Remove spur or Cut fascia?Posted by Mike P on 9/03/03 at 20:24 (128729)
How can a doctor decide which is the best surgery for a patient that has heel pain for over 2 years? X-rays show a prominent spur and an MRI shows NO abnormalities. I have been a runner for 5 years and have done all the conservative treatments and ESWT. Is is possible to remove the spur and leave the fascia intact? Can the spur agitate the fascia to provide pain that mimics fasciitis?
Re: Remove spur or Cut fascia?Dr. Z on 9/03/03 at 20:42 (128730)
When I do surgery I perform both procedures at the same time. You are inside the foot so why not do both.
The mri can show a normal fascia and still have pf. The criteria for surgery is first step morning pain or after you have been sitting for any length of time and get up, you then have pain
Pin point pain at the insertional plantar fascia with phyical examination. No TTS and or nerve entrapement.
I like the mininial incision heel spur operation. If ESWT fails to resolve foot pain then this is the procedure I do.
Very important that it is determined that your pf is the problem before any foot surgery is considered.
Re: Remove spur or Cut fascia?Dr. David S. Wander on 9/04/03 at 20:06 (128791)
Hi David (Dr. Z)
I don't agree with your comment 'you are inside the foot so why not do both'. I understand your thought, but any surgery that is not necessary should not be performed. If you do not truly believe that the spur is actually causing the pain, then it should be left alone. Removing the spur via any method, whether it is an open procedure or minimal incision procedure can cause complications such as periostitis, bone infection, stress fracture, etc. Once again, I understand your thought but I don't believe in performing any procedure that will probably not change the outcome.
Re: Remove spur or Cut fascia?Dr. Z on 9/04/03 at 20:55 (128799)
I will just tell it like it is and make it simple. In my experience of doing mimial incision plantar partial fasciotomy you will get more sucessful results when you remove the spur and cut the fascia. If you just cut the fascia the results will be less effective.
What I meant by already being in there is that since you are at the area where the spur is located you should remove the spur.
What I believe is that there is a fasciosis and the spurring is part of the insertional pain. By cutting the fascia and removing the spurring at the same time you have a greater chance of a cure.
I have gone back on a few cases and removed the spur when the release still left the patient in pain and the pain was then cured
Whether the spur removal was the reason is very difficult to determine
I call this situation a soft tissue mal-union at the insertion and you need to remove and or cut the fascia and or bone at the insertion to get the best healing situation
I do believe that the spur removal is very important when doing minimial incision plantar partial fasciotomy. That is just my opinion
Re: Remove spur or Cut fascia? Third opinionEd Davis,DPM on 9/04/03 at 20:56 (128800)
My opinion may be a bit closer to Dr. Wander's on this one. We need to make a decision on whether the spur itself is in some way contributing to the problem. Many would agree that, in the majority of cases, the spur is not the culprit and that removing it increases healing time. As such, I would usually recommend releasing the fascia only unless the spur is sizable.
Sometimes heel spurs are of sufficient size to be termed 'weight bearing spurs.' The calcaneal inclination angle (pitch of the heel bone) can decrease over time, particularly in patients with tight gastrosoleus achilles. That progressive decrease in pitch can create somewhat of a downward angulation of the spur such that the spur can become a source of pain -- not a common scenario though.
Re: Remove spur or Cut fascia? Third opinionDr. Z on 9/04/03 at 21:29 (128804)
There are many times that we don't even remove the entire spur. I make my cut into the fascia at the interface where the fascia inserts into the bone, thus the name insertional plantar fasciitis. I am creating trauma to that specific area. The spur 'area' is the land mark for where the bone and the fascia meet. In addition cutting the fascia distal to this area is
the reason you can have nerve damage. Staying close to the bone is very safe.
This has nothing to do with is it the spur or is it the fascia. The area where you are doing the surgery is what is most important and that area is where the spur and the fascia insertion are located
Re: Remove spur or Cut fascia? Third opinionMike P on 9/04/03 at 21:53 (128813)
So Doctors...how can you determine what is causing the pain...the fascia or the spur????
Thanks so much!
Re: Remove spur or Cut fascia? Third opinionDr. Z on 9/05/03 at 01:33 (128820)
You can't. So you do both
Re: Remove spur or Cut fascia? Third opinionMike P on 9/05/03 at 09:24 (128847)
Thank you doctors for your help!
