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surgery?

Posted by Lisa G on 4/29/02 at 17:17 (081615)

hi everyone...
i've had a second opinion...and the podiatrist and orthopedist both recommend endoscopic plantar fasciotomy to help my chronic plantar fasciitis of 8 years...i have literally done everything to help correct this condition...i am kind of excited at the idea of some relief finally...yet apprehensive about the surgery...i haven't scheduled it because i have another health issue i need to deal with first... i'm only 29 and i SWEAR my body is literally falling to pieces...ok...sorry...having a self-pity moment...anyway...anyone who has had the surgery...if you could let me know how it went...what the recovery time is...etc...i'd appreciate it...thanks lisa

Re: surgery?

BrianG on 4/29/02 at 18:42 (081646)

Hi Lisa,

I had a failed EPF in Sept 1999. I was led to believe the pain would be minimal, and I'd be back in my sneakers with a week or so. It wasn't so. I had bad pain, for at least 2-3 weeks. It was months before the pain finally was gone. My right arch now hurts in that foot, and the PF is worse than ever. I never hurt in the arch before it.

In talking to other doctors, since my operation, they had led me believe the procedure was a failure because not enough of the fascia was cut. It's very hard to see everything in that area, by using such a tiny camera. I personally think a lot of the failures are due to the design of the kits, that the doctors use. If I haven't scared you away by now, please take some time to talk to your doctor. Tell him that you would like to talk with patients he has cured. Ask if they have had the PF as long as you have. Ask the doctor if any of his EPF patients have gotten TTS after the procedure. There are a lot of people posting here that have developed TTS and other nerve type problems after failed EPF's. I wish you the best, but please try to have ESWT treatment before being cut. Once that happens, there is no turning back. Unfortunatly you can hurt more after an EPF, than before it. Also, a lot of Pods have stopped doing this procedure, because of the low success rate.

Regards
BrianG

Re: DON'T DO IT!

Been There x 4 on 4/29/02 at 20:00 (081664)

I've written this same thing a couple of times now, but I'm going to say it again. I've had 4 operations on my feet and can barely walk now. I started out with a 'simple' partial PF release. Find an orthopedic surgeon who does cord lengthening procedures. He/she will lengthen the cord in the back of your calf, causing the tension to ease up all up and down your leg AND YOUR FOOT, including the plantar fascia.

I would give anything to have known this before I let the first guy cut on my foot. I know there are some success stories out there, but they are far and few between. You are playing Russian Roulette with your feet if you go ahead and have a release. Once cut ... you have to face the consequences the rest of your life.

Sorry to sound so negative about PF releases, but that's because I AM negative about them. I will never advise ANYONE to have one.

Incidentally, I recently learned that my very first PF release was a total failure and that I need to have a 5th operation (my other 3 were on my other foot). If I get brave enough to do this after all I've been through, the ONLY way I'll let anyone touch me again is by lengthening the cord. During the last operation that I had, which was a total reconstruction of my foot, I had the cord lengthened on that leg. Although that foot is currently a mess, pain wise, I can at least say that the tension on the bottom of my foot is normal now (ala cord lengthening). It works.

Re: DON'T DO IT!

Lisa G on 4/29/02 at 23:53 (081703)

thank you been there and brian g...at this point been there...i can barely walk as it is...and as far as the eswt that you have suggested brian...i don't think that is an option here...ty both for your opinions...in all the research i've done...talking to people...and the dr's recommendations...it seems half are for it...and half are against it...

thanks again =)
lisa

Re: DON'T DO IT!

Pam B on 4/30/02 at 08:02 (081736)

Lisa, I have been where you are very recently and had the open PF/spur excision surgery in Feb...I can tell you for me it was a god sent....yes I have ongoing problems but after eight years of putting up with this stuff and not being able to put my foot flat on the floor for months at a time, I am here to tell you I am not sorry at all....the ESWT was not an option for me either due to insurance....and since the PF took my ability away to be independent financially, there were no options that I have not tried in eight years and could not personally afford the ESWT...please research the EPF though....even my pod agreed that the open procedure is better...the healing time is longer but the outcome is better...as we all know on this board, PF pretty much only knows remission and not cure...and for some of us that have tried it all and cannot walk more than we can....surgery is the only option....if you have the surgery, make certain that you follow your instructions to the letter for the least amount of pain and the best possible outcome...I know surgery is a personal decision and a very hard one to make when you think of what can happen...but sometimes it is necessary...just remember, we are here for you if you need us :)good luck

Re: DON'T DO IT!

Lisa G on 4/30/02 at 08:16 (081740)

gosh pam...thanks so much for you post...i have had this for 8 years too...and i can no longer work...mostly because of my feet, but also have other mitigating factors...i have it in both feet...my pod yesterday said that there is a very good chance it could come back long term if i have the surg...i have been trying to get as many opinions as possible...neither dr i saw recomended the open procedure...maybe because i need to have both feet done...but i will ask about it...

anyway...thanks again pam...nice to have a positive response...eventhough i appreciate the not so positive responses as well... =) lisa

Re: DON'T DO IT!

BrianG on 4/30/02 at 09:00 (081749)

Hi Lisa,

I really think that ESWT will be available to most people in the next year, or so. You've gone this far, can't you hold out a lttle longer? A pan management clinic could probably buy you the time needed to get ESWT. Your own docter s telling you that you could be worse off after the surgery. That won't happen with ESWT. Please give this some more thought.

BrianG

PS Most doctors usually speciallize in only one type of surgery. Could it be that both the one's you have seen don't do the open surgery?

Re: DON'T DO IT!

Linda on 4/30/02 at 10:14 (081764)

I have had fascia release, and tarsal tunnel release with heel spur removal in both feet, and i am very glad i had it done. I have no pain, and i have had plantar faciitis since 1986. I have had nothing put a positive experience, and after years of suffering, I have no pain at all.

Re: One last comment ....

Been There x 4 on 4/30/02 at 10:46 (081765)

I am very pleased (and relieved) to hear from those of you who have had such good results from your releases. What you need to understand, however, is what happens to those who do not have the same results from their surgery that you have had. It's terrific that you are doing so well ... but talk to the people who are more or less crippled forever as a result of having a PF release.

I think those of you who are encouraging these other people to have surgery are going to feel pretty bad if they go ahead and have them, based on your recommendations, and their results are irreparable failures.

I apologize for sounding fatalistic, but I have worked in healthcare for 20 years and know my way around the system pretty well. If there is someone out there who is still determined to have a PF release, do yourself a huge favor and do some research first. Find out from some of the top orthopedic surgeons in the country what their opinions are related to PF releases. I believe you will have a difficult time finding any of them who are doing this procedure any more, based on the number of negative results in the past.

If you don't know who to contact, please let me know and I will give you some names. These are surgeons who treat people from around the world, not just from around this country. If these guys, who are at the top of their field, don't do releases any more, should anyone?

Re: One last comment ....

john h on 4/30/02 at 12:23 (081779)

Ben There x 4: there are in fact many surgeons who will not do a fascia release under any circumstance. My personal feeling is that the success of a PF surgery is very much related to the skill of the doctor in his diagnosis and his skill as a surgeon. From talking to Dr. Z and some other Doctors the fascia release, unless it is an open procedure, is performed very much with 'feel'. The doctor may release 50% or 75% as even he cannot be sure how much he is releasing. I talked to one doctor who still releases 100% of the fascia. I sure would not want to be one of the first few patients a Doctor performs a PF on. Being a Doctor is very much like being a pilot. You definitely get better with age and experience. Know your Doctor!!!!!!!!!!!! There are a lot of successful PF surgeries. We just do not hear about them. After you have tried everything including ESWT and you are still in pain it gets down to you as a patient in are you willing to accept the pain you are in or accept the risk that goes with PF surgery. You need to understand that you can be made worse for life or that you may be cured or you may not get relief and not be made worse. Know your risk. Know your doctor. Get 2nd and 3rd opinions. And know all about the types of PF surgeries and above all be patient and do not rush into anything. PF with time will often cure itself.

Re: DON'T DO IT!

Pam B on 4/30/02 at 14:18 (081801)

Brian, I can appreciate advising PF sufferers to wait for ESTW and I cant speak for Lisa, but I can tell you all this other stuff that is wrong with my foot now is because of the pain and the way I walked for so long.....I know surgery is not the best option for everyone, but sometimes it is better than continuing to harm our bodies......I know in my case, I am now paying for the long term effects of putting this off for eight years.....it is like a nasty disease that keeps spreading......I know from talking to others here the same thing has happened to them......so I guess if it is just the PF and spurs ESTW is worth the wait but for some of us, enough is enough when other things start happening when we are unable to even put our foot on the floor in a normal manner.....at least that is my feeling on it...your advice is sound advice but again, the decision is a personal one that we make when the time is right for us.....I admire anyone who can deal with this pain, but eight years was enough for me....I appreciate your thoughts :)

Re: surgery?

Ed Davis, DPM on 4/30/02 at 14:37 (081810)

Did you also post on the doctor's board. I would be concerned if you have a tight gastrosoleus achilles complex that is not addressed. That, in my opinion, can often lead to failure of a plantar fascial release.
Ed

Re: DON'T DO IT!

Ed Davis, DPM on 4/30/02 at 14:47 (081812)

The lengthening of the heel cord, via the classic achilles tendon lengthening or a gastrocnemius recession is not an afterthought. It either needs to be done simultaneuosly with the plantar fascial release or not. Not all individuals will be helped by a heel cord lengthening but those who do need it, should have it done simultaneously with the plantar fascial release. Heel cord lengthenings are not without consequence so they need to be performed only when indicated.

Success stories are not 'far and few in between' as you state. I am sorry that you had a bad experience but that is not a common occurrence in the hands of knowledgeable practitioners. There is a certain variability of results which is independent of surgical technique. About 15 to 20% of surgeries will not lead to resolution and because of this variability we like to avoid the surgery unless it is absolutely necessary. I am not familiar with the details of your situation, but, in 20 years of practice, I have never performed more than one operation per foot for plantar fasciitis.
Ed

Re: surgery?

Lisa G on 4/30/02 at 15:30 (081820)

thank you for response dr davis...i talked at length with my pod...and he really suggested having the EPF on both feet at the same time...i do have other medical issues...so perhaps that is why...i will definitely re-address my tight achilles tendons and calves with him...he did say that my problem is all due to my tight achilles tendon...and there were 2 ways to fix the problem...lengthen the fascia in my feet...or lengthen my tendons...but he said the foot route is easier...i am rather concerned about the tightness in my calves...i stretch them regularly...and after 8 years...they are as tight...if not tighter...and i foresee having foot pain long term after having the EPF due to the tightness...ok...you've given me some more things to think about...thank you lisa

Re: surgery?

