Plantar fascia surgery
Overview of Plantar Fascia Surgery
The plantar aponeurosis extends from the base of the heel to the base of the toes, and is part of the sural-achellian-plantar system. This fibrous structure is very robust, relatively flexible, and its biomechanical capabilities are exceptional. It returns energy during walking and allows the foot to adapt to the ground's surface, with or without shoes.
Pathologies of the plantar aponeurosis can be traumatic or microtraumatic. Traumatic lesions of the plantar aponeurosis are rare, while microtraumatic lesions are common, in which case we speak of plantar aponeurositis.
Symptoms of the plantar aponeurosis
Acute ruptures of the plantar aponeurosis, or traumatic ruptures, are rare. They can occur in elite athletes as a result of a high-energy accident. In such cases, there is a large hematoma on the sole of the foot, with functional impairment. Bearing weight again is impossible.
Microtraumatic lesions lead to plantar aponeurositis. Plantar aponeurositis falls into what is called talalgias, that is, heel pains. These are mechanical pains with a "warm up" phase when the foot gets going. The pain appears with the first steps out of bed, then gradually fades as the day progresses and with activity.
During breaks, the aponeurosis cools down, and resuming activity brings pain again. There are no nighttime pains, and the pain does not tend to increase in intensity as the day goes on.
If the symptoms are not purely mechanical, neurological involvement should be considered as part of a tarsal tunnel syndrome. The patient's interview is a key component in diagnosing plantar aponeurositis and tarsal tunnel syndrome.
Causes and Risk Factors
High-arched feet tend to contract, especially at the level of the plantar aponeurosis. This increases the tension on the plantar aponeurosis, which can become painful.
Flat feet tend to "lose muscle tone" and collapse. This increases strain on the plantar aponeurosis, which can undergo significant stretching and cause pain.
Contraction of the calf muscles, or gastrocnemius muscles, is very common in cases of plantar aponeurositis.
Poorly fitted footwear is also a risk factor for plantar aponeurositis. It is important to have shoes adapted to each type of physical activity.
Repetitive efforts during sports activity are also a potential source of pain in the plantar aponeurosis.
Treatments for plantar fascia
Plantar fasciitis pain is caused by excessive tension in the plantar fascia. It is therefore mechanical pain. Traditional painkillers and anti-inflammatories are generally of little effectiveness against this type of pain.
Functional treatment is the primary approach; it allows for the healing of plantar fasciitis in 90 % of cases after one year of treatment. While plantar fasciitis pain can appear quickly, functional treatment may be lengthy to achieve pain relief. Functional treatment involves stretching the posterior muscle chains, strengthening a flat foot, correcting poor footwear habits, and adapting or correcting athletic training.
If functional treatment performed for 6 to 12 months fails, surgical treatment may be proposed. Surgery is therefore rare. The surgical procedure consists of performing a selective plantar fasciotomy using a percutaneous approach.
Surgical treatment
Preparation and anesthesia before the procedure
The indication for surgical treatment of plantar fasciitis is determined during consultation. Once the surgical procedure is scheduled, it is necessary to see the anesthesiologist preoperatively.
How does the procedure take place?
The procedure is performed on an outpatient basis, meaning you are admitted and discharged on the same day at the clinic. The anesthesia is regional, meaning it involves the foot and ankle.
The procedure consists of performing a selective percutaneous plantar fasciotomy. This technique allows for partial lengthening of the tightest portion of the plantar fascia.
Possible complications of the procedure
As with any surgical procedure, there are general complications such as infection and phlebitis. More specifically, since the procedure is performed percutaneously, it is necessary to have reliable landmarks to avoid any nerve injury in the sole of the foot.
Postoperative recovery
Wearing a postoperative shoe with a rigid sole is necessary for one month. Stretching of the posterior muscle chains can also be resumed one month after surgery, as the healing process can potentially cause some tightness.
Conclusion
Plantar fasciitis is a common condition for which functional treatment is sufficient in the vast majority of cases. If functional treatment fails, surgical treatment may be considered.
FAQ
Surgical intervention may be considered in cases of plantar fasciitis resistant to properly conducted functional treatment. The indication for surgery is exceptional. In case of complete rupture of the plantar fascia, there is no method of repair available; it is necessary to allow the plantar fascia to heal.
The operative risks of surgery for plantar fasciitis are the same as for any surgical procedure. More specifically, there is a neurological risk when performing surgery on the plantar fascia.
Daily life can be resumed without restriction one month after surgery, and a return to sports is generally considered three months postoperatively.