Cryosurgery for the Treatment of Chronic Plantar Fasciitis: A Prospective Randomized Study

BACKGROUND

In a prospective randomized study, we compared two different surgical techniques used in plantar fasciitis surgery.

METHODS

Forty-eight patients diagnosed as having plantar fasciitis and treated for at least 6 months with no response to conservative modalities were included in this study. The patients were randomly assigned to receive endoscopic plantar fascia release (EPFR) or cryosurgery (CS). Patients were evaluated using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) as a primary outcome measurement at baseline and 3 weeks and 3, 6, and 12 months after surgery. At the final follow-up visit, the Roles-Maudsley score was used to determine patient satisfaction.

RESULTS

Five patients did not complete the 1-year follow-up examination (one in the EPFR group and four in the CS group). Thus, the study group included 43 patients. Although both groups showed significant improvement at the final evaluation, the patients in the EPFR group had significantly better AOFAS-AHS scores at 3 months. The success rate (Roles-Maudsley scores of excellent and good) in the EPFR group at 12 months was 87% and in the CS group was 65%.

CONCLUSIONS

Both EPFR and CS were associated with statistically significant improvements at 1-year follow-up. At 3-month follow-up, EPFR was associated with better results and a higher patient satisfaction rate compared with CS.

Comparison of the therapeutic outcomes between open plantar fascia release and percutaneous radiofrequency ablation in the treatment of intractable plantar fasciitis

BACKGROUND

Heel pain is one of the most common complaints in foot and ankle clinic, and one of the leading causes of heel pain is plantar fasciitis.

METHODS

A retrospective analysis was carried out in 31 cases (39 feet) of patients with intractable plantar fasciitis. In the enrolled 26 cases, 16 patients (19 feet) received open plantar fascia release, and the other 15 patients (20 feet) received percutaneous radiofrequency ablation. The surgical results were assessed by visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AH) before and after surgery in all patients.

RESULTS

All 31 patients were followed up successfully, with a mean follow-up time of 58.77 months. There were no differences of patient's demographics and characteristics information between the two groups. The average operative time of the feet in the open plantar fascia release is longer than that in the percutaneous radiofrequency ablation. Furthermore, the percutaneous radiofrequency ablation group had a shorter recovery time to normal activity than the open plantar fascia release group. There were no differences of postoperative VAS scores and the AOFAS-AH scores between the two groups. All patients reported satisfaction after either operation.

CONCLUSION

The symptoms of pain and limb function were significantly improved in patients both of the partial plantar fascia release treated group and the percutaneous radiofrequency ablation treated group. The two types of surgical procedures shared the same long-term curative effects. However, percutaneous radiofrequency ablation was a better technique from the point of shorter operative time and postoperative recovery time.

TRIAL REGISTRATION

Retrospectively registered.

Evaluation and Treatment of Chronic Plantar Fasciitis

Plantar fasciitis is the most common cause of chronic heel pain in adults, affecting both young active patients and older sedentary individuals. It results from repetitive stress to the plantar fascia at its origin on the medial tubercle of the calcaneus and is often associated with gastrocnemius tightness. The diagnosis can be made clinically with a focused history and physical examination; imaging is reserved for atypical presentations and those that do not respond to initial treatment. The most common presenting symptom is aching plantar heel pain, which is worst with first step in the morning or after periods of rest. Diagnosis is confirmed with point tenderness at the origin of the plantar fascia on the medial tubercle of the calcaneus. Initial treatment consists of activity modification, anti-inflammatory medication, gastrocnemius and plantar fascia stretching, and an in-shoe orthosis that lifts and cushions the heel. These nonoperative treatments lead to complete resolution of pain in 90% of patients but can take 3-6 months. Patients who remain symptomatic despite a 6-month trial of nonoperative therapy may be considered for minimally invasive treatment or surgery. Platelet-rich plasma injections and therapeutic ultrasound are among a number of minimally invasive treatments that stimulate the body's healing response. Corticosteroid injections temporarily relieve pain, but may increase the risk of plantar fascia rupture and fat pad atrophy. Botulinum toxin injections relax the calf muscles, which decreases the stress in the plantar fascia. Operative treatments include gastrocnemius recession and medial head of gastrocnemius release, which decrease the stress on the plantar fascia and partial planter fasciotomy, which stimulates a healing response.

LEVEL OF EVIDENCE

Level V, expert opinion.

The clinical outcome of endoscopic plantar fascia release: A current concept review

PURPOSE

To clarify whether endoscopic plantar fascia release is safe and effective in the treatment of chronic plantar fasciitis. Secondary goals were a. to compare the clinical outcome between EPFR and non-operative treatment and b. to describe the various EPFR surgical approaches and their outcomes.

MATERIALS AND METHODS

Two reviewers (MM and EBC) independently conducted the search using the MEDLINE/PubMed database. This database was queried with the terms 'endoscopic plantar fascia release' and 'endoscopic plantar fasciotomy'. To maximize the search, backward chaining of reference lists from retrieved papers was also undertaken.

RESULTS

From the initial 63 studies we finally chose and assessed 15 studies which were eligible to our inclusion-exclusion criteria. A total number of 535 patients (576 feet) were reported, with a slightly higher female rate. The vast majority of the studies were case series (66.7% of all), while two papers were randomized controlled trials (13.3%), two were case control studies (13.3%), and one was cohort study (6.7%). The overall quality of the studies included in this review, as it was evaluated according to the GRADE Working Group guidelines, was low, while it ranged from very low to high. All studies showed that the postoperative clinical and functional subjective scores were significantly improved with the use of EPFR. Overall, the postoperative complications' rate was 11.0%. The most common complications which were recorded were persistent heel pain (5.6%), paresthesias or numbness (4.3%), soft tissue healing problems (1.7%), and superficial infection (0.4%).