Pam B on 4/30/02 at 17:36 (081836)

I would like to state for the record that I did not advise anyone to have the surgery.....what I did say was it is a personal choice and I indicated it as a last resort after years of suffering.....any surgery is a risk......the way I see it is when you have PF your life is changed to start with whether you are able to manage it conservativly or if you have to resort to surgery.....once you have tried everything else and cant walk and ESTW is not an option for you.....surgery may be the only option for you to lessen your pain and suffering enabling you some quaility back to your life...I am not saying it cant fail, I am saying sometimes you are already crippled prior to surgery.....I am certainly not a doctor nor do I work in the health industry, I was simply stating my opinion that all surgeries are not failures....for someone considering surgery it is only right they have all the information available to make that personal choice and that means the successes and the failures...I believe with a good doctor and the right attitude, surgery can be a good thing in some resistant patients.....I for one, am glad I had surgery as an option available to me :)and I am thankful that I found relief

Re: DON'T DO IT!

BrianG on 4/30/02 at 18:06 (081841)

Hi Pam,

I've been exactlly where you and Lisa are, myself. This is my 9th year of debilatating chronic pain from PF. I jumped at the chance for EPF on my 'worst' foot 2 1/2 years ago. I felt I had no other choice, but it was before I knew about ESWT. It turned out to be a total failure, but I feel I was somewhat lucky , as I only have a small amount of additional arch pain in that foot. We have people here that ended up much worse than myself.

I am currently unable to work, because of the pain, and have applied for SSD. The only reasn I have my sanity at all, is because I am lucky enough to have a doctor treat me with a pain management program. This is what I am advising others to look at. Reduce your pain until ESWT is available, and stay off your feet as much as possible. I don't want to end up even more disabled than I already am, which could happen very easily with more surgery. Sometimes we feel that we have to take a certain path, but with a little more information, we may find a much easier road to go down. I hope the best for everyone, no matter what treatment they have. Just realize that you do have some alternatives to more surgery. Pain should not be the reason someone chooses surgery!

Regards
BrianG

PS I have given out this web site before, and it's now time once again. It's a good place to learn a little about pain management: http://www.pain.com

Re: DON'T DO IT!

Lisa G on 4/30/02 at 20:45 (081873)

hi brian...no i don't think that i can wait one year or longer...eventhough i have gone this far...my life is totally on hold right now...i cannot even think about getting pregnant right now because of my feet...and we are beyond ready to think about starting a family...i have other medical issues that i feel will be drastically helped by having my feet feel better...i am at a pain management clinic right now for all my problems, including feet...and i appreciate your suggestion =) ... i do...my dr didn't really tell me that i could be worse off...just that there are risks...just as with any surg...

thanks brian...i am taking all the posts i recieve into consideration ...
lisa

Re: One last comment ....

Joe S on 4/30/02 at 21:17 (081884)

Just curious been ther 4x... How much do you weigh?

Re: One last comment ....

Joe S on 4/30/02 at 21:19 (081885)

Yes. I totally agree. Definitely get 2nd and 3rd opinions. Make an informed decision about your healthcare. You are your own best patient advocate.

Re: One last comment ....

Been There x 4 on 4/30/02 at 21:47 (081889)

Hi Joe -- I'm 5'11' and weigh 135 lbs.

Re: surgery?

Julie on 5/01/02 at 02:27 (081901)

Lisa

I would be interested to know what steps have been taken to help you lengthen your gastrocnemius/soleus/achilles complex. You say you stretch them regularly, but this rings warning bells for me. What stretching do you do? The wrong stretches, exercising incorrectly, can sometimes have the opposite effect to the one you want, especially if you are stretching against pain (as you obviously are/were).

As far as the achilles is concerned, it's easy to say 'it's tight, so stretch it', but in fact tendons do not 'stretch'. My own view is that if they can tighten and shorten (as they do in women who wear high heels) they can probably be brought back to their normal/optimum length, but this takes time and great care, especially in cases of PF, where most stretching will irritate the injured fascia at its weakest, most vulnerable point.

In a situation like yours I would suggest that a night splint is the best road to go down. It works by applying a gentle, consistent stretch to the entire complex of muscles and tendons over a period of several hours. Has this been tried? And whatever exercise you do, it should be non- weight-bearing.

I don't have all the details of your history in my head, so please forgive me if you've answered this question before.

Re: surgery?

Lisa G on 5/01/02 at 03:49 (081906)

hi julie =)
i have been doing several stretches to work on the tightness in my calves...and i know i am doing them right because i have a very strict physical therapist =)

i also understood that tendons/fascia do not stretch...but i have continued with stretching my calves because i know they are tight...very tight...and i know that my tight calves are part of my problem...just part though...and right now...i don't know what else to try to get them to stretch and loosen up...

i tried night splints when i first developed PF...but they were very uncomfortable...and my feet went numb...i have a sleeping disorder...and back pain...and i just could not wear the night splints ...

the only exercise i am currently doing...or was doing before i fell and tore up my knee...was walking...i have a dog...and we live in an apt...so she NEEDS to be walked...i would take her out several times a day for shorter walks...instead of one long one...which i think helped my feet pain a little...

as is many situations...mine is complex...lots of variables...with my feetsies, tendons and calves being just one...i do feel if i can get my feet pain under control...that some of my other problems would be helped...

thank you for your response...lisa...oh...ps...i know this was just a point you were making =) but i do not wear high heels...haven't since BEFORE my PF developed...i hate high heels lol

Re: surgery?

Julie on 5/01/02 at 07:05 (081918)

Lisa

The problem with trying to stretch a tendon is that the muscle which is attaches to the bone is very elastic, whereas the tendon, though it has collagen fibres, is very much less so. So when you stretch the back of the leg - the gastroc/soleus/achilles complex - it's the muscles that you are primarily stretching. The tendon, being far less elastic, won't stretch. It's almost impossible to find a way of stretching a tendon without isolating it from the its muscle attachments, which is impossible.

However, stretching the calf muscles does pull on the achilles tendon, and if it is damaged already, the damage will increase. If you have plantar fasciitis, you are also pulling on the fascia at the weak, vulnerable point where it inserts in the heelbone.

I don't know what stretches you are doing as advised by your physiothgerapist. But if you are doing any weight-bearing stretching, this is what is happening, and I would be willing to bet it is contributing to your pain and to the intractability of your PF.

I think you should take a big step back and evaluate what you have been doing to yourself.

I also think you should consult another podiatrist before you even begin to consider surgery. The doctors who help us here have all, at various times, expressed their negative view of EPF. I would be wary of a pod who advised EPF, and extremely wary of one who wanted to do it on both feet.

Re: surgery? PS

Julie on 5/01/02 at 07:07 (081919)

I pushed the button too soon. I meant to say also that you should really try another night splint. Most of them are uncomfortable, apparently, though I've no personal experience, but the one Scott sells on this sight (click on the link) has had very good reports from users.

Re: surgery?

michelec on 5/01/02 at 09:30 (081935)

Hi Lisa. I just had open release done on April 19. I have had almost no pain so far. I am still in a walking cast and using crutches and if I put too much weight on the foot it hurts a little. But I am very optimistic. When I was trying to decide about surgery and found this board I was almost scared away by all the negative stories of surgery and the constant barrage of ESWT. I totally agree with PamB's assessment of ESWT -- if it isn't covered by insurance, I can't afford it. But after much soul-searching and chatting with people who have had successful surgeries on this board I decided to go with my pod's recommendation for surgery. He feels that the endoscopic type just doesn't allow for well enough view of the fascia. Yes the open takes longer to heel but I've had pain for 2+ years and a longer recovery isn't a hard pill to swallow since I've already had pain for so long.

It has been great to see the recovery stories that have been posted of late. I always felt that it's much more common for those who continue to have pain after treatment and surgery to continue to post because they are still looking for the magic bullet. Those who are heeled, get on with their life and don't visit as often or ever anymore. Try to remember that.

I wish you the best of luck in your surgery. I definitely recommend you talk with your doc about the open procedure vs. the endoscopic but the final decision has to be yours.

Re: surgery?

john h on 5/01/02 at 10:52 (081963)

I strongly second Julie in that doing surgery on both feet at the same time for PF is a dangerous approach. I do not think any of the 5-6 doctors who I have seen would ever consider this and some of them will not even consider surgery. Most of the doctors in our city who performed EPF surgery have dropped it in favor of MIS. From some of the literature I read nerve damage can and has occured as the scopes are inserted into the foot as this insertion is very much in the blind. I can not be more strong in my 'opinion' that PF surgery on both feet at the same time is a very bad idea.

Re: surgery?

Ed Davis, DPM on 5/01/02 at 16:31 (082022)

Lisa:

I cannot agree with the perspective that your doc has provided. I don't feel that it is a matter of doing one procedure or the other. They are not mutually exclusive. I strongly prefer that a tight achilles is dealt with conservatively. Nevertheless, if one has already made the decision to have a PF release, it seems logical to address the achilles at the same time. I feel that a tight achilles-gastrosoleus complex that is not addressed, can lead to failure of the PF release surgery and is also more likely to lead to complications such as cuboid syndrome. It depends on how tight the gastrosoleus-achilles complex is.
Ed

Re: One last comment ....

Joe S on 5/01/02 at 19:16 (082049)

I didn't mean to sound crude. However, you are on the opposite extreme of most plantar fascial release failures. I believe there is a direct relationship between plantar fasciitis and weight. Also, have you ever considered that you may have a Baxter's Nerve Entrapment? Basically, this is one of the big differential diagnoses of nonresponsive heel pain treated as plantar fasciitis. Do a literature search on the condition. To summarize, Baxter Nerve Entrapment is an entrapment of one of the lateral plantar nerve. Here is an article devoted to the condition by Dr. Alan Banks, one of the nations premier authorities in Podiatric Medicine and Surgery. He is the director of probably the best Podiatric Surgical Residency in the U.S. Here is an article in its entirety for you to read. This may be of benefit to you.

Analysis of Release of the First Branch of the
Lateral Plantar Nerve

JAPMA VOLUME 90 / NUMBER 6 / JUNE 2000

Robert M. Goecker, DPM*
Alan S. Banks, DPM†

*Submitted during third-year residency, Northlake Regional Medical Center, Tucker, GA. Mailing address:1961 Floyd St, Ste C, Sarasota, FL 34239.

