Podcast

Plantar Fasciitis Surgery
October 3, 2013

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Plantar fasciotomy. This is the cutting of the plantar fascia. This can be done either through an open incision in which the plantar fascia is exposed during the cutting process or endoscopically, using small fiberoptic instruments. The effect is the same. It is effective. Most clinical studies cite an 80-95% success rate. His treatment has never set well with me. For all the reasons that I have listed above, the plantar fascia is a very important structure and cutting it can have dire consequences. And when plantar fasciotomies go wrong, they can go very wrong. Some of the most unhappy, painful patient’s that I have seen have been people with failed plantar fasciotomies. The loss of this guidewire to the arch can lead to pain in the joints along the outside of the foot, stress fractures, and I believe, eventually, arthritis within the middle portion of the foot.

There have been other methods that have come and gone. Over the last 15 years, I have seen many of them. Orthotripsy or extracorporeal shock wave treatment is the application of repeated high energy shockwave is generated in a water bladder using a spark plug and concentrated onto the heel. This was approved by the FDA in 2000. There was a lot of initial enthusiasm for it. The initial studies showed a 65% success rate with one treatment and an 85% success rate with 2 treatments. However, a later study published in the Journal of the American Medical Association (JAMA) seemed to place the send out. Then, one of the companies most active in manufacturing the machines used for this treatment became embroiled in a false advertising lawsuit. Even though many articles seemed to continue to support this form of treatment, it has become very difficult to get it approved by insurance and to get the machines to do the treatment.

Platelet rich plasma is perhaps the one that is most up in the air. During this procedure, blood was taken from the body and spun in a centrifuge. This separates the blood into components. There is the watery plasma which contains soluble proteins and electrolytes. There is the red blood cells which settle to the bottom. Finally, there is the in between layer, which contains platelets, full of growth factors. The problem is that the type and concentration of these growth factors varies from person to person and from technique to technique. Not all of these growth factors are likely to be helpful. So a “soup” of growth factors is used, but it is impossible to tell whether it is the best combination. Some encouraging clinical studies have been published, but a number of them have been discouraging.

Botulism toxin is made by bacteria. When it is injected in small doses, it has been used to paralyze muscles in the face, to give a more youthful, wrinkle free appearance. Injection of doses of this protein have been shown to give relief of the plantar fasciitis pain. It is unclear whether this is because it has paralyzed key muscles or because it has some direct pain relieving effect. The dosages that are used can be quite expensive ($2000 or more)

Coblation is the burning of small areas of tissue using a radiofrequency probe that has a lower temperature than standard cautery techniques in the operating room. This is passed through the damaged tissue several times. Some good results have been published, but despite the fact that the technique has been around for over 10 years it has not met with widespread acceptance. My own experience with this technique has been somewhat unpredictable.

The FAST procedure has been recently introduced. FAST stands for “focused aspiration of scar tissue”, but I’m sure that this abbreviation is used to imply that the technique has a quick recovery. It uses an ultrasound probe to liquefy the damaged tissue within the plantar fascia. Certainly the manufacturer’s and doctor’s in vault in its development have been enthusiastic about its results. Personally, I am still waiting for published results of this procedure.

The problem with all of these procedures is that they focus on the scar tissue within the plantar fascia and not the underlying problem, the weakness in the arch muscles. To some extent, without addressing the underlying problem, the procedure may be doomed to fail. In practice, these procedures work a surprisingly large percent of the time. However, often their hype does not live up to the results.

In conclusion, the plantar fascia is a key structure in the foot. The foot in turn is an amazing and delicate mechanism. Plantar fasciitis itself is a sign of a weak foot, a condition that is, in place given our shoewear choices, Western lifestyle with its obesity, diabetes, and other medical problems, and increased lifespan.

Current surgical management is not adequate, but in the worst cases may be all that we have. Fortunately, in practice, it seems to be largely successful. Unfortunately, they’re too many situations in which it does not give adequate pain control or leads to complications that are worse than the initial problem. Hopefully, new treatments are on the horizon which will give better results and fewer complications.