CONCLUSIONS

There was weak evidence to support that endoscopic plantar fascia release was safe and effective for the treatment of chronic plantar fasciitis.

Endoscopic plantar fasciotomy for plantar fasciitis: A systematic review and network meta-analysis of the English literature

BACKGROUND

Currently, there is limited evidence on outcomes for endoscopic plantar fasciotomy.

OBJECTIVES

An evidence-based literature review for outcomes of endoscopic plantar fasciotomy for the treatment of plantar fasciitis is provided.

METHODS

A comprehensive evidence-based literature review of PubMed and Cochrane databases was conducted on 9th March 2019, which identified 12 relevant articles assessing the efficacy of endoscopic plantar fasciotomy. The studies were then assigned to a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against endoscopic plantar fascia release.

RESULTS

Based on the results of this evidence-based review, there is poor evidence (grade C) to support endoscopic plantar fascia release. Release of the medial 2/3 of the plantar fascia in endoscopic plantar fasciotomy was associated with higher AOFAS score.

CONCLUSION

Although the majority of the level of evidence was low (level IV) and grade of recommendation was poor (grade C), there seemed to be good outcomes for endoscopic plantar fasciotomy. There is a need for more high quality level I randomized controlled trials with validated outcome measures to allow for stronger recommendations to be made.

What is the evidence for efficacy, effectiveness and safety of surgical interventions for plantar fasciopathy? Protocol for a systematic review

INTRODUCTION

Plantar fasciopathy (PF) is a degenerative condition of the plantar fascia, secondary to repetitive overloading. For the majority, PF is self-limiting with greater than 80% of those affected gaining complete resolution within 1 year. However, persistent symptoms develop in approximately 10% of cases. Clinical practice guidelines for first-line treatment of PF recommend conservative management. For people with persistent symptoms that have not resolved following a trial of 6-12 months of conservative management, surgery may be offered. However, to date there are no systematic reviews of the effectiveness of the various surgical procedures for PF. We aim to systematically review quantitative studies assessing the effectiveness of surgical interventions in the management of PF.

METHODS AND ANALYSIS

We will search for all published and unpublished randomised clinical trials evaluating surgical interventions in the management of PF. Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (OVID), EMBASE (OVID), Web of Science (ISI) and Google Scholar will be searched without restrictions on date or language of publication. Inclusion criteria will include people over 18 years, diagnosed by clinical examination with PF, or with an alternative diagnostic label (eg, plantar fasciitis, plantar heel pain, plantar fasciosis). The primary outcomes are changes in pain severity/intensity for first-step pain, and incidence and nature of adverse events. Secondary outcomes include foot and ankle-related disability/function, health-related quality of life, cost-effectiveness, changes in other reported measures of pain (eg, overall pain) and medication use. Outcomes will be assessed (1) short term (≤3 months after intervention), (2) medium term (>3 months to ≤6 months after intervention) or (3) long term (>6 months to ≤2 years after treatment). All data extraction will be performed by at least two independent reviewers on the basis of a priori developed extraction form. Where adequate data are found meta-analysis will be used to combine the results of studies for all core comparisons and outcomes using random effects models. Overall certainty of the evidence for each outcome will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at appropriate conferences.

PROSPERO REGISTRATION NUMBER

CRD42019133563.

Plantar fasciitis treated with endoscopic partial plantar fasciotomy-One-year clinical and ultrasonographic follow-up

BACKGROUND

Endoscopic operations for plantar fasciitis generally have good clinical outcome. The aim of this study was to record the effect of endoscopic partial fasciotomy and heel spur removal and evaluate by ultrasonography whether the fascia regenerates and the heel spur reforms.

METHODS

Eleven consecutive patients were evaluated before and 3, 6 and 12 months after surgery. Operations were performed endoscopically using a deep fascial approach with a medial and a lateral portal. Bony spurs were removed and the medial half of the plantar fascia was transected. All patients followed a standardized rehabilitation program.

RESULTS

Median Foot Function Index values decreased from 119 pre-surgery to 69 and 12 (p=0.004), at 3 months and 1year post-operatively respectively. Median VAS-score for first step pain was likewise reduced from median 71mm to 29mm and 7mm (p=0.004), respectively. Median fascial thickness at the medial insertion was 6.0mm (range 4.6-6.8mm) pre-operatively. A heel spur was present in 9 cases. One year postoperatively a well-defined fascia in the area of resection was demonstrated in 8 cases. In the rest of the cases scar tissue made it impossible to clearly outline the fascia. Nine of the feet showed good medial fascial tensioning. There was no evidence of recurrence of the bony spur.

CONCLUSIONS

Endoscopic partial plantar fascia resection reduced pain symptoms and increased function significantly 3 months after operation, with additional effect achieved 12 months after surgery. Based on ultrasonography the resected fascia regenerated/healed, and a calcaneal spur did not recur.

