Plantar Fasciitis Surgery
Surgical care of plantar fasciitis is performed after conservative measures fail to provide lasting relief. There are several different techniques that are used based on need and surgeon preference. All have generally equal success rates.
The traditional and very successful method of surgery to address plantar fasciitis is called a fasciectomy. In this procedure, an incision is made in the side of the heel, and the fascia is identified. A small section of the fascia is removed, allowing for scar tissue to cross the gap and effectively lengthen the fascia. This removed the strain that the fascia undergoes with weight bearing, and cures the condition. At the same time, any heel spur that is present on the bottom of the heel bone is shaved down, to prevent against any potential irritation it may have on the scar tissue that rill form during recovery. Once the procedure is completed, the foot is protected in a sterile dressing and is supported in a walking boot to prevent undue stress to the incision. Healing of the skin usually takes up to three weeks to complete, and full activity is generally allowed in five or six weeks.
A variation of this procedure is called a fasciotomy, in which the fascia is not cut but is altered or treated to produce a healing response so the tissue can become actively repaired. A current technique to produce this result involves using a wand that creates radiofrequency waves. The fascia is penetrated by the wand tip at various depths in regular intervals and a radiofrequency wave is produced from the wand that generates an inflammatory response and converts chronic inflammation into a significant acute inflammation, this time with proper stimulation of the body’s healing cells. The use of platelet gel, a healing compound produced from spinning and concentrating one’s own blood product, can help improve the tissue healing as well in some cases. The recovery period of this procedure is about the same as a fasciectomy, although more inflammation is created post-operatively that can cause discomfort. This inflammation is vital to the success of the procedure, and is a necessary part of this technique. The procedure’s advantage is in the fact that the length of the fascia is left alone, preserving anatomy.
One final technique that has been introduced relatively recently involves no incision, but merely multiple pokes into the heel tissue with a syringe containing platelet rich plasma (PRP). Prepared similarly to the above mentioned platelet gel, PRP generates an inflammatory response and stimulates the healing process through an injected concentration of cells and chemicals that normally produce healing, but are lacking in fascia tissue stuck in a state of chronic inflammation. PRP is injected into the heel in a grid-like pattern in a sterile procedure room with local and sedation anesthesia. Research on this minimally invasive technique shows promise, and for those whose health or daily life do not allow for a more traditional open procedure it can be considered.
Tarsal Tunnel Surgery
Tarsal tunnel release surgery is performed when conservative measures have failed and has one simple purpose: to release pressure off of the nerve and its branches running through the tissue tunnel. Under general anesthesia, a curved incision a few inches long is made on the inner side of the foot just under the ankle. The ligament that covers the top of the tarsal tunnel is released and left in an open position to permanently relieve pressure on the nerve. The nerve is then carefully separated from the artery and vein that accompany it, and the surgeon follows it as far back and as far forward as needed within the tarsal tunnel and the region outside of it to ensure there is no further restriction. A search is also made for any masses, abnormally thick muscle tissue, or varicose vein branches that may be pinching on the nerve. If these are found, they will be removed.
Once the procedure is completed, the foot is protected in a sterile dressing and is supported in a walking boot to prevent undue stress to the incision. Healing of the skin usually takes up to three weeks to complete, and full activity is usually regained within five to six weeks, although everyone heals at different rates.
Achilles Tendon and Back of Heel Spur/Haglund’s Deformity Surgery
Corrective surgery for Achilles tendonitis and spurs or a Haglund’s deformity on the back of the heel is considered when all reasonable conservative measures have failed to provide tissue healing and pain relief. An incision is made on the back of the heel, usually to one side of the Achilles tendon or the other. The Achilles tendon is then exposed, and any damage to the tissue is repaired by either removing unhealthy tissue or calcified tissue, or sewing any tears in the tendon. If a heel spur is present, the tendon may or may not have to be removed from the heel bone. If the spurs are higher than the tendon attachment, the bone can be shaved down without having to disrupt the attachment of the tendon. This is also usually the case when shaving down a Haglund’s deformity. If the spur is directly behind the Achilles attachment, then the tendon will have to be released form the bone. The spur is then shaved down completely, and the tendon is reattached using a tendon anchor buried into the heel bone.
If the Achilles tendon is particularly frayed or weakened, a graft may be used to strengthen it. This graft can be a pre-made biological product, or it may be obtained from other less necessary soft tissue in one’s own body.
Recovery can vary depending on whether the Achilles tendon was removed from the heel bone. If it was not removed, once the procedure is completed the foot is protected in a sterile dressing and is supported in a walking boot to prevent strain to the Achilles attachment. Most people are able to regain full activity within four to six weeks. If the Achilles tendon was removed, the leg is given a fiberglass cast below the knee to lock the ankle into position and prevent the Achilles tendon from tearing off of the heel bone. This is done for four weeks while the tendon reattaches to bone, after which the foot is protected in a walking boot to prevent undue strain. Slow activity and normal shoes can be regained approximately four weeks after that. From there onward the Achilles tendon slowly strengthens over the next several months, although most people can resume full activity in a shorter period of time.
Scott R. Kilberg DPM 