† Member, The Podiatry Institute, Tucker, GA; Director of Residency Training, Northlake Regional Medical Center, Tucker, GA.

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The authors conducted a retrospective study of the release of the first branch of the lateral plantar nerve in the treatment of chronic heel pain unrelieved by conservative treatment modalities. A total of 17 patients (18 feet) were evaluated following external neurolysis for heel pain caused by entrapment of the first branch of the lateral plantar nerve. The average postoperative follow-up time was 32.8 months, with a range of 10 to 72 months. Every patient deemed the surgery successful. At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. There was one postoperative complication, medial calcaneal nerve entrapment; it was successfully treated with neurectomy. (J Am Podiatr Med Assoc 90(6): 281-286, 2000)

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Plantar heel pain is usually attributed to plantar fasciitis or heel spur syndrome. In certain individuals, however, a different entity can produce similar pain and symptoms. Several authors have described a neurogenic source of heel pain: entrapment of the first branch of the lateral plantar nerve.1-12

The first branch of the lateral plantar nerve is a mixed nerve with both motor and sensory fibers. Muscles supplied by this nerve include the abductor digiti minimi, flexor digitorum brevis, and quadratus plantae. Sensory fibers supply the calcaneal periosteum, the long plantar ligament, and the skin at the plantar lateral aspect of the foot. This branch originates from the lateral plantar nerve proximal to the abductor hallucis and then dives through the fascia at the superior margin of the abductor. The nerve courses distally between the abductor hallucis muscle and the medial edge of the quadratus plantae until it reaches the inferior margin of the abductor fascia. There it turns laterally between the flexor digitorum brevis and the quadratus plantae.1 The nerve at this point lies adjacent to the calcaneus approximately 0.5 cm distal to the medial tubercle of the calcaneus.2, 3 Failure of traditional heel spur surgery may be due to damage and subsequent entrapment of the first branch of the lateral plantar nerve or an inadequate release of a primary neurogenic source of heel pain. Obviously, the nerve is not released through the traditional open heel spur surgical approach. This nerve branch should not be confused with the medial calcaneal nerve, a purely sensory nerve that lies in the superficial fascia of the heel.4, 5

In 1963, Tanz6 proposed the first branch of the lateral plantar nerve as an overlooked source of plantar heel pain, and he demonstrated the nerve's anatomy from cadaveric dissection. However, it was not until 1981 that Przylucki and Jones3 correlated actual patient symptoms with this structure. Their surgical treatment for this condition consisted of excision of the nerve. Subsequently, other authors reported successful treatment of this type of chronic heel pain with external neurolysis rather than nerve excision.1, 4, 5, 7, 8, 10-12

Baxter and Thigpen7 in 1984 described two possible sites of entrapment. The first is the sharp fascial edge of the abductor hallucis muscle where the nerve changes course and turns laterally. Another possible site is the medial ridge of the calcaneus where the nerve passes beneath the tuberosity and origin of the flexor digitorum brevis and the plantar fascia. Therefore, nerve impingement may be caused by an increase in mass, such as a calcaneal spur, within the flexor digitorum brevis. Rondhuis and Huson13 concluded that the exact site of the entrapment is where the nerve passes between the taut deep fascia of the abductor hallucis muscle and the medial caudal margin of the medial head of the quadratus plantae muscle (Fig. 1). Pronation, muscle hypertrophy, or other sources of irritation have been cited as instigating events that may irritate the nerve as it passes through the fascial port of the abductor hallucis.

Patients with heel pain secondary to nerve entrapment may present with slightly different symptoms than individuals suffering from plantar fasciitis. In the former condition, the pain is usually not as great in the morning or after periods of rest, but seems to be more pronounced after activity. Przylucki and Jones3 noted that compression of the first branch of the lateral plantar nerve may occur by physiologic motion secondary to pronatory forces. As the foot is pronating, the tension of the fascial structures increases, resulting in compression of the nerve. This suggests that the nerve compression may be not only static (constant) but also dynamic and can worsen with pathologic gait patterns.

However, in some patients a history more similar to that associated with plantar fasciitis may be described. Chronic inflammation of the plantar fascia may coexist with, and possibly predispose to, entrapment of the first branch of the lateral plantar nerve.4, 5 Therefore, the patient may initially have some component of plantar medial heel pain as well. In such cases, the plantar fascial symptoms will tend to respond to the conservative modalities, but the symptoms related to the nerve entrapment may tend to persist. In some instances, the patient may complain of pain radiating toward the lateral aspect of the heel following the normal anatomical course of the nerve. There may be associated motor weakness of the abductor digiti minimi indicated by the patient's inability to abduct the fifth toe (Fig. 2). Abduction of the fifth toe may be a difficult task for many people to perform, but in some individuals with this entrapment, a difference may be observed between the symptomatic and asymptomatic sides.

Regardless of the history, the diagnosis of entrapment of the first branch of the lateral plantar nerve may be made during the clinical examination. The exact source of the patient's symptoms may be determined by careful palpation of the plantar aspect of the heel. Clinically, the pathognomonic sign of this entity is greater pain with compression over the medial aspect of the heel than plantarly (Fig. 3). Hendrix et al8 labeled this test the nerve compression test. Palpation in this region pinches the nerve between the deep fascia of the abductor hallucis and medial caudal margin of the quadratus plantae, resulting in pain and possible paresthesia.1 Hendrix et al8 have also found that plantarflexion and inversion of the foot (Phalen's maneuver) may be helpful in diagnosing entrapment of the terminal branches of the tarsal tunnel, including the first branch of the lateral plantar nerve. This movement reduces the width of the porta pedis and causes the superior margin of the abductor hallucis to compress the nerve, producing nerve impingement signs and symptoms. The nerve is also felt to be compressed at the exit site of the fascia between the abductor and flexor brevis.4, 5

The role of other diagnostic tests, such as electromyography and nerve conduction velocities, has been described by Schon et al.9 They found electrophysiologic abnormalities in 23 of 38 symptomatic heels, although careful review reveals that abnormalities in the lateral plantar nerve were found in only 7 patients (16%). It is also worth noting that the first branch of the lateral plantar nerve is technically difficult to isolate. It must therefore be emphasized that diagnostic tests are not a substitute for good clinical evaluation. If one does not trust a clinical diagnosis of nerve entrapment, technetium bone scans and magnetic resonance imaging (MRI) evaluations can be used to rule out an inflammatory source of heel pain. In the first few cases evaluated by the authors, patients underwent technetium bone scans and MRI evaluations, both of which failed to demonstrate inflammatory change in the heel area. This suggests that in these patients the pain is more consistent with nerve entrapment. Therefore, simple release of the plantar fascia will have limited effects on the symptoms.

The purpose of this article is to report on the success and long-term efficacy of release of the first branch of the lateral plantar nerve in those patients who failed to respond to conservative treatment modalities.

Materials and Methods

A total of 17 patients (18 feet) with painful medial heel pain were first treated with conservative modalities, such as padding, strapping, orthoses, various forms of immobilization, cortisone injections, and diagnostic nerve blocks. All patients had received extensive conservative treatment. Some of the patients had received conservative care by other physicians prior to surgical intervention by the authors. Anyone with prior heel surgery was excluded from the study. In each of these cases, the diagnosis of nerve entrapment was based on a positive clinical history and physical diagnostic findings consistent with entrapment of the first branch of the lateral plantar nerve. No other diagnostic modalities are necessary or routinely used by the authors for this condition. Surgery was elected in recalcitrant cases. The surgeries included in the study were performed over a 5-year period. All patients' charts were reviewed, and each patient was evaluated by means of a follow-up examination or a telephone interview. The outcome of the procedures was assessed by means of a questionnaire (Fig. 4).

The surgical technique that was used consists of an oblique incision made over the medial aspect of the heel overlying the course of the first branch of the lateral plantar nerve. The distal extent of the incision ends just beyond the junction of the calcaneal tuber and the plantar fascia. When the incision is oriented in this manner, it remains relatively parallel to the branches of the medial calcaneal nerve; this creates less potential for postoperative entrapment of these structures (Fig. 5).

Dissection is carried through the subcutaneous tissue until the deep fascia over the abductor hallucis can be identified. The superficial fascia is then bluntly separated anteriorly and posteriorly so that the abductor fascia may be clearly visualized. A carefully controlled inverted T-incision is then made, with the horizontal component of the T beginning at the inferior margin of the deep fascia overlying the abductor hallucis muscle. The vertical incision is then made extending proximally from the middle of the horizontal arm to the superior aspect of the abductor hallucis muscle belly. The muscle belly of the abductor is freed from the fascia at the superior margin and retracted inferiorly, exposing the fascia separating the abductor hallucis from the quadratus plantae. A vertical incision is then made through this deeper fascial layer, and a segment of tissue is removed. This should eliminate any constriction of the first branch of the lateral plantar nerve. As the nerve may also be compressed at the inferior edge of the abductor muscle, this fascia deep to the abductor hallucis muscle belly is vertically sectioned as far inferiorly as possible. The abductor muscle is retracted superiorly, and any remaining intermuscular fascia between the abductor and flexor digitorum brevis is sectioned. This circumferentially releases the fascia around the abductor hallucis muscle belly.

Next, a small portion (approximately one-quarter) of the medial aspect of the plantar fascia is sectioned to completely free the abductor hallucis and eliminate any potential irritation at this level. However, the windlass effect of the plantar fascia is maintained. Sometimes, if it is deemed necessary, an inferior calcaneal spur is gently removed with hand instruments. A Freer elevator is usually placed over the spur to prevent damage to the soft tissues and nerve at this level.

Following surgery, the patient is kept nonweightbearing for 3 weeks. A cast or posterior splint, as opposed to a soft bandage alone, has worked well. It is felt that maintaining the foot in a neutral position prevents coaptation of the incised fascial tissues.

Orthotic support is reinstituted following surgery, especially in patients in whom the plantar fascia is partially sectioned. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and the lateral column. Pain or discomfort in this region was noted postoperatively, despite significant improvement in the heel. This generalized cramping, achiness, and midfoot pain tends to resolve over time and is effectively treated with biomechanical support.