Endoscopic Plantar Fasciotomy; Deep Fascial Versus Superficial Fascial Approach: A Prospective Randomized Study

In the present randomized prospective study, 2 different surgical techniques of endoscopic plantar fascia release were compared. Of 547 patients with a diagnosis of plantar fasciitis, 46 with no response to conservative treatment for ≥6 months were included. Of the 46 patients, 5 were lost to follow-up. In group 1 (n = 21), plantar fascia release was performed using a deep fascial approach (DFA), and in group 2 (n = 20), the superficial fascial approach (SFA) with a slotted cannula technique was used. Patients were evaluated using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale and visual analog scale at baseline and 3 weeks and 3, 6, and 12 months after the initial surgery. At the final follow-up appointment, the Roles-Maudsley score was used to determine patient satisfaction. At the final follow-up examination, the mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale scores had increased from 53.12 to 83.68, with a decrease in the mean visual analog scale score from 7.95 to 1.65 noted. According to the Roles-Maudsley score, the success rate after 1 year was 90.47% for DFA group, 95% for the SFA group, and 92.68% for all patients. Although no significant difference was found between the final functional scores, better early postoperative scores were found in the SFA group. The mean duration of the procedure was measured as 27.22 ± 9.41 minutes overall, 35 ± 5.62 minutes in the DFA group, and 19.05 ± 4.01 minutes in the SFA group. Two early and two late complications occurred in the DFA group with none reported in the SFA group. In conclusion, the SFA is a faster and safer method of endoscopic plantar fascia release with better early postoperative scores.

Mid-Sole Release of the Plantar Fascia Combined With Percutaneous Drilling of the Calcaneus for Treatment of Resistant Heel Pain

BACKGROUND

Heel pain with or without calcaneal spur is a challenging problem. Once conservative measures have failed, surgery may be indicated; there has been debate about the best surgical procedure. Two standard operative procedures have been either releasing the plantar fascia or removing the spur with drilling of the calcaneus. In this study, we evaluated the results of percutaneous drilling of the calcaneus combined with mid-sole release of the plantar fascia for treatment of resistant heel pain.

METHODS

This study included 20 cases with resistant heel pain after failure of conservative measures for 6 months. Clinical, radiological evaluation and scoring patients' conditions according to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scale was done preoperatively and postoperatively. Percutaneous drilling of the calcaneus combined with mid-sole release of the plantar fascia was done in all cases, and the functional results were evaluated through the follow-up period that extended from 9 to 16 months with a mean duration of 12 ± 2.3 months.

RESULTS

There was statistically significant improvement in the mean AOFAS Ankle-Hindfoot scale score from 50.8 ± 7.5 preoperatively to 91.6 ± 7 postoperatively at the last follow-up. There were no surgery-related complications, and the mean time for full recovery was 8 ± 3.7 weeks with no recurrence of pain by the last follow-up.

CONCLUSIONS

The results were very satisfactory with using this minimally invasive and simple technique for treatment for resistant heel pain.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Endoscopic Decompression of the First Branch of the Lateral Plantar Nerve and Release of the Plantar Aponeurosis for Chronic Heel Pain

Entrapment of the first branch of the lateral plantar nerve is a commonly missed cause of recalcitrant plantar heel pain. The diagnosis is made on a clinical ground with maximal tenderness at the site of nerve entrapment. Treatment of the nerve entrapment is similar to that for plantar fasciitis, with rest, activity modification, nonsteroidal anti-inflammatory drugs, stretching exercise, and local steroid injection. Surgical release of the deep abductor hallucis fascia is indicated when conservative treatment failed. Endoscopic release of the nerve through the dorsal and plantar portals, as well as endoscopic plantar aponeurosis release, is a feasible approach.

Long-Term Outcome of Open Plantar Fascia Release

BACKGROUND

Plantar fasciitis is thought to be a self-limiting condition best treated by conservative measures, but despite this many patients have a prolonged duration of symptoms and surgery may be indicated. Partial plantar fascial release is reported to have a short-term success rate of up to 80%, but anecdotally this was not thought to represent our local experience.

METHODS

An audit of long-term patient-reported outcomes following open partial plantar fascia release was performed. A total of 30 patients (33 feet) were identified over a 10-year period and case notes were reviewed. Patients were contacted by letter and invited to complete 2 validated patient-reported outcome score questionnaires (Visual Analog Scale-Foot and Ankle [VAS-FA] and Manchester Oxford Foot Questionnaire [MOXFQ]). Responses were received from 24 patients (26 feet). The average ages were 42.4 (range 24-61) for male and 46.2 (range 33-60) for female patients, with a female/male ratio of 2.7:1. The average duration of treatment prior to operative intervention was 3.1 years (range 1-5). Preoperatively, our cohort underwent a range of conservative measures. All patients were reviewed postoperatively, and average time from surgery to completion of questionnaires was 80 months (range 14-130).

RESULTS

The outcomes were worse in patients who had received preoperative steroid injections and this was found to be statistically significant. The mean MOXFQ score was 33.6 ± 3.9 (0-64). Mean VAS-FA score was 57.8 ± 4.9 (24-100).

CONCLUSION

This study found a negative correlation between duration of follow-up and outcome, in both MOXFQ and VAS-FA, showing that patients continued to improve many years postoperatively. The authors also found worse outcomes with preoperative steroid injections, better outcomes in older patients, and a weak gender bias, suggesting results in men were better than those in women. A prolonged recovery period and generally poor outcomes leads the authors to suggest that open plantar fascia release is of questionable clinical value and that patients may improve in the natural course of the disease, in spite of surgery.

LEVEL OF EVIDENCE

Level III, comparative study.

Lateral plantar nerve release with or without calcaneal drilling for resistant plantar fasciitis

PURPOSE

To compare the outcome following lateral plantar nerve release with or without calcaneal drilling for resistant plantar fasciitis.

METHODS

30 women and 3 men aged 30 to 60 (mean, 45) years with resistant plantar fasciitis were randomised to undergo release of the first branch of the lateral plantar nerve with (group 1, n=18) or without (group 2, n=15) calcaneal drilling.

RESULTS

Patients were followed up for a mean of 27 months. According to the modified Mayo scoring system for plantar fasciotomy, group 1 was superior to group 2 in terms of score (93.9±6.97 vs. 83±8.2, p<0.001) and grading (15 excellent, 2 good, and one fair vs. 6 excellent, 4 good, and 5 fair; p=0.031). Three patients in group one and one patient in group 2 (16.7% vs. 6.6%, p=0.381) developed complications of heel numbness, foot oedema, and 2 cases of superficial wound infection, respectively.

