Plantar fasciitis is a common condition affecting the ligament (plantar fascia) that supports arch of the foot. This ligament attaches to the bottom of the heel and connects to the ball of the foot. When strained, the ligaments attachment to the heel bone becomes inflamed – resulting in the painful condition called “Plantar Fasciitis”.
Most patients complain of pain in the heel, directly on the bottom of the foot. Less commonly, the arch may also be painful. It may feel like a deep pain, and/or a burning or tearing of the heel. The pain may be dull and mild or severe and sharp. In some cases, patients may not be able to put weight on the heel at all. Often patient may experience pain after periods of inactivity, such as with the first few steps out of bed after sleeping.
Though the pain may appear suddenly, the condition usually develops over a long period of time due to excessive stress on the arch. Contributing factors include flat feet, overweight, a tight calf muscle and excessive walking and standing. Rarely does the condition occur from a single traumatic event.
Bone spurs of the heel are commonly identified on a xray. The spur develops from progressive strain on the plantar fascia at the attachment onto the heel bone – resulting in a heel spur. Heel spurs also occur in people without heel pain, and may be normal findings. While it may feel like the pain is due to walking on the heel spur, it does not necessarily indicate that the plantar fasciitis is more advanced.
The symptoms of plantar fasciitis usually resolve with non-surgical treatments. A combination of treatments is necessary. It may take 2-12 months to be pain free.
Plantar Fasciitis Surgery
Plantar fasciitis can be treated with surgery when non-operative measures do not resolve the symptoms. Most surgeons require that patients fail at least 9 months of conservative treatments (such as injections, physical therapy, arch supports, etc) before surgery. There are two aspects of plantar fasciitis syndrome that are important when considering plantar fasciitis surgery:
1) the “tight” plantar fascia ligament, and
2) the presence of a heel (bone) spur.
Dr. Blitz evaluates both of these components, in conjunction with your symptoms to choose the best method for your surgical plan.
How Is Plantar Fasciitis Surgically Treated?
The basis for all plantar fasciitis surgery involves a surgical lengthening of the plantar fascia ligament. The plantar fascia ligament can either be transected (cut) or cut with a section removed. It is important to note that only part of the ligament is cut/sectioned – complete sectioning can destabilize the foot.
The secondary component is whether or not to remove the bone spur, if present. The bone spur is often a secondary manifestation of the tight ligament, and usually not directly causing the pain you may experiencing in the heel. Therefore removing the bone spur depends on the size of the spur, location of the spur, direction the spur points (forward or down), presence of a fracture, and/or your symptoms.
The three main approaches to plantar fasciitis surgery, they are listed below:
Open Plantar Fascia Release (and heel spur removal). This technique involves a surgical incision that allows direct access to the ligament as well as the heel spur. The incision can be on the inside of the foot, or on the the bottom of the foot.
Plantar (or Bottom) Approach: The benefit of the incision on the bottom on the foot (called the plantar approach) allows direct visualization of the ligament and the bone spur. Dr. Blitz finds this plantar approach particularly useful when the plantar fascia ligament is thickened and diseased from chronic inflammation (a term called plantar fasciosis), and a section needs to be removed. Additionally, this approach allows for easy access to the bone spur on the bottom of the heel, allowing for direct visualization and removal. A variation of this approach is called the In-step Plantar fascia release that focuses more on the release of the plantar fascia ligament, rather than the bone spur removal. Open Plantar approaches often require a period of non-weightbearing to allow for the skin to heal as the incision is on the bottom of the foot.
Medial (or Side) Approach: This is also an open approach to plantar fascia release, but because the point of entry is located on the inside of the foot, there is poor visualization of the plantar fascia ligament and any bone spurs. Here the surgeon releases the ligament by feeling the structure and cutting it “blindly” or without direct visualization. Additionally, bone spurs are removed in a similar fashion using. The side approach may allow weight to be placed quicker than the bottom approach, but is determined by your surgeon.
Minimal Incision Plantar Fascia Release.This technique generally called for several small cuts into various areas on the arch of the foot, releasing the plantar ligament. Again, this technique focuses on the ligament release. Typically these cuts are made on the bottom of the foot but surgeons may approach the ligament from the side.