Results

Seventeen patients (18 feet) who had undergone release of the first branch of the lateral plantar nerve using the previously described technique were available for follow-up clinical or telephone evaluation. The average duration of heel pain prior to surgery was 21.2 months, with a range of 6 to 120 months. The time elapsed since surgery ranged from 10 to 72 months, with an average postoperative follow-up time of 32.8 months. Every patient deemed the surgery successful. On a pain scale of 0 to 4, all patients were asked to rate their pain both preoperatively and postoperatively (Table 1). At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. The average preoperative heel pain rating was 3.67, and the average postoperative pain rating was 0.5. A paired t-test was performed on the pain level data, revealing a statistically significant difference to a level of P< .001. There was one postoperative complication, medial calcaneal nerve entrapment, which was successfully treated with neurectomy. This patient is currently asymptomatic.

Three patients complained of a dull pain and a feeling of weakness across the top of the foot between 5 and 10 months postoperatively. Symptoms in this area can probably be attributed to the 'settling phenomenon' that occurs after partial plantar fasciotomy. Thordarson et al14 showed a progressive loss of the arch-supporting function of the plantar fascia as the fascia was sequentially sectioned from medial to lateral. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and subsequent pain.

Two patients also experienced vague lateral column pain. Both of these events were transient. In order to protect the midfoot and lateral column from increased stress after plantar fasciotomy, the authors section only the most medial expansion of the plantar fascia and suggest the use of postoperative orthoses.

Discussion

The vast majority of patients suffering from heel pain achieve symptomatic relief with conservative measures. However, it is important to remain aware of sources of heel pain other than plantar fasciitis. Although reports of neurogenic heel pain have been linked to medial calcaneal nerve entrapment, tarsal tunnel syndrome, and heel neuromas, recent literature suggests that entrapment of the mixed (motor and sensory) nerve to the abductor digiti minimi may be a common source of medial heel pain.1-12 Histologic examination of the nerve branches that have been excised under the described intermuscular septum between the abductor hallucis and quadratus plantae revealed evidence of hypertrophy, perineural fibrosis, increased endoneural collagen, and loss of myelinated fibers consistent with nerve entrapment.1, 3, 7

Once a diagnosis of nerve entrapment is made, conservative treatment modalities similar to those used for plantar fasciitis are instituted. However, it is the authors' experience that these patients demonstrate a less positive response to conservative and supportive treatment modalities. In these cases, a surgical approach that deals with potential nerve entrapment is employed.

As with any procedure, surgical approaches vary and have been adapted over time. Przylucki and Jones3 first described surgical management of this condition. Their approach involved removal of the calcaneal exostosis, plantar fasciotomy, and excision of the muscular branch of the lateral plantar nerve to the abductor digiti minimi. The procedure was performed in only three cases, and the incision placement and exact technique were not discussed.

Baxter and Thigpen7 performed the first large retrospective study of neurolysis of the first branch of the lateral plantar nerve. They performed the procedure on 34 heels using a modified DuVries heel spur incision. They recommended releasing the deep fascia of the abductor hallucis muscle and, if necessary, sectioning a small portion of plantar fascia as well as excising a small portion of a plantar heel spur, decompressing the nerve. They also noted that complete plantar fascial releases and heel spur resection should be avoided.

Henricson and Westlin10 performed the neurolysis through an oblique curved incision extending from below the medial malleolus toward the medial anterior edge of the heel pad. Kenzora11 used a plantar midline incision. These two techniques were used to avoid complications of medial calcaneal nerve injury secondary to the DuVries incision.

Baxter and Pfeffer1 published the results of a retrospective study involving 69 feet that underwent neurolysis. The incisional approach was modified to an oblique vertical incision over the medial heel similar to that described by Henricson and Westlin.10 This incision parallels the course of the nerve and is less likely to injure the medial calcaneal nerve. However, Baxter and Pfeffer still reported two medial calcaneal nerve entrapments with their new incision. The authors, as well as Sammarco and Helfrey,12 have also used the oblique vertical medial heel incision successfully. Even with this incision, extreme caution must be employed at the superior aspect of the incision to avoid injury to the medial calcaneal nerve branch. In the authors' review of 18 surgical procedures, one patient did experience a medial calcaneal nerve entrapment, which was successfully treated with nerve excision.

Recently, Hendrix et al8 proposed a transverse medial oblique approach that allowed them to decompress not only the first branch of the lateral plantar nerve but also the posterior tibial, medial plantar, and lateral plantar nerves. They released the terminal branches of the posterior tibial nerve because of their belief that the chronic heel pain is related to distal tarsal tunnel syndrome. The authors of the present article believe that it is not necessary to decompress the other distal branches of the posterior tibial nerve (tarsal tunnel release) concomitantly with the first branch of the lateral plantar nerve, especially when a limited incision is used for exposure and release.

Finally, one must consider the possibility of plantar fasciitis or heel spur syndrome coexisting with the nerve entrapment. Chronic inflammation from plantar fasciitis and large calcaneal spurs have been linked etiologically to entrapment of the first branch of the lateral plantar nerve.11 The current authors did section the most medial expansion of the plantar fascia in every patient and removed two very large heel spurs. Other authors also report sectioning a portion of the plantar fascia and excising large spurs if deemed necessary during nerve release.1, 11, 12 Baxter and Pfeffer1 did not section the plantar fascia in any patient to preserve the windlass mechanism. They did, however, remove any spur that was present. Considering the effect of a plantar fasciotomy on the foot, the authors recommend minimal release followed by postoperative support to minimize any deleterious effects on the midfoot or lateral column.

Conclusion

In the vast majority of patients, heel pain is due to plantar fasciitis and can be treated conservatively. In certain individuals, a neurogenic source of heel pain entrapment of the first branch of the lateral plantar nerve must be considered, especially in recalcitrant cases. Readers are encouraged to examine the medial heel as part of the initial evaluation of patients with heel pain. The long-term results of the surgical release of this nerve with partial plantar fasciotomy have been promising.

References

1. Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279: 229, 1992.
2. Arenson DJ, Cosentino GL, Suran SM: The inferior calcaneal nerve. JAPA 70: 552, 1980.
3. Przylucki H, Jones CL: Entrapment neuropathy of muscle branch of the lateral plantar nerve: a cause of heel pain. JAPA 71: 119, 1981.
4. Banks AS: 'Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '94, ed by CA Camasta, NS Vickers, JA Ruch, p 27, The Podiatry Institute, Tucker, GA, 1994.
5. Banks AS: 'Entrapment of the First Branch of the Lateral Plantar Nerve: Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '95, ed by CA Camasta, NS Vickers, JA Ruch, p 159, The Podiatry Institute, Tucker, GA, 1995.
6. Tanz SS: Heel pain. Clin Orthop 28: 169, 1963.
7. Baxter DE, Thigpen CM: Heel pain operative results. Foot Ankle 5: 16, 1984.
8. Hendrix CL, Jolly GP, Garbalosa JG, et al: Entrapment neuropathy: the etiology of intractable chronic heel pain syndrome. J Foot Ankle Surg 37: 273, 1998.
9. Schon LC, Glennon TP, Baxter DE: Heel pain syndrome: electrodiagnostic support for nerve entrapment. Foot Ankle 14: 129, 1993.
10. Henricson AS, Westlin NE: Chronic calcaneal pain in athletes: entrapment of the calcaneal nerve? Am J Sports Med 12: 152, 1984.
11. Kenzora JE: The painful heel syndrome: an entrapment neuropathy. Bull Hosp Jt Dis 47: 178, 1987.
12. Sammarco GJ, Helfrey RB: Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle 17: 520, 1996.
13. Rondhuis JJ, Huson A: The first branch of the lateral plantar nerve and heel pain. Acta Morphol Neerl Scand 24: 269, 1986.
14. Thordarson DB, Kumar PJ, Hedman TP, et al: Effect of partial versus complete plantar fasciotomy on the windlass mechanism. Foot Ankle 18: 16, 1997.

Re: One last comment ....

John h on 5/01/02 at 21:11 (082067)

Joe: My doctor was trained by Dr. Baxter in Houston. He performed a Baxter procedure on me where a portion of the fascia ( 1/2' semi circular wedge) is removed from over the Baxter nerve. At the same time he also performed TTS surgery examining the nerve through the tarsal tunnel and from well above the ankle that left about a 6-7 inch scar. I am a little better. Certainly no worse. Still have foot pain. By removing the wedge of fascia you are also doing a bit of a fascia release but very little and supposedly removing pressure on the Baxter nerve. One of the other ladies on the board just recently had a Baxter procedure performed and she seems to be doing very well. Carl Lewis had this procedure and got back to world class running.

Re: One last comment ....

Joe S on 5/02/02 at 07:44 (082101)

Exactly. My point is all heel pain is not necessarily plantar fasciitis.

Re: One last comment ....

john h on 5/02/02 at 11:48 (082132)

Joe S: Dr Gordon who is very knowlegeable in ESWT and who is an Orthopedic Surgeon in Canada recently told me that a certain percentage of people will just not be able to get rid of the the foot pain no matter what they do. He gave me an approximate percentage but I do not remember what it was. From all the reading on this board for the past 3-4 years I would agree with him. There are people who have posted here who have had PF type pain for 20 years. I have had it for 7 although I am much better than I was 5 years ago. I have seen post from people who seemed to have found a cure after 10 years. Mohez had bilaterial PF for some years and was not well at all. He recently posted that he had 11 ESWT treatments with 3 different machines and now is apparently cured. I have always thought that PF pain comes from a variety of sources and in fact is more than one disease process which is why what works for one does not work for another.

Re: Thanks

Sharon W on 5/02/02 at 12:57 (082145)

I just wanted to say, I appreciated you posting that article. I read it through several times and I am wondering if it might apply to me... I think I will show it to my pod.

Anyway, THANKS!

-- Sharon

Re: Thanks Joe

Been There x 4 on 5/02/02 at 16:29 (082165)

I'm not able to read your entire article right now, but took a quick glance at it and will try to digest the whole thing tonight when I have more time. I did have nerve entrapment, which was released during my last surgery. For some reason, however, it feels as bad now if not worse than it did before the surgery. Hmmmmm .... does this mean it's entrapped again? Frankly, I'm getting so tired of all of this.

Thanks again for taking the time to post your article. Hopefully, it will give me some new insight into where to go now with my feet.

Take care --

Re: DON'T DO IT!

Karen G. on 5/06/02 at 11:45 (082629)

Hi Linda,

When you had your surgery, did you go through a period of time during post op when you had the same symptoms you had prior to surgery? I had a partial fasciotomy and distal tarsal tunnel release on my left foot on March 4th, 2002. I started PT a few weeks ago. I had the expected post op pain...but now I'm feeling the old familiar symptoms again. Did this happen to you? If so how long did it last? I'm hoping the procedure was successful but I'm concerned about the symptoms.

