Plantar fasciitis is a common condition causing heel pain, resulting from damage and inflammation of the plantar fascia, the tissue spanning the bottom of the foot from the heel bone to the toes. This tissue acts as a shock absorber and supports the arch. Surgery is considered a last resort for chronic cases, typically reserved for patients with persistent, limiting pain for at least six to twelve months despite rigorous non-surgical treatments. These conservative measures usually include physical therapy, stretching, night splints, orthotic devices, and anti-inflammatory medications. The goal of the surgical procedure, known as a plantar fasciotomy, is to relieve the excessive tension within the fascia that causes chronic pain.
Pre-Surgical Assessment and Planning
Before any operation, an evaluation is conducted to confirm the diagnosis and ensure the patient is a suitable candidate for surgery. Diagnostic imaging, such as X-rays, is used to identify any associated heel spurs or rule out other potential causes of heel pain. Magnetic Resonance Imaging (MRI) or ultrasound may also be employed to assess the thickness and integrity of the plantar fascia.
Patient selection requires documentation of failed conservative treatment and significant limitation in daily activities due to pain. Logistical planning involves selecting the appropriate anesthesia, which can range from general anesthesia to a regional nerve block or local sedation. The patient is positioned on the operating table to allow the surgeon optimal access to the heel area.
Surgical Techniques for Fascia Release
The primary objective of plantar fasciitis surgery is a controlled, partial release of the fascia to decrease tension, not a complete severance of the ligament. Two main techniques are used: open fasciotomy and endoscopic fasciotomy. Both methods aim to lengthen the fascia, but they differ in the size of the incision and the tools utilized.
Open Fasciotomy
The traditional approach is the Open Fasciotomy, which involves a small incision, usually along the bottom or side of the foot near the heel. This incision allows the surgeon direct visual access to the plantar fascia, enabling them to precisely cut a portion of the tightest segment. The larger incision may require a longer period of initial non-weight bearing compared to the minimally invasive technique.
Endoscopic Fasciotomy
Endoscopic Fasciotomy is a less invasive option that utilizes specialized equipment. This method requires one or two very small puncture incisions, often less than a centimeter long, near the ankle bone. A miniature camera, or endoscope, is inserted through one incision to provide a magnified view of the fascia on a monitor. The surgeon uses a small knife inserted through the second puncture to perform the partial release. This technique is associated with less tissue trauma and a potentially quicker initial recovery time.
In some cases, the surgeon may perform related procedures concurrently if they are contributing to the patient’s pain. This includes the removal of a bony prominence, or heel spur, from the calcaneus bone, if the spur is determined to be the cause of irritation. Another potential addition is a proximal medial gastrocnemius release, a procedure to lengthen the calf muscle, which indirectly reduces tension on the plantar fascia.
Immediate Post-Procedure Care
Immediately following the procedure, the foot is bandaged and often placed in a splint or walking boot to protect the surgical site. Pain management begins immediately, often utilizing a long-acting nerve block administered during surgery, which numbs the area for several hours. Oral pain medications are prescribed to manage discomfort once the nerve block wears off.
Patients are monitored in the recovery room for vital signs and swelling control. Swelling control is achieved primarily through elevation of the foot above heart level, a practice encouraged for the first few days post-surgery. Instructions regarding weight-bearing are specific to the individual case and the technique used, but patients are typically advised to use crutches and limit weight on the heel for the first 24 to 48 hours.
Long-Term Recovery and Outcomes
The long-term recovery process is gradual and relies on a structured rehabilitation program. Physical therapy typically starts a few weeks after the operation to restore flexibility and strength to the foot and ankle. The initial focus of therapy is gentle range-of-motion exercises, progressing to strengthening and stretching of the calf and foot muscles.
Patients usually transition from a protective boot to a supportive shoe within two to three weeks for endoscopic procedures and slightly longer for open surgery. A full return to higher-impact activities, such as running or sports, generally takes three to six months, as the body needs time to adapt to the altered mechanics of the foot. The procedure has a high rate of effectiveness, with many patients reporting long-term relief from chronic pain.
While success rates are generally positive, potential long-term complications can occur, though they are uncommon. These include nerve irritation or entrapment due to scar tissue formation near the incision site. Because the fascia is partially released, there is also a slight risk of a change in foot biomechanics, such as a flattening of the arch or secondary pain in other joints like the knee or hip.