Endoscopic Plantar Fascia Release.An endoscopic release refers to using special instruments and cameras that allow for small incisions (placed on the inside and sometimes the outside) of the foot while releasing the ligament under direct visualization. Bone spurs can’t generally be removed with endoscopic procedures. A great advantage of this technique is that the incision is small and kept off the bottom of the foot, so surgeons tend to mobilize patients quickly. A disadvantage is that bone spurs can’t be removed in with this endoscopic technique.
Is It Necessary To Remove The Heel Spurs?
Not all patients who have plantar fasciitis have heel spurs. Plantar fasciitis, is also known as heel spur syndrome, because they tend to occur together. It is generally thought that the heel spurs develop over time due to the plantar fascia ligament pulling on the heel bone, and this micro-trauma (and inflammation) eventually encourages the bone to grow focally and develop a heel spur. In some people, genetic conditions may simply form the heel spurs, such as certain arthritic conditions (ankylosis spondylitis).
Some heel spurs can be small whereas some can be extremely large. Size of the heel spurs don’t always correlate with pain. It is possible to even fracture heel spurs. Patients typically think the heel spur is what is pushing on the bottom of the foot, and this is what causes pain. Generally, heel spurs point forward and not down. Theoretically a downward pointing bone spur would be a pressure spot, making walking it seem like one were stepping on a nail.
What Anesthesia Is Needed For Plantar Fascia Surgery
Heel spur or plantar fascia surgery is performed as outpatient surgery – this allows you to go home the same day after your procedure. Surgery may be performed in a hospital or an ambulatory surgery center. Some doctors have surgical suites in their offices.
Depending on the extent of the plantar fascia surgery, it can be performed under a local, regional, spinal or general anesthetic. Local and regional blocks with monitored anesthesia care (also known as twilight) are most commonly performed. The foot will be numbed with an anesthetic while an anesthesiologist provides sedation.
Is Hardware Implanted Into The Foot With Heel Spur or Plantar Fasciitis Surgery?
No. The use of surgical hardware for plantar fascia release surgery NOT necessary. It is a soft tissue procedure, and no retained implants or hardware is necessary.
Walking After Plantar Fasciitis Surgery
Walking after plantar fasciitis surgery is dependent on the method (procedure) surgeons choose to correct the heel pain. Some patients can return to walking quickly after surgery whereas other may require casts and crutches. A period of non-weightbearing may be needs for upto 6 weeks in some cases, but again depends on the clinical scenario.
What Are The Risks Of Plantar Fasciitis Surgery
There are general risks associated with and surgery (including plantar fascia surgery) and the use of anesthesia. Complications may occur and are not necessarily your fault, or the fault of your surgeon. Nonetheless, you should understand the risks.
Heel surgery complications include, but are not limited to: infection, pain (temporary or permanent), swelling, hematoma, bleeding, blood clot, poor wound healing, incision breakdown, poor bone healing, nerve injury (temporary or permanent), disability, recurrence, compartment syndrome, development of hammer/claw toes, flail toe, metatarsalgia, unsightly scar, stiffness, shortness of toe, weakness in foot, loss of toe to purchase ground, need for revisional surgery, and/or catastrophic loss.
Why Choose Dr. Blitz As Your Plantar Fasciitis Surgeon?
• Overall Experience: Dr. Blitz has over 13 years of major experience in the field. He is considered an international expert in foot surgery.
• Board Certification: Dr. Blitz is Board Certified in Foot Surgery and Reconstructive Foot Surgery by the American Board of Podiatric Medicine (ABPS).
• Peer-reviewed and General Publications: Over that past decade Dr. Blitz has published dozens articles , case reports, and letters in scientific journals on a variety of topics. Dr. Blitz has published in the Journal of Foot & Ankle Surgery, Archives of Plastic Surgery, Clinics in Podiatric Medicine & Surgery, Podiatry Today, Huffington Post and the Mount Sinai Journal of Medicine.
• Lecturer: Dr. Blitz has a solid history of lecturing on foot surgery.
• Innovator: Dr. Blitz is an innovator for bunion surgery as he has holds a provisional patent of a commercially available medical implant (www.contourslapidus.com) that is used by surgeons throughout the country.
• Internet Research: A simple method to learn about your surgeons professional activates outside of his/her website.
• Patient Feedback: Please visit Dr. Blitz’s Patient Comments page, or his Facebook page.
• In The News: Dr. Blitz has been on various media outlets as an expert in foot surgery.