Thanks for any info you have to offer.
Karen G.

Re: surgery?

BrianG on 4/29/02 at 18:42 (081646)

Hi Lisa,

I had a failed EPF in Sept 1999. I was led to believe the pain would be minimal, and I'd be back in my sneakers with a week or so. It wasn't so. I had bad pain, for at least 2-3 weeks. It was months before the pain finally was gone. My right arch now hurts in that foot, and the PF is worse than ever. I never hurt in the arch before it.

In talking to other doctors, since my operation, they had led me believe the procedure was a failure because not enough of the fascia was cut. It's very hard to see everything in that area, by using such a tiny camera. I personally think a lot of the failures are due to the design of the kits, that the doctors use. If I haven't scared you away by now, please take some time to talk to your doctor. Tell him that you would like to talk with patients he has cured. Ask if they have had the PF as long as you have. Ask the doctor if any of his EPF patients have gotten TTS after the procedure. There are a lot of people posting here that have developed TTS and other nerve type problems after failed EPF's. I wish you the best, but please try to have ESWT treatment before being cut. Once that happens, there is no turning back. Unfortunatly you can hurt more after an EPF, than before it. Also, a lot of Pods have stopped doing this procedure, because of the low success rate.

Regards
BrianG

Re: DON'T DO IT!

Been There x 4 on 4/29/02 at 20:00 (081664)

I've written this same thing a couple of times now, but I'm going to say it again. I've had 4 operations on my feet and can barely walk now. I started out with a 'simple' partial PF release. Find an orthopedic surgeon who does cord lengthening procedures. He/she will lengthen the cord in the back of your calf, causing the tension to ease up all up and down your leg AND YOUR FOOT, including the plantar fascia.

I would give anything to have known this before I let the first guy cut on my foot. I know there are some success stories out there, but they are far and few between. You are playing Russian Roulette with your feet if you go ahead and have a release. Once cut ... you have to face the consequences the rest of your life.

Sorry to sound so negative about PF releases, but that's because I AM negative about them. I will never advise ANYONE to have one.

Incidentally, I recently learned that my very first PF release was a total failure and that I need to have a 5th operation (my other 3 were on my other foot). If I get brave enough to do this after all I've been through, the ONLY way I'll let anyone touch me again is by lengthening the cord. During the last operation that I had, which was a total reconstruction of my foot, I had the cord lengthened on that leg. Although that foot is currently a mess, pain wise, I can at least say that the tension on the bottom of my foot is normal now (ala cord lengthening). It works.

Re: DON'T DO IT!

Lisa G on 4/29/02 at 23:53 (081703)

thank you been there and brian g...at this point been there...i can barely walk as it is...and as far as the eswt that you have suggested brian...i don't think that is an option here...ty both for your opinions...in all the research i've done...talking to people...and the dr's recommendations...it seems half are for it...and half are against it...

thanks again =)
lisa

Re: DON'T DO IT!

Pam B on 4/30/02 at 08:02 (081736)

Lisa, I have been where you are very recently and had the open PF/spur excision surgery in Feb...I can tell you for me it was a god sent....yes I have ongoing problems but after eight years of putting up with this stuff and not being able to put my foot flat on the floor for months at a time, I am here to tell you I am not sorry at all....the ESWT was not an option for me either due to insurance....and since the PF took my ability away to be independent financially, there were no options that I have not tried in eight years and could not personally afford the ESWT...please research the EPF though....even my pod agreed that the open procedure is better...the healing time is longer but the outcome is better...as we all know on this board, PF pretty much only knows remission and not cure...and for some of us that have tried it all and cannot walk more than we can....surgery is the only option....if you have the surgery, make certain that you follow your instructions to the letter for the least amount of pain and the best possible outcome...I know surgery is a personal decision and a very hard one to make when you think of what can happen...but sometimes it is necessary...just remember, we are here for you if you need us :)good luck

Re: DON'T DO IT!

Lisa G on 4/30/02 at 08:16 (081740)

gosh pam...thanks so much for you post...i have had this for 8 years too...and i can no longer work...mostly because of my feet, but also have other mitigating factors...i have it in both feet...my pod yesterday said that there is a very good chance it could come back long term if i have the surg...i have been trying to get as many opinions as possible...neither dr i saw recomended the open procedure...maybe because i need to have both feet done...but i will ask about it...

anyway...thanks again pam...nice to have a positive response...eventhough i appreciate the not so positive responses as well... =) lisa

Re: DON'T DO IT!

BrianG on 4/30/02 at 09:00 (081749)

Hi Lisa,

I really think that ESWT will be available to most people in the next year, or so. You've gone this far, can't you hold out a lttle longer? A pan management clinic could probably buy you the time needed to get ESWT. Your own docter s telling you that you could be worse off after the surgery. That won't happen with ESWT. Please give this some more thought.

BrianG

PS Most doctors usually speciallize in only one type of surgery. Could it be that both the one's you have seen don't do the open surgery?

Re: DON'T DO IT!

Linda on 4/30/02 at 10:14 (081764)

I have had fascia release, and tarsal tunnel release with heel spur removal in both feet, and i am very glad i had it done. I have no pain, and i have had plantar faciitis since 1986. I have had nothing put a positive experience, and after years of suffering, I have no pain at all.

Re: One last comment ....

Been There x 4 on 4/30/02 at 10:46 (081765)

I am very pleased (and relieved) to hear from those of you who have had such good results from your releases. What you need to understand, however, is what happens to those who do not have the same results from their surgery that you have had. It's terrific that you are doing so well ... but talk to the people who are more or less crippled forever as a result of having a PF release.

I think those of you who are encouraging these other people to have surgery are going to feel pretty bad if they go ahead and have them, based on your recommendations, and their results are irreparable failures.

I apologize for sounding fatalistic, but I have worked in healthcare for 20 years and know my way around the system pretty well. If there is someone out there who is still determined to have a PF release, do yourself a huge favor and do some research first. Find out from some of the top orthopedic surgeons in the country what their opinions are related to PF releases. I believe you will have a difficult time finding any of them who are doing this procedure any more, based on the number of negative results in the past.

If you don't know who to contact, please let me know and I will give you some names. These are surgeons who treat people from around the world, not just from around this country. If these guys, who are at the top of their field, don't do releases any more, should anyone?

Re: One last comment ....

john h on 4/30/02 at 12:23 (081779)

Ben There x 4: there are in fact many surgeons who will not do a fascia release under any circumstance. My personal feeling is that the success of a PF surgery is very much related to the skill of the doctor in his diagnosis and his skill as a surgeon. From talking to Dr. Z and some other Doctors the fascia release, unless it is an open procedure, is performed very much with 'feel'. The doctor may release 50% or 75% as even he cannot be sure how much he is releasing. I talked to one doctor who still releases 100% of the fascia. I sure would not want to be one of the first few patients a Doctor performs a PF on. Being a Doctor is very much like being a pilot. You definitely get better with age and experience. Know your Doctor!!!!!!!!!!!! There are a lot of successful PF surgeries. We just do not hear about them. After you have tried everything including ESWT and you are still in pain it gets down to you as a patient in are you willing to accept the pain you are in or accept the risk that goes with PF surgery. You need to understand that you can be made worse for life or that you may be cured or you may not get relief and not be made worse. Know your risk. Know your doctor. Get 2nd and 3rd opinions. And know all about the types of PF surgeries and above all be patient and do not rush into anything. PF with time will often cure itself.

Re: DON'T DO IT!

Pam B on 4/30/02 at 14:18 (081801)

Brian, I can appreciate advising PF sufferers to wait for ESTW and I cant speak for Lisa, but I can tell you all this other stuff that is wrong with my foot now is because of the pain and the way I walked for so long.....I know surgery is not the best option for everyone, but sometimes it is better than continuing to harm our bodies......I know in my case, I am now paying for the long term effects of putting this off for eight years.....it is like a nasty disease that keeps spreading......I know from talking to others here the same thing has happened to them......so I guess if it is just the PF and spurs ESTW is worth the wait but for some of us, enough is enough when other things start happening when we are unable to even put our foot on the floor in a normal manner.....at least that is my feeling on it...your advice is sound advice but again, the decision is a personal one that we make when the time is right for us.....I admire anyone who can deal with this pain, but eight years was enough for me....I appreciate your thoughts :)

Re: surgery?

Ed Davis, DPM on 4/30/02 at 14:37 (081810)

Did you also post on the doctor's board. I would be concerned if you have a tight gastrosoleus achilles complex that is not addressed. That, in my opinion, can often lead to failure of a plantar fascial release.
Ed

Re: DON'T DO IT!

Ed Davis, DPM on 4/30/02 at 14:47 (081812)

The lengthening of the heel cord, via the classic achilles tendon lengthening or a gastrocnemius recession is not an afterthought. It either needs to be done simultaneuosly with the plantar fascial release or not. Not all individuals will be helped by a heel cord lengthening but those who do need it, should have it done simultaneously with the plantar fascial release. Heel cord lengthenings are not without consequence so they need to be performed only when indicated.

Success stories are not 'far and few in between' as you state. I am sorry that you had a bad experience but that is not a common occurrence in the hands of knowledgeable practitioners. There is a certain variability of results which is independent of surgical technique. About 15 to 20% of surgeries will not lead to resolution and because of this variability we like to avoid the surgery unless it is absolutely necessary. I am not familiar with the details of your situation, but, in 20 years of practice, I have never performed more than one operation per foot for plantar fasciitis.
Ed

Re: surgery?

Lisa G on 4/30/02 at 15:30 (081820)

thank you for response dr davis...i talked at length with my pod...and he really suggested having the EPF on both feet at the same time...i do have other medical issues...so perhaps that is why...i will definitely re-address my tight achilles tendons and calves with him...he did say that my problem is all due to my tight achilles tendon...and there were 2 ways to fix the problem...lengthen the fascia in my feet...or lengthen my tendons...but he said the foot route is easier...i am rather concerned about the tightness in my calves...i stretch them regularly...and after 8 years...they are as tight...if not tighter...and i foresee having foot pain long term after having the EPF due to the tightness...ok...you've given me some more things to think about...thank you lisa

Re: surgery?