CONCLUSION

Adding calcaneal drilling to release of the first branch of the lateral plantar nerve achieves better outcome than release alone in patients with resistant plantar fasciitis.

Endoscopic Plantar Fasciotomy Improves Early Postoperative Results: A Retrospective Comparison of Outcomes After Endoscopic Versus Open Plantar Fasciotomy

Plantar fasciotomy is offered to patients with recalcitrant plantar fasciitis. Few studies have characterized the functional outcomes over time for the endoscopic approach compared with the open approach. We hypothesized that patients undergoing endoscopic surgery will have better postoperative functional outcomes early in the postoperative period but equivalent long-term outcomes compared with patients undergoing open surgery. We analyzed the prospectively collected data of all patients undergoing plantar fasciotomy at our institution from December 2007 to August 2014. A total of 42 feet of 38 patients were included in the analysis. The clinical data were collected preoperatively and at 3 and 6 months and 1 year. The functional outcomes analyzed included the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale, the Medical Outcomes Study, Short-Form, 36-item Health Survey, and patient satisfaction and expectations. Patients undergoing endoscopic surgery had significantly greater American Orthopaedic Foot and Ankle Society Ankle-Hindfoot and SF-36 Health Survey scores and lower pain scores at the 3-month period. They were also significantly more likely to be satisfied with and have had their expectations met by surgery. Compared with the open approach, the patients who had undergone endoscopic plantar fasciotomy experienced significantly greater improvements in the subjective and objective functional outcomes, with less pain and greater satisfaction, and had had their expectations met earlier in the recovery period, with equivalent long-term outcomes, compared with the patients who had undergone open plantar fasciotomy.

Classification of Calcaneal Spurs and Their Relationship With Plantar Fasciitis

Calcaneal spurs, as a cause of plantar fasciitis, are currently debatable. A prospective study was performed to classify calcaneal spurs according to the findings from an investigation of the relationship between calcaneal spurs and plantar fasciitis. Thirty patients with calcaneal spurs and plantar heel pain underwent calcaneal spur removal and endoscopic plantar fasciotomy. The relationship between the classification of calcaneal spurs and plantar fasciitis was evaluated by endoscopic findings, clinical symptoms, radiographic images, and biopsy findings. The visual analog scale for pain and the American Orthopedic Foot and Ankle Society ankle-hindfoot scores for functional evaluation were used preoperatively and postoperatively, respectively. The mean follow-up period was 24 months. Two separate types of calcaneal spurs were recognized. Type A calcaneal spurs were located superior to the plantar fascia insertion, and type B calcaneal spurs were located within the plantar fascia. Magnetic resonance imaging results showed a more severe plantar fasciitis grade in type B calcaneal spurs preoperatively. Histologic examination showed that the numbers of granulocytes per image in type B spurs were significantly increased compared with those in type A spurs. Statistically significant improvements were found in the mean visual analog scale and American Orthopedic Foot and Ankle Society scores and magnetic resonance imaging results in both groups. The amount of change in the visual analog scale score and American Orthopedic Foot and Ankle Society score, the number of granulocytes per image, and calcaneal spur length showed a high association with the classification of the calcaneal spurs. Calcaneal spurs were completely removed and did not recur in any of the patients on radiographic assessment during the follow-up period. Calcaneal spurs can be classified into 2 distinct types that are indicative of the severity of plantar fasciitis.

Intermediate-term results of partial plantar fascia release with microtenotomy using bipolar radiofrequency microtenotomy

Plantar fasciitis is a common condition, with most patients treated successfully with nonoperative management. Recalcitrant disease has been managed with surgical procedures that vary in design and associated morbidity. The present study sought to determine the intermediate-term results of percutaneous bipolar radiofrequency microtenotomy in recalcitrant plantar fasciitis. The patient medical records were reviewed, and data were gathered for all the patients who met the inclusion criteria. The foot function index and visual analog scale (VAS) pain scale questionnaires were mailed to the 111 patients. Of the 111 patients, 61 (55.0%) returned their questionnaires and were ultimately included in the present analysis. Of the 61 patients, 44 (72.1%) were female and 17 were (27.9%) male, with an average reported follow-up of 33.3 ± 8.6 (range 16.1 to 46.6) months. The median postoperative VAS score was 0.0 (range 0.0 to 10.0), and the median foot function index score was 3.1 (range 0.0 to 97.1). The patients were subdivided into success and failure groups according to their satisfaction. Of the 61 patients, 51 (83.6%) were satisfied and would recommend the procedure to a friend. The median VAS score in the success group was 0.0 (range 0.0 to 5.0), and the median VAS score in the failure group was 6.0 (range 0.0 to 10.0), a significant difference (p < .001). A significant difference was also seen in the foot function index score between the success (median 2.4, range 0.0 to 25.7) and failure (median 37.4, range 0.0 to 97.1) groups (p < .001). Bipolar radiofrequency microtenotomy appears to be a safe procedure that can provide outcomes equivalent to those with open surgery, with less morbidity, for recalcitrant plantar fasciitis.

Surgery for Patients With Recalcitrant Plantar Fasciitis: Good Results at Short-, Medium-, and Long-term Follow-up

BACKGROUND

Plantar fasciitis is a common cause of foot pain, and although many episodes are self-limiting with short duration, 10% leave chronic symptoms. Recalcitrant cases can be managed surgically, with studies demonstrating good results in the short term but uncertainties over longer term outcomes.