Re: Remove spur or Cut fascia? Third opinionDr. David S. Wander on 9/05/03 at 19:45 (128900)
Mike, it's my strong belief that it is not both, but it is the fascia that is causing the pain and possibly an inflammation at the interface of the fascia and the bone, but not the spur. As has been noted on this site many times, the 'spur' is not usually a pointy object like people imagine, but it is actually a shelf of bone going across the heel bone. In my opinion, removing the spur is rarely indicated and creates more trauma to the bone. A soft tissue procedure (releasing the fascia) is now a soft tissue and bone procedure once the decision is made to remove the spur. My experience does not parallel Dr. Z's experience. I have found that patients that have had the fascial release and spur removal have additional complications and a longer recovery.
Re: Remove spur or Cut fascia? Third opinionDr. Z on 9/05/03 at 20:19 (128905)
Have you ever read the articles by Dr. Mercado from Chicago. He only removed the spur and the results were excellent.
I do agree that patients that have OPEN plantar fascia release with bone spur removal will have additional complications and a longer recovery. Patients that have minimial incision partial plantar fasciotomy with osteotomy( spur removal) don't have the complications that you see with the OPEN procedure.
As you know whether you cut the fascia you are risking serious complications by disruption of the windlass mechanism in the human foot. This is why ESWT is much superior to any pf surgery.
Re: Remove spur or Cut fascia?Mike P on 9/05/03 at 21:48 (128913)
Dr. Wander....according to your website of free handouts...you make the following statement 'an MRI may be performed if a small 'stress' type fracture is suspected. Additionally, an MRI is useful in determining the status of the surrounding tissue and can determine if there is a tear of the fascia or any other soft tissue and bone abnormalities.' I had an MRI several weeks ago and the Dr reading the images stated 'there are no abnormalities in this patients foot' except for the presence of a heel spur. Based on his diagnosis, am I to believe the problem may rest in the heel spur (on X-ray also) aggravating the fascia in this case so that it will not heal. I see the you and Dr Z have seperate schools of thought on taking off the spur. What has been your experience in leaving the spur alone and success rate in relieving the pain. I have no classic pain out of bed in the AM....only throughout the day as I stand for many hours in a teaching capacity. Thanks for your comments. It is appeciated!
Re: Remove spur or Cut fascia?Dr. Z on 9/05/03 at 22:03 (128917)
I want to add one more thing. Doing any pf and or heel spur surgery without the classic first step pain can lead to serious complication. You can have normal fascia reading via mri and an abnormal fascia with an ultrasound evaluation.
Re: Remove spur or Cut fascia?BGCPed on 9/06/03 at 07:10 (128932)
Mike just a question. I noted you are a runner and said you tried all the classic treatments. I dont want to add to your question but if you dont have pain when rising but do during your work day what shoes do you wear while teaching?
Also what if any kind of orthotic do you have? They are not always done right. I get many runners per week that have 1 or 2 gym bags filled with shoes and orthotics that didnt work. A few questions to ask yourself are you most symptomatic during work days and does it increase as the week goes on?
is it better or worse when you get home if you take your work shoes off? if you get a few days off work and bum around in your running shoes does it get better or worse? I am not trying to confuse you just throwing that out there. you could post a few pics of you standing barefoot from the front and from the back (on a hard floor no carpet) also a pic of your orthotics if you have them and your running shoe and work shoe.
This may sound like a hassle but I have seen many many pt that get spur surgery that were given bad orthotics and poor shoe advice. This is not a slam but an observation. I am the first to say there are many people doing orthotics that have no business doing them.
In your case I would hate to see you get cut without having your footwear, size and orthotics evaluated. I do orthotics for Hansons Running Team so I deal with high level runners every day.
I would make this offer to you. If you can post the pics myself or one of the Drs may see something that was missed. I know via pics is not the greatest method but. I would also offer you to come to my facility to have your orthotics, gait, footwear etc evaluated. If I think I can help I would not charge you to make a pair. I do them while you wait so they are done in 1 hour and I have a Hansons Running Shop next door so you can also get a proper shoe if needed.
I am 1 hour from Detroit. I dont know your location but it may be worth it for you. A flight can be cheaper than some people charge for orthotics. Again I am not trying to add to your questions or second guess your Dr but surgery is final. It is common sene to exhaust all forms of conservative treatment.