Pam B on 4/30/02 at 17:36 (081836)

I would like to state for the record that I did not advise anyone to have the surgery.....what I did say was it is a personal choice and I indicated it as a last resort after years of suffering.....any surgery is a risk......the way I see it is when you have PF your life is changed to start with whether you are able to manage it conservativly or if you have to resort to surgery.....once you have tried everything else and cant walk and ESTW is not an option for you.....surgery may be the only option for you to lessen your pain and suffering enabling you some quaility back to your life...I am not saying it cant fail, I am saying sometimes you are already crippled prior to surgery.....I am certainly not a doctor nor do I work in the health industry, I was simply stating my opinion that all surgeries are not failures....for someone considering surgery it is only right they have all the information available to make that personal choice and that means the successes and the failures...I believe with a good doctor and the right attitude, surgery can be a good thing in some resistant patients.....I for one, am glad I had surgery as an option available to me :)and I am thankful that I found relief

Re: DON'T DO IT!

BrianG on 4/30/02 at 18:06 (081841)

Hi Pam,

I've been exactlly where you and Lisa are, myself. This is my 9th year of debilatating chronic pain from PF. I jumped at the chance for EPF on my 'worst' foot 2 1/2 years ago. I felt I had no other choice, but it was before I knew about ESWT. It turned out to be a total failure, but I feel I was somewhat lucky , as I only have a small amount of additional arch pain in that foot. We have people here that ended up much worse than myself.

I am currently unable to work, because of the pain, and have applied for SSD. The only reasn I have my sanity at all, is because I am lucky enough to have a doctor treat me with a pain management program. This is what I am advising others to look at. Reduce your pain until ESWT is available, and stay off your feet as much as possible. I don't want to end up even more disabled than I already am, which could happen very easily with more surgery. Sometimes we feel that we have to take a certain path, but with a little more information, we may find a much easier road to go down. I hope the best for everyone, no matter what treatment they have. Just realize that you do have some alternatives to more surgery. Pain should not be the reason someone chooses surgery!

Regards
BrianG

PS I have given out this web site before, and it's now time once again. It's a good place to learn a little about pain management: http://www.pain.com

Re: DON'T DO IT!

Lisa G on 4/30/02 at 20:45 (081873)

hi brian...no i don't think that i can wait one year or longer...eventhough i have gone this far...my life is totally on hold right now...i cannot even think about getting pregnant right now because of my feet...and we are beyond ready to think about starting a family...i have other medical issues that i feel will be drastically helped by having my feet feel better...i am at a pain management clinic right now for all my problems, including feet...and i appreciate your suggestion =) ... i do...my dr didn't really tell me that i could be worse off...just that there are risks...just as with any surg...

thanks brian...i am taking all the posts i recieve into consideration ...
lisa

Re: One last comment ....

Joe S on 4/30/02 at 21:17 (081884)

Just curious been ther 4x... How much do you weigh?

Re: One last comment ....

Joe S on 4/30/02 at 21:19 (081885)

Yes. I totally agree. Definitely get 2nd and 3rd opinions. Make an informed decision about your healthcare. You are your own best patient advocate.

Re: One last comment ....

Been There x 4 on 4/30/02 at 21:47 (081889)

Hi Joe -- I'm 5'11' and weigh 135 lbs.

Re: surgery?

Julie on 5/01/02 at 02:27 (081901)

Lisa

I would be interested to know what steps have been taken to help you lengthen your gastrocnemius/soleus/achilles complex. You say you stretch them regularly, but this rings warning bells for me. What stretching do you do? The wrong stretches, exercising incorrectly, can sometimes have the opposite effect to the one you want, especially if you are stretching against pain (as you obviously are/were).

As far as the achilles is concerned, it's easy to say 'it's tight, so stretch it', but in fact tendons do not 'stretch'. My own view is that if they can tighten and shorten (as they do in women who wear high heels) they can probably be brought back to their normal/optimum length, but this takes time and great care, especially in cases of PF, where most stretching will irritate the injured fascia at its weakest, most vulnerable point.

In a situation like yours I would suggest that a night splint is the best road to go down. It works by applying a gentle, consistent stretch to the entire complex of muscles and tendons over a period of several hours. Has this been tried? And whatever exercise you do, it should be non- weight-bearing.

I don't have all the details of your history in my head, so please forgive me if you've answered this question before.

Re: surgery?

Lisa G on 5/01/02 at 03:49 (081906)

hi julie =)
i have been doing several stretches to work on the tightness in my calves...and i know i am doing them right because i have a very strict physical therapist =)

i also understood that tendons/fascia do not stretch...but i have continued with stretching my calves because i know they are tight...very tight...and i know that my tight calves are part of my problem...just part though...and right now...i don't know what else to try to get them to stretch and loosen up...

i tried night splints when i first developed PF...but they were very uncomfortable...and my feet went numb...i have a sleeping disorder...and back pain...and i just could not wear the night splints ...

the only exercise i am currently doing...or was doing before i fell and tore up my knee...was walking...i have a dog...and we live in an apt...so she NEEDS to be walked...i would take her out several times a day for shorter walks...instead of one long one...which i think helped my feet pain a little...

as is many situations...mine is complex...lots of variables...with my feetsies, tendons and calves being just one...i do feel if i can get my feet pain under control...that some of my other problems would be helped...

thank you for your response...lisa...oh...ps...i know this was just a point you were making =) but i do not wear high heels...haven't since BEFORE my PF developed...i hate high heels lol

Re: surgery?

Julie on 5/01/02 at 07:05 (081918)

Lisa

The problem with trying to stretch a tendon is that the muscle which is attaches to the bone is very elastic, whereas the tendon, though it has collagen fibres, is very much less so. So when you stretch the back of the leg - the gastroc/soleus/achilles complex - it's the muscles that you are primarily stretching. The tendon, being far less elastic, won't stretch. It's almost impossible to find a way of stretching a tendon without isolating it from the its muscle attachments, which is impossible.

However, stretching the calf muscles does pull on the achilles tendon, and if it is damaged already, the damage will increase. If you have plantar fasciitis, you are also pulling on the fascia at the weak, vulnerable point where it inserts in the heelbone.

I don't know what stretches you are doing as advised by your physiothgerapist. But if you are doing any weight-bearing stretching, this is what is happening, and I would be willing to bet it is contributing to your pain and to the intractability of your PF.

I think you should take a big step back and evaluate what you have been doing to yourself.

I also think you should consult another podiatrist before you even begin to consider surgery. The doctors who help us here have all, at various times, expressed their negative view of EPF. I would be wary of a pod who advised EPF, and extremely wary of one who wanted to do it on both feet.

Re: surgery? PS

Julie on 5/01/02 at 07:07 (081919)

I pushed the button too soon. I meant to say also that you should really try another night splint. Most of them are uncomfortable, apparently, though I've no personal experience, but the one Scott sells on this sight (click on the link) has had very good reports from users.

Re: surgery?

michelec on 5/01/02 at 09:30 (081935)

Hi Lisa. I just had open release done on April 19. I have had almost no pain so far. I am still in a walking cast and using crutches and if I put too much weight on the foot it hurts a little. But I am very optimistic. When I was trying to decide about surgery and found this board I was almost scared away by all the negative stories of surgery and the constant barrage of ESWT. I totally agree with PamB's assessment of ESWT -- if it isn't covered by insurance, I can't afford it. But after much soul-searching and chatting with people who have had successful surgeries on this board I decided to go with my pod's recommendation for surgery. He feels that the endoscopic type just doesn't allow for well enough view of the fascia. Yes the open takes longer to heel but I've had pain for 2+ years and a longer recovery isn't a hard pill to swallow since I've already had pain for so long.

It has been great to see the recovery stories that have been posted of late. I always felt that it's much more common for those who continue to have pain after treatment and surgery to continue to post because they are still looking for the magic bullet. Those who are heeled, get on with their life and don't visit as often or ever anymore. Try to remember that.

I wish you the best of luck in your surgery. I definitely recommend you talk with your doc about the open procedure vs. the endoscopic but the final decision has to be yours.

Re: surgery?

john h on 5/01/02 at 10:52 (081963)

I strongly second Julie in that doing surgery on both feet at the same time for PF is a dangerous approach. I do not think any of the 5-6 doctors who I have seen would ever consider this and some of them will not even consider surgery. Most of the doctors in our city who performed EPF surgery have dropped it in favor of MIS. From some of the literature I read nerve damage can and has occured as the scopes are inserted into the foot as this insertion is very much in the blind. I can not be more strong in my 'opinion' that PF surgery on both feet at the same time is a very bad idea.

Re: surgery?

Ed Davis, DPM on 5/01/02 at 16:31 (082022)

Lisa:

I cannot agree with the perspective that your doc has provided. I don't feel that it is a matter of doing one procedure or the other. They are not mutually exclusive. I strongly prefer that a tight achilles is dealt with conservatively. Nevertheless, if one has already made the decision to have a PF release, it seems logical to address the achilles at the same time. I feel that a tight achilles-gastrosoleus complex that is not addressed, can lead to failure of the PF release surgery and is also more likely to lead to complications such as cuboid syndrome. It depends on how tight the gastrosoleus-achilles complex is.
Ed

Re: One last comment ....

Joe S on 5/01/02 at 19:16 (082049)

I didn't mean to sound crude. However, you are on the opposite extreme of most plantar fascial release failures. I believe there is a direct relationship between plantar fasciitis and weight. Also, have you ever considered that you may have a Baxter's Nerve Entrapment? Basically, this is one of the big differential diagnoses of nonresponsive heel pain treated as plantar fasciitis. Do a literature search on the condition. To summarize, Baxter Nerve Entrapment is an entrapment of one of the lateral plantar nerve. Here is an article devoted to the condition by Dr. Alan Banks, one of the nations premier authorities in Podiatric Medicine and Surgery. He is the director of probably the best Podiatric Surgical Residency in the U.S. Here is an article in its entirety for you to read. This may be of benefit to you.

Analysis of Release of the First Branch of the
Lateral Plantar Nerve

JAPMA VOLUME 90 / NUMBER 6 / JUNE 2000

Robert M. Goecker, DPM*
Alan S. Banks, DPM†

*Submitted during third-year residency, Northlake Regional Medical Center, Tucker, GA. Mailing address:1961 Floyd St, Ste C, Sarasota, FL 34239.

† Member, The Podiatry Institute, Tucker, GA; Director of Residency Training, Northlake Regional Medical Center, Tucker, GA.