PURPOSE

To assess the outcome following surgical intervention for patients with plantar fasciitis.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Seventy-nine patients were identified from operative diaries undergoing plantar fasciotomy surgery between 1993 and 2009. They were contacted to investigate long-term results using self-reported outcome measures.

RESULTS

Sixty-eight responses were received (86% response rate), with an average of 7 years (range, 1-15 years) of follow-up. Patients reported an average reduction in pain by visual analog scale of 79%, and 84% of patients were happy with the surgical results. Greater success was achieved in patients with shorter duration of symptoms preoperatively. No deterioration in success was seen over time.

CONCLUSION

Plantar fasciotomy surgery for plantar fasciitis remains controversial, with biomechanical arguments against surgery; however, this article reports good success following surgery over a long follow-up period. The results of current operative techniques need to be fully investigated for longer term success, as do the outcomes of newer nonoperative management strategies.

Prospective study of percutaneous radiofrequency nerve ablation for chronic plantar fasciitis

BACKGROUND

Chronic plantar heel pain is one of the most painful foot conditions and is generally associated with plantar fasciitis. This study reports 2-year follow-up results of radiofrequency nerve ablation (RFNA) of the calcaneal branches of the inferior calcaneal nerve in patients with chronic heel pain associated with plantar fasciitis.

METHODS

After receiving approval from the institutional review board, we prospectively evaluated the results of the RFNA of the calcaneal branches of the inferior calcaneal nerve on 35 feet in 29 patients with plantar heel pain between 2008 and 2011. All of the patients who were treated had been complaining of heel pain for more than 6 months and had failed conservative treatment. All of the patients were evaluated (quantitatively) using the average 10-point Visual Analog Scale (VAS) before treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure. We also evaluated 26 feet in 20 patients with American Orthopaedic Foot and Ankle Society scale (AOFAS) scores before the treatment, as well as at their 1-month, 1-year, and 2-year follow-up after the procedure.

RESULTS

The average VAS score of the feet was 9.2 ± 1.9 before treatment, 0.5 ± 1.3 at 1 month after the procedure, 1.5 ± 2.1 at 1-year follow-up, and 1.3 ± 1.8 at 2-year follow-up (P < .001). The average AOFAS scores of the patients were 66.9 ± 8.1 (range, 44-80) before treatment, 95.2 ± 6.1 (range, 77-100) at 1 month after the procedure, 93 ± 7.5 (range, 71-100) at the 1-year follow-up, and 93.3 ± 7.9 (range, 69-100) at the 2-year follow-up. At the 1- and 2-year follow-up, 85.7% of the patients rated their treatment as very successful or successful.

CONCLUSION

These findings suggest that RFNA of the calcaneal branches of the inferior calcaneal nerve was an effective pain treatment option for chronic heel pain associated with plantar fasciitis that did not respond to other conservative treatment options.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A prospective, randomized, double-blinded study with crossover to determine the efficacy of radio-frequency nerve ablation for the treatment of heel pain

BACKGROUND

Previous studies have demonstrated that radio-frequency nerve ablation (RFNA) can be an effective treatment for plantar fasciosis. This study provides additional evidence in support of this treatment, with statistically significant data that demonstrate the success of this technique.

METHODS

In this multicenter, randomized, prospective, double-blinded study with crossover, 17 patients were divided into two groups, with eight initially receiving RFNA treatment and nine initially receiving sham treatment. If no improvement was observed after 4 weeks, a crossover was offered. Results of the treatment were evaluated by the patient and by a blinded physician using a visual analog pain scale to rate first-step pain, average pain, and peak pain in the heel region.

RESULTS

We observed a statistically significant improvement in the symptoms of plantar fasciosis in patients actively treated with RFNA and no significant improvement in the sham-treated group. More important, those treated with sham subsequently demonstrated statistically significant improvement after subsequent RFNA treatment.

CONCLUSIONS

Using a prospective, randomized study with sham treatment and crossover, this study demonstrates the efficacy of RFNA for the treatment of plantar fasciosis.

Subcalcaneal bursitis with plantar fasciitis treated by arthroscopy

We report the successful arthroscopic treatment of a case of subcalcaneal bursitis with plantar fasciitis. To our knowledge, this is the first report on arthroscopic excision of a subcalcaneal bursa. Right heel pain developed in a 50-year-old woman, without any obvious cause. She reported that the heel pain occurred immediately after waking and that the heel ached when she walked. Magnetic resonance imaging showed an extra-articular, homogeneous, high-intensity lesion in the fat pad adjacent to the calcaneal tubercle on T2-weighted sagittal and coronal images and thickening of the plantar fascia on T2-weighted sagittal images. A diagnosis of a recalcitrant subcalcaneal bursitis with plantar fasciitis was made, and surgery was performed. The arthroscope was placed between the calcaneus and the plantar fascia. With the surgeon viewing from the lateral portal and working from the medial portal, the dorsal surface of the degenerative plantar fascia was debrided and the medial half of the plantar fascia was released, followed by debridement of the subcalcaneal bursal cavity through the incised plantar fascia. Full weight bearing and gait were allowed immediately after the operation. At the latest follow-up, the patient had achieved complete resolution of heel pain without a recurrence of the mass, confirmed by magnetic resonance imaging.

Endoscopic approach for plantar fasciopathy: a long-term retrospective study

PURPOSE

The purpose of this study was to report the long term effectiveness of endoscopic plantar fascia release for recalcitrant plantar fasciopathy.

