Endoscopic Plantar Fascia Release

doi:10.1016/S0749-8063(00)90053-7

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 16, Issue 3, April 2000, Pages 290-298

https://doi.org/10.1016/S0749-8063(00)90053-7 Get rights and content

Abstract

Summary: An anatomic exploration showed that reliable landmarks could allow a safe division of the plantar fascia. The reference line was the posterior border of the medial malleolus, 1 cm from the plantar skin. A clinical study on 53 patients (65 feet) showed that, at follow-up of over 2 years, the procedure effectively relieved heel pain in 89% of patients, morning stiffness in 92%, and allowed 71% to return to unrestricted sports activity. There were 2 complications with lateral heel pain. Patients must be properly selected, and must have had the full range of conservative treatment. Symptoms should have been intractable for approximately 1 year. In this group, good results can be expected with minimum short-term morbidity.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 3 (March), 2000: pp 290–298

Section snippets

ANATOMY

We dissected 6 anatomic specimens to clearly define the landmarks for transection of the plantar fascia and to observe the neurovascular structures for safety. The point of division of the plantar fascia is approximately 1 cm distal from its attachment at the medial tuberosity of the calcaneus. The plantar fascia is divided from superficial to deep as described by Barrett and Day.3, 4

We found that a reliable portal could be established medially using the posterior bony ridge of the medial

SURGICAL TECHNIQUE

We used a technique similar to that described by Barrett and Day.3, 4 Some patients were given a general anesthetic and a tourniquet was used. In others we used a foot block and elastic escmark bandage around the ankle for hemostasis. All procedures were performed in an outpatient setting.

The medial portal was established along a line referencing the posterior border of the medial malleolus. The extension of this line to the sole of the foot marks the site of the portal (Figure 3, Figure 4,

RESULTS

Fifty-five consecutive patients were studied; there was complete information on 53. Twelve cases were bilateral, so there were 65 feet in all. All met the preoperative selection criteria outlined above. They were assessed preoperatively and postoperatively based on the criteria of pain at rest, morning stiffness, pain with activities of daily living, pain with sports, and resumption of sporting activities. The results were analyzed statistically using the null hypothesis that there would be no

DISCUSSION

Plantar fasciitis was known as “policeman's heel.” The British origin of the term described policemen wearing ill-fitting shoes and chasing criminals on foot. Although the term is not used commonly today, it describes well the forces that predispose healthy individuals to plantar fasciitis. These people participate in weight-bearing activities with repetitive impact such as joggers, tennis players, and ballet dancers.⁷ Individuals who wear improper shoes, run on their toes, on soft terrain, or

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Endoscopic plantar fasciotomy; a multi surgeon prospective analysis of 652 cases
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Endoscopic plantar fasciotomy versus traditional heel spur surgery: A prospective study
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Cited by (34)