--------------------------------------------------------------------------------

The authors conducted a retrospective study of the release of the first branch of the lateral plantar nerve in the treatment of chronic heel pain unrelieved by conservative treatment modalities. A total of 17 patients (18 feet) were evaluated following external neurolysis for heel pain caused by entrapment of the first branch of the lateral plantar nerve. The average postoperative follow-up time was 32.8 months, with a range of 10 to 72 months. Every patient deemed the surgery successful. At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. There was one postoperative complication, medial calcaneal nerve entrapment; it was successfully treated with neurectomy. (J Am Podiatr Med Assoc 90(6): 281-286, 2000)

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Plantar heel pain is usually attributed to plantar fasciitis or heel spur syndrome. In certain individuals, however, a different entity can produce similar pain and symptoms. Several authors have described a neurogenic source of heel pain: entrapment of the first branch of the lateral plantar nerve.1-12

The first branch of the lateral plantar nerve is a mixed nerve with both motor and sensory fibers. Muscles supplied by this nerve include the abductor digiti minimi, flexor digitorum brevis, and quadratus plantae. Sensory fibers supply the calcaneal periosteum, the long plantar ligament, and the skin at the plantar lateral aspect of the foot. This branch originates from the lateral plantar nerve proximal to the abductor hallucis and then dives through the fascia at the superior margin of the abductor. The nerve courses distally between the abductor hallucis muscle and the medial edge of the quadratus plantae until it reaches the inferior margin of the abductor fascia. There it turns laterally between the flexor digitorum brevis and the quadratus plantae.1 The nerve at this point lies adjacent to the calcaneus approximately 0.5 cm distal to the medial tubercle of the calcaneus.2, 3 Failure of traditional heel spur surgery may be due to damage and subsequent entrapment of the first branch of the lateral plantar nerve or an inadequate release of a primary neurogenic source of heel pain. Obviously, the nerve is not released through the traditional open heel spur surgical approach. This nerve branch should not be confused with the medial calcaneal nerve, a purely sensory nerve that lies in the superficial fascia of the heel.4, 5

In 1963, Tanz6 proposed the first branch of the lateral plantar nerve as an overlooked source of plantar heel pain, and he demonstrated the nerve's anatomy from cadaveric dissection. However, it was not until 1981 that Przylucki and Jones3 correlated actual patient symptoms with this structure. Their surgical treatment for this condition consisted of excision of the nerve. Subsequently, other authors reported successful treatment of this type of chronic heel pain with external neurolysis rather than nerve excision.1, 4, 5, 7, 8, 10-12

Baxter and Thigpen7 in 1984 described two possible sites of entrapment. The first is the sharp fascial edge of the abductor hallucis muscle where the nerve changes course and turns laterally. Another possible site is the medial ridge of the calcaneus where the nerve passes beneath the tuberosity and origin of the flexor digitorum brevis and the plantar fascia. Therefore, nerve impingement may be caused by an increase in mass, such as a calcaneal spur, within the flexor digitorum brevis. Rondhuis and Huson13 concluded that the exact site of the entrapment is where the nerve passes between the taut deep fascia of the abductor hallucis muscle and the medial caudal margin of the medial head of the quadratus plantae muscle (Fig. 1). Pronation, muscle hypertrophy, or other sources of irritation have been cited as instigating events that may irritate the nerve as it passes through the fascial port of the abductor hallucis.

Patients with heel pain secondary to nerve entrapment may present with slightly different symptoms than individuals suffering from plantar fasciitis. In the former condition, the pain is usually not as great in the morning or after periods of rest, but seems to be more pronounced after activity. Przylucki and Jones3 noted that compression of the first branch of the lateral plantar nerve may occur by physiologic motion secondary to pronatory forces. As the foot is pronating, the tension of the fascial structures increases, resulting in compression of the nerve. This suggests that the nerve compression may be not only static (constant) but also dynamic and can worsen with pathologic gait patterns.

However, in some patients a history more similar to that associated with plantar fasciitis may be described. Chronic inflammation of the plantar fascia may coexist with, and possibly predispose to, entrapment of the first branch of the lateral plantar nerve.4, 5 Therefore, the patient may initially have some component of plantar medial heel pain as well. In such cases, the plantar fascial symptoms will tend to respond to the conservative modalities, but the symptoms related to the nerve entrapment may tend to persist. In some instances, the patient may complain of pain radiating toward the lateral aspect of the heel following the normal anatomical course of the nerve. There may be associated motor weakness of the abductor digiti minimi indicated by the patient's inability to abduct the fifth toe (Fig. 2). Abduction of the fifth toe may be a difficult task for many people to perform, but in some individuals with this entrapment, a difference may be observed between the symptomatic and asymptomatic sides.

Regardless of the history, the diagnosis of entrapment of the first branch of the lateral plantar nerve may be made during the clinical examination. The exact source of the patient's symptoms may be determined by careful palpation of the plantar aspect of the heel. Clinically, the pathognomonic sign of this entity is greater pain with compression over the medial aspect of the heel than plantarly (Fig. 3). Hendrix et al8 labeled this test the nerve compression test. Palpation in this region pinches the nerve between the deep fascia of the abductor hallucis and medial caudal margin of the quadratus plantae, resulting in pain and possible paresthesia.1 Hendrix et al8 have also found that plantarflexion and inversion of the foot (Phalen's maneuver) may be helpful in diagnosing entrapment of the terminal branches of the tarsal tunnel, including the first branch of the lateral plantar nerve. This movement reduces the width of the porta pedis and causes the superior margin of the abductor hallucis to compress the nerve, producing nerve impingement signs and symptoms. The nerve is also felt to be compressed at the exit site of the fascia between the abductor and flexor brevis.4, 5

The role of other diagnostic tests, such as electromyography and nerve conduction velocities, has been described by Schon et al.9 They found electrophysiologic abnormalities in 23 of 38 symptomatic heels, although careful review reveals that abnormalities in the lateral plantar nerve were found in only 7 patients (16%). It is also worth noting that the first branch of the lateral plantar nerve is technically difficult to isolate. It must therefore be emphasized that diagnostic tests are not a substitute for good clinical evaluation. If one does not trust a clinical diagnosis of nerve entrapment, technetium bone scans and magnetic resonance imaging (MRI) evaluations can be used to rule out an inflammatory source of heel pain. In the first few cases evaluated by the authors, patients underwent technetium bone scans and MRI evaluations, both of which failed to demonstrate inflammatory change in the heel area. This suggests that in these patients the pain is more consistent with nerve entrapment. Therefore, simple release of the plantar fascia will have limited effects on the symptoms.

The purpose of this article is to report on the success and long-term efficacy of release of the first branch of the lateral plantar nerve in those patients who failed to respond to conservative treatment modalities.

Materials and Methods

A total of 17 patients (18 feet) with painful medial heel pain were first treated with conservative modalities, such as padding, strapping, orthoses, various forms of immobilization, cortisone injections, and diagnostic nerve blocks. All patients had received extensive conservative treatment. Some of the patients had received conservative care by other physicians prior to surgical intervention by the authors. Anyone with prior heel surgery was excluded from the study. In each of these cases, the diagnosis of nerve entrapment was based on a positive clinical history and physical diagnostic findings consistent with entrapment of the first branch of the lateral plantar nerve. No other diagnostic modalities are necessary or routinely used by the authors for this condition. Surgery was elected in recalcitrant cases. The surgeries included in the study were performed over a 5-year period. All patients' charts were reviewed, and each patient was evaluated by means of a follow-up examination or a telephone interview. The outcome of the procedures was assessed by means of a questionnaire (Fig. 4).

The surgical technique that was used consists of an oblique incision made over the medial aspect of the heel overlying the course of the first branch of the lateral plantar nerve. The distal extent of the incision ends just beyond the junction of the calcaneal tuber and the plantar fascia. When the incision is oriented in this manner, it remains relatively parallel to the branches of the medial calcaneal nerve; this creates less potential for postoperative entrapment of these structures (Fig. 5).

Dissection is carried through the subcutaneous tissue until the deep fascia over the abductor hallucis can be identified. The superficial fascia is then bluntly separated anteriorly and posteriorly so that the abductor fascia may be clearly visualized. A carefully controlled inverted T-incision is then made, with the horizontal component of the T beginning at the inferior margin of the deep fascia overlying the abductor hallucis muscle. The vertical incision is then made extending proximally from the middle of the horizontal arm to the superior aspect of the abductor hallucis muscle belly. The muscle belly of the abductor is freed from the fascia at the superior margin and retracted inferiorly, exposing the fascia separating the abductor hallucis from the quadratus plantae. A vertical incision is then made through this deeper fascial layer, and a segment of tissue is removed. This should eliminate any constriction of the first branch of the lateral plantar nerve. As the nerve may also be compressed at the inferior edge of the abductor muscle, this fascia deep to the abductor hallucis muscle belly is vertically sectioned as far inferiorly as possible. The abductor muscle is retracted superiorly, and any remaining intermuscular fascia between the abductor and flexor digitorum brevis is sectioned. This circumferentially releases the fascia around the abductor hallucis muscle belly.

Next, a small portion (approximately one-quarter) of the medial aspect of the plantar fascia is sectioned to completely free the abductor hallucis and eliminate any potential irritation at this level. However, the windlass effect of the plantar fascia is maintained. Sometimes, if it is deemed necessary, an inferior calcaneal spur is gently removed with hand instruments. A Freer elevator is usually placed over the spur to prevent damage to the soft tissues and nerve at this level.

Following surgery, the patient is kept nonweightbearing for 3 weeks. A cast or posterior splint, as opposed to a soft bandage alone, has worked well. It is felt that maintaining the foot in a neutral position prevents coaptation of the incised fascial tissues.

Orthotic support is reinstituted following surgery, especially in patients in whom the plantar fascia is partially sectioned. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and the lateral column. Pain or discomfort in this region was noted postoperatively, despite significant improvement in the heel. This generalized cramping, achiness, and midfoot pain tends to resolve over time and is effectively treated with biomechanical support.

Results

Seventeen patients (18 feet) who had undergone release of the first branch of the lateral plantar nerve using the previously described technique were available for follow-up clinical or telephone evaluation. The average duration of heel pain prior to surgery was 21.2 months, with a range of 6 to 120 months. The time elapsed since surgery ranged from 10 to 72 months, with an average postoperative follow-up time of 32.8 months. Every patient deemed the surgery successful. On a pain scale of 0 to 4, all patients were asked to rate their pain both preoperatively and postoperatively (Table 1). At the time of follow-up examination, nine feet were asymptomatic and nine feet experienced mild pain after extended activity. The average preoperative heel pain rating was 3.67, and the average postoperative pain rating was 0.5. A paired t-test was performed on the pain level data, revealing a statistically significant difference to a level of P< .001. There was one postoperative complication, medial calcaneal nerve entrapment, which was successfully treated with neurectomy. This patient is currently asymptomatic.