MATERIALS

Twenty-three consecutive patients underwent endoscopically-assisted plantar fascia release for symptomatic plantar fasciopathy unresponsive to nonoperative measures. The clinical diagnosis was supported by imaging (plain radiographs and magnetic resonance imaging [MRI]) and the American Orthopaedic Foot & Ankle Society (AOFAS) score was administered to all patients. All patients underwent endoscopic plantar fascia release. Postoperatively, patients were assessed at clinical examination and the AOFAS score was administered.

RESULTS

Twenty-two (26 feet) of the 23 patients included in our original cohort returned to our clinic at an average final follow-up of 9.6 years. The mean preoperative AOFAS score of 51 (range, 41-63) improved to 89 (range, 41-97) at the last follow-up, with no statistically significant difference between patients with or without calcaneal bone spur (p = 0.43). At the last appointment, physically active patients reported significantly higher AOFAS scores than sedentary patients (p = .008).

CONCLUSIONS

This endoscopic plantar approach could be a viable alternative to more invasive procedures for management of recalcitrant plantar fasciopathy. Future randomised controlled trials are needed.

Open technique is more effective than percutaneous technique for TOPAZ radiofrequency coblation for plantar fasciitis

BACKGROUND

Microtenotomy coblation using a radiofrequency (RF) probe is a minimally invasive procedure for treating chronic tendinopathy. It has been described for conditions including tennis elbow and rotator cuff tendinitis. There have been no long term studies to show its effectiveness in plantar fasciitis.

METHODS

A prospective non-randomised trial was conducted on 48 patients who had failed conservative treatment for plantar fasciitis, between 2007 and 2009. The procedure was performed using the TOPAZ microdebrider device (ArthroCare, Sunnyvale, CA), either via an open or a percutaneous method. Fifty-nine feet were treated and followed up for up to 1 year thereafter. Preoperative, 3, 6 and 12 months post-operative VAS pain, American Orthopaedic Foot-Ankle Society (AOFAS) hindfoot and SF-36 scores, patient expectation and satisfaction scores were analysed.

RESULTS

VAS scores improved significantly in both groups at 1-year follow-up. The open group had a more significant improvement in the VAS score at 1-year follow-up. AOFAS hindfoot scores improve significantly for both groups pre- and post-operatively, but there was no significant difference between both groups at the 1-year mark. SF-36 scores showed equally significant improvement in both groups 1 year post-operatively. Expectation and satisfaction scores were equally high in both arms.

CONCLUSIONS

TOPAZ RF coblation is a good and effective method for the treatment of recalcitrant plantar fasciitis. Clinical results improve with time for up to 1-year post-operatively. The open method seems to have a more significant improvement in pain VAS scores at 1-year postoperatively.

A review of 105 consecutive uniport endoscopic plantar fascial release procedures for the treatment of chronic plantar fasciitis

Plantar fasciitis is a common cause of heel pain in the U.S. Army soldier, resulting in a significant loss of man hours. Given the heavy operations tempo of the U.S. military, successful treatment options need to be considered and used as quickly as possible. Plantar fasciitis can be successfully treated in up to 90% of patients using conservative measures. Operative intervention might need to be considered for those in whom conservative measures have failed. The present report is a review of 105 consecutive uniport endoscopic plantar fascial release procedures performed by the principal investigator during a 9-year period. The following data were collected and analyzed: gender, age, weight, height, body mass index, medical treatment facility, procedure laterality, preoperative pain levels, postoperative pain levels at 3 months, first ambulatory day in the controlled ankle motion boot, return to activity as tolerated, and complications. Three major points were of interest: evidence of improvement in chronic plantar fasciitis when treated with uniport endoscopic procedures; the patient attributes associated with self-reported pain levels 90 days postoperatively; and the patient attributes associated with the average time until patients were able to return to activities as tolerated in a controlled ankle motion boot. It was noted that 44.5% of those with a body mass index of 29.80 kg/m(2) or greater reported a postoperative pain level of 0; and 96.3% of those with a body mass index of 25.53 kg/m(2) or less reported postoperative pain levels of 0. The analyzed data were used to characterize the clinical outcomes of the procedure, identify changes in outcome with surgeon experience, and identify whether certain patient subgroups have better outcomes, allowing surgeons to identify which patient might be the best candidates for an endoscopic release procedure.

Heel pain in the athlete

Context:

Heel pain, a relatively common problem in the athlete, can present a diagnostic and therapeutic dilemma. The purpose of this article is to review treatment techniques for common causes of heel pain in the athlete.

Evidence Acquisition:

Articles in the English literature through August 2008 were selected and reviewed in the context of the management of heel pain in the athlete. Clinical and surgical photographs are presented as an illustration of preferred techniques and pertinent pathologic findings.

Results:

Although nonoperative treatment remains the mainstay for most painful heel pathologies, a number of surgical interventions have shown encouraging results in carefully selected patients.

Conclusions:

The management of heel pain in the athlete requires diagnostic skill, appropriate imaging evaluation, and a careful, initially conservative approach to treatment. Surgical treatment can be successful in carefully selected patients.

Clinical presentation and self-reported patterns of pain and function in patients with plantar heel pain

BACKGROUND

Plantar heel pain is a common disorder of the foot. The purpose of this study was to explore the relationship between duration of symptoms in plantar fasciitis patients and demographic factors, the intensity and location of pain, extent of previous treatment, and self-reported pain and function.

METHODS

The charts of patients presenting with plantar heel pain between June 2008 and October 2010 were reviewed retrospectively and 182 patients with a primary diagnosis of plantar fasciitis were identified. Patients with symptoms less than 6 months were identified as acute and patients with symptoms greater than or equal to 6 months were defined as having chronic symptoms. Comparisons based on duration of symptoms were performed for age, gender, body mass index (BMI), comorbidities, pain location and intensity, and a functional score measured by the Foot and Ankle Ability Measure (FAAM).