Effects and risks of performing a single incision endoscopic plantar fasciotomy — An anatomical study
2022, Foot and Ankle Surgery
Citation Excerpt :
In none of the specimens of both groups any of the major vascular (MPA, LPA) or nervous structures (MPN, LPN, BN) has been damaged. These results as well as the anatomical quantifications are in line with previous studies evaluating dual incision fasciotomy [11,13]. The abductor hallucis muscle was damaged superficially in four specimens (10%).
Chronic plantar fasciitis with insufficient improvement after conservative treatment can be addressed by surgery. Endoscopic plantar fasciotomy using a single incision technique is an innovative treatment strategy. The aim of this study was to evaluate the effects and potential risks of damaging anatomical structures when performing this technique.
40 fresh-frozen foot specimens underwent single incision endoscopic plantar fasciotomy. Operations of group A (n = 20) were done by an experienced surgeon, operations of group B (n = 20) were done by unexperienced residents.
In both groups, all major vessels or nerves remained undamaged. Sufficient transection (>90%) was found in 16 of 20 specimens (group A) and 10 of 20 specimens (group B) (p = 0.047).
Our results show that single incision endoscopic plantar fasciotomy can be safely performed even by unexperienced surgeons. In contrast to that, complete transection of the medial fascicle is dependent on the surgeon’s experience.
Endoscopic plantar fasciotomy for plantar fasciitis: A systematic review and network meta-analysis of the English literature
2019, Foot
Citation Excerpt :
Most of the studies included in our systematic review performed a partial endoscopic plantar fasciotomy. Only Ogilvie-Harris [23] performed a complete plantar fascia release. Complete release biomechanically risks causing a loss of the windlass effect in the foot, subsequent decrease in arch height and increased strains on the plantar ligaments and increased stress and pain in the midfoot [11,29].
Currently, there is limited evidence on outcomes for endoscopic plantar fasciotomy.
An evidence-based literature review for outcomes of endoscopic plantar fasciotomy for the treatment of plantar fasciitis is provided.
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.
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.
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.
Percutaneous Plantar Fascia Release With Needle: Anatomic Evaluation with Cadaveric Specimens
2019, Journal of Foot and Ankle Surgery
Percutaneous plantar fascia release with needle is a novel procedure for the treatment of plantar fasciitis. The objective of this cadaveric study is to perform an anatomic evaluation of the percutaneous plantar fascia release method using a conventional hypodermic needle. In this study, we used 14 fresh-frozen cadaveric trans-tibial amputation specimens. Percutaneous plantar fasciotomy with a conventional hypodermic needle was performed. After a proper dissection, the width of the plantar fascia, the thickness of the medial border, and the width of the cut segment were measured and recorded. Any muscle damage on the flexor digitorum brevis and damaged area depth were recorded. Any damage on the lateral plantar nerve and the first branch of the lateral plantar nerve, also known as Baxter's nerve, and their distance to fasciotomy were also recorded. Mean width (± standard deviation) of the plantar fascia was measured as 20.34 ± 4.25 mm. The mean thickness of the medial border of the plantar fascia was 3.04 ± 0.54 mm. Partial fasciotomy was performed in all cadavers with 49.47% ± 7.25% relative width of the plantar fascia. No lateral plantar nerve, or its first branch Baxter's nerve, was damaged, and the mean distance from the deepest point of the fasciotomy up to the Baxter's nerve was 8.62 ± 2.62 mm. This cadaveric study demonstrated that partial plantar fasciotomy can be achieved via percutaneous plantar fascia release with a conventional hypodermic needle without any nerve damage.
Plantar fasciitis treated with endoscopic partial plantar fasciotomy—One-year clinical and ultrasonographic follow-up
2019, Foot
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.
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.
Median Foot Function Index values decreased from 119 pre-surgery to 69 and 12 (p = 0.004), at 3 months and 1 year post-operatively respectively. Median VAS-score for first step pain was likewise reduced from median 71 mm to 29 mm and 7 mm (p = 0.004), respectively. Median fascial thickness at the medial insertion was 6.0 mm (range 4.6–6.8 mm) 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.
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.
Ultrasound-Assisted Endoscopic Partial Plantar Fascia Release
2013, Arthroscopy Techniques
Citation Excerpt :
We do not allow the patients to perform high-impact activities such as running for at least 2 months, and athletes participate in a sports-specific training program before returning to sports. Complication rates after EPFR have been reported to range from 3% to 10%.1,16,17 Although neurologic complication rates are not very high, there is the risk of nerve damage by introducing the arthroscopic cannula deep to the plantar fascia and it has been reported previously by various authors.16,18,19
Various surgical treatment procedures for plantar fasciitis, such as open surgery, percutaneous release, and endoscopic surgery, exist. Skin trouble, nerve disturbance, infection, and persistent pain associated with prolonged recovery time are complications of open surgery. Endoscopic partial plantar fascia release offers the surgeon clear visualization of the anatomy at the surgical site. However, the primary medial portal and portal tract used for this technique have been shown to be in close proximity to the posterior tibial nerves and their branches, and there is always the risk of nerve damage by introducing the endoscope deep to the plantar fascia. By performing endoscopic partial plantar fascia release under ultrasound assistance, we could dynamically visualize the direction of the endoscope and instrument introduction, thus preventing nerve damage from inadvertent insertion deep to the fascia. Full-thickness release of the plantar fascia at the ideal position could also be confirmed under ultrasound imaging. We discuss the technique for this new procedure.
Subcalcaneal bursitis with plantar fasciitis treated by arthroscopy
2013, Arthroscopy Techniques
Citation Excerpt :
Recently, an arthroscopic technique for plantar fascia release has gained popularity and has been shown to be effective in cases in which there is no need for Baxter nerve decompression.11-15 The arthroscopic approach for the plantar fascia includes either a superficial fascial dry technique (without arthroscopic fluid lavage), by use of a slotted or transparent cannula similar to the arthroscopic carpal tunnel release (the arthroscope is located between the skin and the fascia),11-13 or a deep fascial technique with arthroscopic fluid lavage (the arthroscope is located deep in the fascia).14,15 Komatsu et al.15 reported that the deep fascial approach for plantar fasciitis allows a wide visual field and working space.
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.

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^*: Address correspondence and reprint requests to D. J. Ogilvie-Harris, F.R.C.S.C., Toronto Western Hospital, Edith Cavell Wing 1-032, 399 Bathurst St, Toronto, Ontario M5T 2S8, Canada.

^**: 0749-8063/00/1603-2079$3.00/0

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Original ArticleEndoscopic Plantar Fascia Release*,**

Abstract

Section snippets

ANATOMY

SURGICAL TECHNIQUE

RESULTS

DISCUSSION

J Foot Ankle Surg

J Foot Ankle Surg

Clin Podiatr Med Surg

Plantar fasciitis, etiology, surgical results and review of the literature

Clin Orthop

Conservative treatment of plantar heel pain: Long-term follow-up

Foot Ankle Int

Endoscopic plantar fasciotomy: Two portal endoscopic surgical techniques—Clinical results of 65 procedures

J Foot Ankle Surg

Endoscopic plantar fasciotomy versus traditional heel spur surgery: A prospective study

J Foot Ankle Surg

Subcalcaneal heel pain

Orthop Clin North Am

Plantar fasciitis and achilles tendinitis among 150 cases of seronegative spondarthritis

Rheumatol Rehabil

Spondyloparthropathies

BMJ

Plantar fasciitis. Mechanics and pathomechanics of treatment

Clin Sports Med

Original Article
Endoscopic Plantar Fascia Release*,**