Three patients complained of a dull pain and a feeling of weakness across the top of the foot between 5 and 10 months postoperatively. Symptoms in this area can probably be attributed to the 'settling phenomenon' that occurs after partial plantar fasciotomy. Thordarson et al14 showed a progressive loss of the arch-supporting function of the plantar fascia as the fascia was sequentially sectioned from medial to lateral. The loss of support of the plantar fascia results in greater weightbearing forces in the midfoot and subsequent pain.

Two patients also experienced vague lateral column pain. Both of these events were transient. In order to protect the midfoot and lateral column from increased stress after plantar fasciotomy, the authors section only the most medial expansion of the plantar fascia and suggest the use of postoperative orthoses.

Discussion

The vast majority of patients suffering from heel pain achieve symptomatic relief with conservative measures. However, it is important to remain aware of sources of heel pain other than plantar fasciitis. Although reports of neurogenic heel pain have been linked to medial calcaneal nerve entrapment, tarsal tunnel syndrome, and heel neuromas, recent literature suggests that entrapment of the mixed (motor and sensory) nerve to the abductor digiti minimi may be a common source of medial heel pain.1-12 Histologic examination of the nerve branches that have been excised under the described intermuscular septum between the abductor hallucis and quadratus plantae revealed evidence of hypertrophy, perineural fibrosis, increased endoneural collagen, and loss of myelinated fibers consistent with nerve entrapment.1, 3, 7

Once a diagnosis of nerve entrapment is made, conservative treatment modalities similar to those used for plantar fasciitis are instituted. However, it is the authors' experience that these patients demonstrate a less positive response to conservative and supportive treatment modalities. In these cases, a surgical approach that deals with potential nerve entrapment is employed.

As with any procedure, surgical approaches vary and have been adapted over time. Przylucki and Jones3 first described surgical management of this condition. Their approach involved removal of the calcaneal exostosis, plantar fasciotomy, and excision of the muscular branch of the lateral plantar nerve to the abductor digiti minimi. The procedure was performed in only three cases, and the incision placement and exact technique were not discussed.

Baxter and Thigpen7 performed the first large retrospective study of neurolysis of the first branch of the lateral plantar nerve. They performed the procedure on 34 heels using a modified DuVries heel spur incision. They recommended releasing the deep fascia of the abductor hallucis muscle and, if necessary, sectioning a small portion of plantar fascia as well as excising a small portion of a plantar heel spur, decompressing the nerve. They also noted that complete plantar fascial releases and heel spur resection should be avoided.

Henricson and Westlin10 performed the neurolysis through an oblique curved incision extending from below the medial malleolus toward the medial anterior edge of the heel pad. Kenzora11 used a plantar midline incision. These two techniques were used to avoid complications of medial calcaneal nerve injury secondary to the DuVries incision.

Baxter and Pfeffer1 published the results of a retrospective study involving 69 feet that underwent neurolysis. The incisional approach was modified to an oblique vertical incision over the medial heel similar to that described by Henricson and Westlin.10 This incision parallels the course of the nerve and is less likely to injure the medial calcaneal nerve. However, Baxter and Pfeffer still reported two medial calcaneal nerve entrapments with their new incision. The authors, as well as Sammarco and Helfrey,12 have also used the oblique vertical medial heel incision successfully. Even with this incision, extreme caution must be employed at the superior aspect of the incision to avoid injury to the medial calcaneal nerve branch. In the authors' review of 18 surgical procedures, one patient did experience a medial calcaneal nerve entrapment, which was successfully treated with nerve excision.

Recently, Hendrix et al8 proposed a transverse medial oblique approach that allowed them to decompress not only the first branch of the lateral plantar nerve but also the posterior tibial, medial plantar, and lateral plantar nerves. They released the terminal branches of the posterior tibial nerve because of their belief that the chronic heel pain is related to distal tarsal tunnel syndrome. The authors of the present article believe that it is not necessary to decompress the other distal branches of the posterior tibial nerve (tarsal tunnel release) concomitantly with the first branch of the lateral plantar nerve, especially when a limited incision is used for exposure and release.

Finally, one must consider the possibility of plantar fasciitis or heel spur syndrome coexisting with the nerve entrapment. Chronic inflammation from plantar fasciitis and large calcaneal spurs have been linked etiologically to entrapment of the first branch of the lateral plantar nerve.11 The current authors did section the most medial expansion of the plantar fascia in every patient and removed two very large heel spurs. Other authors also report sectioning a portion of the plantar fascia and excising large spurs if deemed necessary during nerve release.1, 11, 12 Baxter and Pfeffer1 did not section the plantar fascia in any patient to preserve the windlass mechanism. They did, however, remove any spur that was present. Considering the effect of a plantar fasciotomy on the foot, the authors recommend minimal release followed by postoperative support to minimize any deleterious effects on the midfoot or lateral column.

Conclusion

In the vast majority of patients, heel pain is due to plantar fasciitis and can be treated conservatively. In certain individuals, a neurogenic source of heel pain entrapment of the first branch of the lateral plantar nerve must be considered, especially in recalcitrant cases. Readers are encouraged to examine the medial heel as part of the initial evaluation of patients with heel pain. The long-term results of the surgical release of this nerve with partial plantar fasciotomy have been promising.

References

1. Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279: 229, 1992.
2. Arenson DJ, Cosentino GL, Suran SM: The inferior calcaneal nerve. JAPA 70: 552, 1980.
3. Przylucki H, Jones CL: Entrapment neuropathy of muscle branch of the lateral plantar nerve: a cause of heel pain. JAPA 71: 119, 1981.
4. Banks AS: 'Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '94, ed by CA Camasta, NS Vickers, JA Ruch, p 27, The Podiatry Institute, Tucker, GA, 1994.
5. Banks AS: 'Entrapment of the First Branch of the Lateral Plantar Nerve: Another Source of Chronic Heel Pain, ' in Reconstructive Surgery of the Foot and Leg: Update '95, ed by CA Camasta, NS Vickers, JA Ruch, p 159, The Podiatry Institute, Tucker, GA, 1995.
6. Tanz SS: Heel pain. Clin Orthop 28: 169, 1963.
7. Baxter DE, Thigpen CM: Heel pain operative results. Foot Ankle 5: 16, 1984.
8. Hendrix CL, Jolly GP, Garbalosa JG, et al: Entrapment neuropathy: the etiology of intractable chronic heel pain syndrome. J Foot Ankle Surg 37: 273, 1998.
9. Schon LC, Glennon TP, Baxter DE: Heel pain syndrome: electrodiagnostic support for nerve entrapment. Foot Ankle 14: 129, 1993.
10. Henricson AS, Westlin NE: Chronic calcaneal pain in athletes: entrapment of the calcaneal nerve? Am J Sports Med 12: 152, 1984.
11. Kenzora JE: The painful heel syndrome: an entrapment neuropathy. Bull Hosp Jt Dis 47: 178, 1987.
12. Sammarco GJ, Helfrey RB: Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle 17: 520, 1996.
13. Rondhuis JJ, Huson A: The first branch of the lateral plantar nerve and heel pain. Acta Morphol Neerl Scand 24: 269, 1986.
14. Thordarson DB, Kumar PJ, Hedman TP, et al: Effect of partial versus complete plantar fasciotomy on the windlass mechanism. Foot Ankle 18: 16, 1997.

Re: One last comment ....

John h on 5/01/02 at 21:11 (082067)

Joe: My doctor was trained by Dr. Baxter in Houston. He performed a Baxter procedure on me where a portion of the fascia ( 1/2' semi circular wedge) is removed from over the Baxter nerve. At the same time he also performed TTS surgery examining the nerve through the tarsal tunnel and from well above the ankle that left about a 6-7 inch scar. I am a little better. Certainly no worse. Still have foot pain. By removing the wedge of fascia you are also doing a bit of a fascia release but very little and supposedly removing pressure on the Baxter nerve. One of the other ladies on the board just recently had a Baxter procedure performed and she seems to be doing very well. Carl Lewis had this procedure and got back to world class running.

Re: One last comment ....

Joe S on 5/02/02 at 07:44 (082101)

Exactly. My point is all heel pain is not necessarily plantar fasciitis.

Re: One last comment ....

john h on 5/02/02 at 11:48 (082132)

Joe S: Dr Gordon who is very knowlegeable in ESWT and who is an Orthopedic Surgeon in Canada recently told me that a certain percentage of people will just not be able to get rid of the the foot pain no matter what they do. He gave me an approximate percentage but I do not remember what it was. From all the reading on this board for the past 3-4 years I would agree with him. There are people who have posted here who have had PF type pain for 20 years. I have had it for 7 although I am much better than I was 5 years ago. I have seen post from people who seemed to have found a cure after 10 years. Mohez had bilaterial PF for some years and was not well at all. He recently posted that he had 11 ESWT treatments with 3 different machines and now is apparently cured. I have always thought that PF pain comes from a variety of sources and in fact is more than one disease process which is why what works for one does not work for another.

Re: Thanks

Sharon W on 5/02/02 at 12:57 (082145)

I just wanted to say, I appreciated you posting that article. I read it through several times and I am wondering if it might apply to me... I think I will show it to my pod.

Anyway, THANKS!

-- Sharon

Re: Thanks Joe

Been There x 4 on 5/02/02 at 16:29 (082165)

I'm not able to read your entire article right now, but took a quick glance at it and will try to digest the whole thing tonight when I have more time. I did have nerve entrapment, which was released during my last surgery. For some reason, however, it feels as bad now if not worse than it did before the surgery. Hmmmmm .... does this mean it's entrapped again? Frankly, I'm getting so tired of all of this.

Thanks again for taking the time to post your article. Hopefully, it will give me some new insight into where to go now with my feet.

Take care --

Re: DON'T DO IT!

Karen G. on 5/06/02 at 11:45 (082629)

Hi Linda,

When you had your surgery, did you go through a period of time during post op when you had the same symptoms you had prior to surgery? I had a partial fasciotomy and distal tarsal tunnel release on my left foot on March 4th, 2002. I started PT a few weeks ago. I had the expected post op pain...but now I'm feeling the old familiar symptoms again. Did this happen to you? If so how long did it last? I'm hoping the procedure was successful but I'm concerned about the symptoms.

Thanks for any info you have to offer.
Karen G.