Thinking about Plantar Fascia Surgery for Heel Pain

Thinking about Plantar Fascia Surgery for Heel Pain

Plantar fasciitis is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, which runs across the bottom of your foot and connects your heel bone to your toes.

Plantar fasciitis commonly causes stabbing pain that usually occurs with your very first steps in the morning. Once your foot limbers up, the pain of plantar fasciitis normally decreases, but it may return after long periods of standing or after getting up from a seated position.

Plantar fasciitis is particularly common in runners. In addition, people who are overweight and those who wear shoes with inadequate support are at risk of plantar fasciitis.

While heel spurs are frequently found it is unclear if they have a role in causing the disease. Microscopic analysis shows that plantar fasciitis is a disorder of the insertion site of the ligament on the bone (enthesopathy) characterized by micro tears, breakdown of collagen, and scarring. As inflammation plays a lesser role many feel the condition should be renamed plantar fasciosis. The diagnosis is typically based on signs and symptoms with diagnostic ultrasound findings sometimes used to help.

Most cases can be treated conservatively with accommodative footwear (shoe inserts), regular calf and ankle muscle stretching, and physical therapy exercises directed toward strengthening other weak muscles in the kinetic chain (knee and hip joint movers). Sometimes therapeutic ultrasound or “shock wave” therapy can help though the data on the effectiveness of these modalities is mixed. Some studies have demonstrated the botulinum toxin (Botox) injections into the thickened abnormal tissue band can be helpful. Steroid injections in the fascia have long been used to treat this condition though recent science has called this practice into question.

Surgical treatment, called plantar fasciotomy, is often considered after conservative treatment has failed to resolve the issue after six months and is viewed as a last resort. Possible complications of plantar fasciotomy include nerve injury, instability of the medial longitudinal arch of the foot, fracture of the calcaneus (heel bone), prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain.

This study looked at the long term effectiveness plantar fasciotomy in patients in the United Kingdom. They studied 24 patients, ages 24-61, more women than men, who had tried conservative treatment for an average of 3 years prior to surgery, and followed them for an average of 6 1/2 years after surgery.  Their conclusions were that receiving steroid injections prior to surgery had a very negative effect on surgical outcome, and even if the patients did not receive a steroid injection, given the prolonged and difficult recovery, plantar fasciotomy was determined to have questionable value, as most patients may have improved over this time period without the surgery.

What does this mean for patients? These findings continue to reinforce other observations that steroid injections are not a long-term solution for tendon and soft tissue degeneration disorders (tendosis). We know steroid injections suppress local stem cells which make it impossible for them to repair the damage. We also know that cutting into an already damaged ligament which hasn’t been able to heal and permanently changing the biomechanics of the foot doesn’t seem to make sense. Instead, the therapeutic goal should be to promote tissue healing and regeneration. If conservative treatment doesn’t work, a platelet rich plasma injection may help. As always, your doctor should make sure that there is no other cause of your heel pain, as heel pain can also be caused or made worse by an irritated S1 nerve in the low back.  But in the end, whether your plantar fasciitis resolves with conservative treatment or requires PRP to accomplish healing, either treatment is a better is better than surgery no matter how you look at it!

If you’re feeling stuck, frustrated, or stymied by chronic plantar fascia pain and want to avoid surgery, the specialists at Columbia Pain Management might be able to help. We are only Center in the Pacific Northwest using a Regenexx SCP, a proprietary form of platelet rich plasma, that allows us to concentrate and customize your treatment beyond what can be done by simple table-top centrifuge. We will confirm you have the right diagnosis, get you the right foot wear and inserts, and make sure your exercise program is directed toward your biomechanical deficiencies.

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