RESULTS

The two groups were similar in age, BMI, gender, and comorbidities. Pain severity, as measured by a visual analog scale, was not statistically significant between the two groups (6.6 and 6.2). The acute and chronic groups of patients reported similar levels of function on both the activity of daily living (62 and 65) and sports (47 and 45) subscales of the FAAM. Patients in the chronic group were more likely to have seen more providers and tried more treatment options for this condition.

CONCLUSION

As plantar fasciitis symptoms extend beyond 6 months, patients do not experience increasing pain intensity or functional limitation. No specific risk factors have been identified to indicate a risk of developing chronic symptoms.

Resistant plantar fasciopathy: shock wave versus endoscopic plantar fascial release

PURPOSE

To compare the results of Extracorporeal shock wave (ESWT) with a modified endoscopic plantar fasciotomy technique for the treatment of recalcitrant heel pain.

METHOD

Sixty-five patients suffering from chronic heel pain that failed to respond to standard nonoperative methods were randomized to undergo either high-energy extracorporeal shock wave therapy (group 1), or modified endoscopic plantar fasciotomy (group 2). The primary outcome measure was the reduction of pain in the two groups from base line to month three post intervention at the first few steps in the morning. In addition, patients' functions were assessed using American Orthopedic Foot and Ankle-Hindfoot Scale (AOFAS) at week three, month three, and month 12 post-intervention, and finally, Roles and Maudsley scores were assessed. The primary analysis was intention-to-treat and involved all patients who were randomly assigned.

RESULTS

Both groups achieved improvement from the base line at 3 weeks, 3 months and 12 months post-intervention. The success rate (Roles and Maudsley score excellent and good) in the ESWT group at month 12 was 70.6 %, while in the fasciotomy group, the success rate was 77.4 % (p = 0.19).

CONCLUSION

In patients who had experienced failure of conventional treatment of plantar fasciopathy, both endoscopic plantar fasciotomy and shock wave therapy can be potentially helpful lines of management.

Preferred management of recalcitrant plantar fasciitis among orthopaedic foot and ankle surgeons

BACKGROUND

There are a number of different treatment options available for recalcitrant plantar fasciitis, with limited high-level evidence to guide nonoperative and operative treatment methods. The purpose of this study was to determine the current preferred nonoperative and operative treatment methods for recalcitrant plantar fasciitis by a group of experienced orthopaedic foot and ankle surgeons.

METHODS

A hypothetical patient with recalcitrant plantar fasciitis was developed as the basis for a survey comprised of seven questions. The questions related to the surgeon's preferred treatment after 4~months of failed nonoperative management and then after 10 months of recalcitrant symptoms. The survey was sent to committee members of the American Orthopaedic Foot and Ankle Society (AOFAS).

RESULTS

Eighty-four orthopaedic surgeons completed the survey (84 out of 116; response rate=72%). At the 4-month visit, when questioned regarding their most preferred next step in management, 37 (44%) respondents favored initiation of plantar fascia-specific stretching (PFSS), 20 (24%) supervised physical therapy, 17 (20%) night splinting, five (6%) steroid injection, three (4%) custom orthotics, and two (2%) cast or boot immobilization. With ongoing symptoms at 10~months, 62 (74%) respondents chose surgery or ECSWT (extracorporeal shock wave therapy) as their next step in management. Some form of surgery (alone or in combination) was chosen by 46 (55%) respondents. The most popular operative interventions were gastrocnemius recession (alone or in combination with another procedure) and open partial plantar fascia release with nerve decompression.

CONCLUSIONS

For shorter duration symptoms, tissue-specific stretching and conditioning methods were favored over anti-inflammatory or structural support modalities which is consistent with available high-level evidence studies. Heterogeneity of operative preferences for chronic symptoms highlighted the need for further high-quality studies.

Functional outcome of endoscopic plantar fasciotomy

BACKGROUND

The majority of cases of plantar fasciitis can be treated nonoperatively; however, a small number of patients remain refractory to nonoperative treatment and operative intervention is indicated. Historically, open treatment has been recommended, but more recently endoscopic plantar fasciotomy (EPF) has produced promising results.

METHODS

Forty-eight patients (56 feet) were identified who underwent endoscopic plantar fasciotomy. Forty-one patients (49 feet) were available for followup. There were 15 men and 26 women, with an average age of 53.8 (range, 42 to 68) years. The mean followup time was 49.5 (range, 6 to 142) months. An AOFAS Hind foot Scale was used for analysis. The influence of gender, duration of symptoms, severity of symptoms, and bilateral verses unilateral release were examined.

RESULTS

Pain resolved completely in 37 feet, decreased in 11 feet, and increased in one foot. The mean postoperative AOFAS Hindfoot score improved 39 points (54 to 93, p < 0.001). Patients with severe symptoms achieved higher mean improvement than the moderate symptom group (p < 0.0001). Patients with symptoms greater than 24~months trended towards lower mean improvement and lower post operative AOFAS Hindfoot scores. Both gender and laterality did not significantly influence outcome. There was one superficial infection, one third and fourth metatarsal stress fracture in the same patient, and transient lateral hindfoot pain in five patients.

CONCLUSION

EPF was an effective operation with reproducible results, low complication rate, and little risk of iatrogenic nerve injury with proper technique.

Endoscopic surgery for plantar fasciitis: application of a deep-fascial approach

PURPOSE

The purpose of this study was to determine the clinical results of deep-fascial medial and lateral portals in performing endoscopic surgery for plantar fasciitis.

