Endoscopic Partial Plantar Fasciotomy
Edited by Christopher W. DiGiovanni, MD
Endoscopic plantar fasciotomy is used to treat recalcitrant plantar fasciitis that has failed to respond to an appropriate duration of non-operative treatment (at least 6 months). The surgical procedure involves releasing a portion of the plantar fascia, just beyond its origin as it comes off the heel bone (calcaneus). This is usually an area where the tissue has abnormally thickened, tightened, calcified, scarred, or even partly torn, and it is this constellation of pathology in whole or in part which likely causes the ongoing pain that brings the patient ultimately to a surgical solution. Plantar fascial release has been traditionally performed through an open incision, but in some instances, surgeons have more recently elected to perform this release endoscopically, allowing for a smaller incision and potentially faster recovery time. The operation does not completely disrupt the entire plantar fascia, which is an important structure for arch stability. Endoscopic release is therefore limited to the pathological area, and is thus preformed through a small incision in the inside of the back part of the foot. A tube and camera attachment are then advanced into the area for visualization, followed by insertion of a special cutting instrument which is designed to release a select amount of plantar fascia tissue in the area where it meets the heel bone.
Endoscopic partial plantar fasciotomy is an operative procedure that is used to treat chronic (not acute) plantar fasciitis that has failed prolonged nonoperative management. It should be performed only by a surgeon who has significant experience performing this surgery via an endoscope (small scope that allows for a smaller incision). Alternatively, the procedure can be performed via traditional open approach with a scalpel, and it should be noted that this is reported to have comparable results.
Potential complications that are specific to a partial plantar fasciectomy relate mostly to its limited exposure and ability to visualize the entire surgical field. While more limited exposures certainly offer some advantages in terms of having smaller incisions, faster healing, and potentially quicker recovery time, the surgeon’s ability to “see less” while trying to accomplish the same goal can, in rare cases, result in certain specific complications. These include:
- Rupture of the plantar fascia. If an excessive amount of the plantar fascia is inadvertently released, or if the plantar fascia is weak or has tremendous strain across it, it is possible for the remaining plantar fascia to rupture following a limited (open or) endoscopic release. This can be very painful, and may lead to flattening of the arch.
- Inadequate release of the plantar fascia tissue. It can sometimes be very difficult to visualize exactly what needs to be cut, and sometimes this can lead to an inadequate fascial release with continued symptoms. If recognized at the time of surgery, however, it is often best for the surgeon to convert the procedure to an open approach to ensure adequate release has been performed.
- Injury to the associated calcaneal branch of the tibial nerve. Unintended injury to this very small nerve during the procedure can lead to sensitivity, burning, and increased discomfort.
Recovery is similar to an open plantar facetectomy and may even be slightly quicker. The tissue needs to be protected for a period of four to six weeks to allow for the area to heal, and to minimize scar formation. During this time, it may be beneficial to have the foot immobilized, with limited to no weight-bearing and progressive physical therapy exercises, although some surgeons will encourage a more stepwise return to weight-bearing as tolerated if the patient feels comfortable doing so. Generally speaking, complete recovery from surgery will require a total of 6-12 months, with the primary goal being some relief of pain.
Edited on April 17, 2015