METHODS

In 10 feet in 8 patients who were treated conservatively for more than 6 months with failure to relieve their symptoms, endoscopic surgery was performed. After the patient was placed in the supine position, a medial portal was made 5 mm deep to the plantar fascia and 10 mm anterior to its origin on the calcaneus under fluoroscopy. The lateral portal was established by placing a blunt trocar deep and perpendicular to the plantar fascia. A 2.7-mm-diameter arthroscope was passed through the deep-lateral portal, and the operative devices were inserted through the deep-medial portal. A motorized shaver was used for making a working space to excise the fat tissue along with a portion of the flexor digitorum brevis muscle. If a heel spur existed, it was resected to establish a clear view of the plantar fascia by use of an arthroscopic burr. After exposure of the plantar fascia, its medial half was removed with electric devices such as an Arthro-Knife (ConMed Linvatec, Largo, FL).

RESULTS

The mean score on the American Orthopedics Foot and Ankle Society Ankle Hindfoot Scale was 64.2 ± 6.3 points before surgery and 92.6 ± 7.1 points at 2 years after surgery (P < .0001). The mean duration to full weight bearing after surgery was 13.9 ± 8.4 days. All patients returned to full athletic activities by a mean of 10.7 ± 2.6 weeks.

CONCLUSIONS

Endoscopic surgery for plantar fasciitis through a deep-fascial approach allows a wide field of vision and working space, permitting reliable resection of the plantar fascia and heel spur.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Minimal invasive percutaneous bipolar radiofrequency for plantar fasciotomy: a retrospective study

The purpose of this study was to present the results of a relatively new, minimally invasive surgical technique for the treatment of chronic plantar fasciitis in 14 patients, 2 of whom underwent the treatment bilaterally one foot at time on separate occasions. This was a retrospective, multicenter, nonrandomized study. All of the patients had failed conservative therapy and had symptoms for at least 6 months. The mean follow-up duration was 15.25 months (range, 6-33 months). The postoperative mean American Orthopaedic Foot & Ankle Society hindfoot score was 82.06 (range, 56-100). None of the patients developed complex regional pain syndrome, and all but 2 (14.29% of patients, 12.5% of feet) of the patients were able to return to regular shoe gear by 2-4 weeks postoperative, and only 1 (7.14% of patients, 6.25% of feet) patient was considered a treatment failure. Based on our experience with minimally invasive percutaneous bipolar radiofrequency plantar fasciotomy, we believe the technique to be a relatively easy intervention that is effective and requires less healing time in comparison with traditional open surgical procedures.

Painful prominences of the heel

Heel pain is a common malady, with reported prevalence ranging from 4% to 21%. Referral to foot and ankle specialists for heel pain is also common, but patient awareness of the cause of heel pain may be limited. Many misconceptions about how heel exostoses relate to heel pain exist in the medical community and the general patient population, with many patients referred for or presenting with the simple complaint ''I have a heel spur.'' This article reviews the common exostoses of the heel, including plantar, lateral, and posterior spurs, with specific attention to the cause and treatments.

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Calcaneal osteotomy for the treatment of plantar fasciitis

BACKGROUND

Plantar fascia release is the main procedure for plantar fasciitis which does not respond to conservative treatment. However, this procedure is sometimes accompanied by lateral column pain due to loss of the longitudinal arch height after surgery. To avoid this complication, we performed calcaneal osteotomy. The aim of this study was to clarify the efficacy of this procedure.

METHODS

A retrospective clinical and radiographic study was conducted for 11 patients (11 feet) who had undergone calcaneal osteotomy for the treatment of intractable plantar fasciitis. Three of the patients were males and eight were females, with an average age of 46 (range 24-70) years. Calcaneal osteotomy was performed from 1 cm anterior of the calcaneal attachment of the plantar fascia to 1 cm anterior of the calcaneal attachment of the Achilles tendon, and the proximal fragment was displaced approximately 5 mm in the plantar direction. The patients with a pronated foot before surgery underwent an additional approximately 5 mm medial displacement of the proximal fragment.

RESULT

Significant improvement was seen between the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score before surgery and at final follow-up (P < 0.0001). With regard to the radiographic parameters which evaluated longitudinal arch height, significant improvement was seen between the talar pitch (P = 0.0002), calcaneal plantar angle (P < 0.0001) and lateral talocalcaneal angle (P = 0.0251) before and at 2 years after surgery. One patient with severe pes planus before surgery showed poor clinical and radiographic results.

CONCLUSIONS

This procedure can bring about good results in patients who do not have severe pes planus.

A retrospective analysis of 22 patients treated with percutaneous radiofrequency nerve ablation for prolonged moderate to severe heel pain associated with plantar fasciitis

A retrospective study involving 22 patients (31 feet) with a history of prolonged moderate to severe heel pain associated with plantar fasciitis were examined to determine if ablation of the sensory branch of the medial calcaneal nerve would result in symptomatic relief. Participants in this study were given subjective questionnaires and visual analog scales in order to rate their symptoms before and after nerve ablation using radiofrequency energy. The results showed that the mean preintervention visual analog pain score was 8.12 +/- 1.61 (with 10 being the worst pain the patient could imagine), and this dropped to 3.26 +/- 1.97 after 1 week and 1.46 +/- 1.76 after 1 month, 1.96 +/- 1.98 at 3 months, and 2.07 +/- 2.06 at 6 months, and the improvement was statistically significant (P < .001) at each stage of follow-up. Furthermore, patients followed for up to 1 year showed no significant worsening of symptoms. Adverse events were limited to hematoma at the site of entry of the radiofrequency cannula. These findings support the conclusion that radiofrequency nerve ablation be considered an alternative to repetitive corticosteroid injections or open surgical intervention for the treatment of recalcitrant plantar heel pain.

LEVEL OF CLINICAL EVIDENCE

4.