Re: Remove spur or Cut fascia?Kathy L on 9/06/03 at 09:50 (128946)
Mike and Drs,
Your post is an interesting one to watch and raised a quesiton in my mind.
Q for Drs: If, for some reason, the PF pain was really getting better, does the body ever disolve the spurs... in other words, do they sometimes get smaller or go away with on their own?
Mike: I hope you saw my recent post on supplements. I can only wish, but I sure wish you could try what I took for 2 weeks to see if it helps you. Cost would be insignificant compared to surgery, and 2 weeks, that's no time at all.
Re: Remove spur or Cut fascia? Third opinionDr. David S. Wander on 9/06/03 at 10:41 (128952)
David (Dr. Z)
Not only have I read Dr. Mercado's articles/bookd, (which were written about 20 year ago), but I was trained by Dr. Mercado in Chicago. Although you state that there are more complications with open vs. MIS procedures, I'm not aware of any legitimate controlled study comparing the two techniques. There are various definitions of 'minimal' incision, some utilize 'blind' cutting, some utilize a flouroscope, some use a traditional blade, some utilize a Smylie knife, etc. I've performed the procedure via just about every method, and my conclusions are:
1) I do not believe in removal of the 'spur' in 99.9% of the cases.
2) I am not an advocate of release of the plantar fascia, no matter what method is used, since I believe that the majority of plantar fasciitis/plantar fasciosis can be relieved with conservative care, and recently even more patients can avoid surgery with the advent of ESWT.
Re: Remove spur or Cut fascia?Dr. David S. Wander on 9/06/03 at 10:54 (128953)
In 1999 I was a co-author of a paper appearing in the American Journal of Roentgenology (Radiology), one of the premier journals utilized by radiologists. The title of the article was 'MR Imaging of Plantar Fasciitis: Edema, Tears and Occult Marrow Abnormalities Correlated with Outcome'. Some of the conclusions of the article were that although we found some unique findings on MRI with patients with plantar fascia pain, the overall treatment outcome did not differ greatly from those patients that have minimal/benign findings on MRI.
Just because you have heel pain, does not mean that you will have any significant findings on MRI. Recent studies have shown that microscopically, there is no inflammation of the fascia, therefore the term fasciitis is not accurate. There is often thickening of the fascia which is referred to as fasciosis. Additionally, just because you have heel pain does not mean you have fasciitis/fasciosis. There are other causes of heel pain such as nerve entrapments, arthritic conditions, biomechanical considerations or a combination of all the above. Unless your 'spur' is one of the very rare spurs that actually projects downward and is full weighbearing, I would strongly caution you against spur removal.
To add fuel to the fire, I believe that Dr. Z will agree with me that not all MRI reports are created equal. I have seen many MRI reports that I do not agree with, and I make sure that all MRI's I order for the foot/ankle are read by radiologists specializing in musculoskeletal MRI. These films can be very tricky to read and unless the findings are very obvious, small findings regarding the fascia or underying small marrow changes may be overlooked.
Re: Remove spur or Cut fascia? Third opinionDr. Z on 9/06/03 at 11:18 (128957)
How can you explain that Mercado only removed the spur and his results
Re: Remove spur or Cut fascia?Dr. Z on 9/06/03 at 11:29 (128958)
No the spur doesn't change in size. In fact sometimes it gets larger as the pain resolves.
Re: Remove spur or Cut fascia? Third opinionBGCPed on 9/06/03 at 12:13 (128965)
I like your approach Dr Wander
Re: Remove spur or Cut fascia?Dorothy on 9/06/03 at 13:57 (128971)
A thoroughly interesting, clear and enlightening post on this. Thank you.
Re: Remove spur or Cut fascia?Pat S on 9/06/03 at 22:18 (128997)
It was enlightening to read this posting. My husband has suffered from plantar fasciitis for 2 1/2 years; has went through all treatments, including Ossatron and we will soon be going to Mayo to see about this surgery. We are so surprised that doctors around our city don't know more about this disabling hurt and the treatment. They seem to think at times that you are lying about the pain...it is very frustrating. Thank you all for your postings, at least we know there are others who suffer from this.
Re: Remove spur or Cut fascia? WAIT!!!!Mike P on 9/07/03 at 00:03 (129000)
To BGCPed...thank you for the offer...let me dwell on it a few days. To Dr Z and Dr Wander..thank you for the information. It is certainly appreciated...not sure what course to take now except for ultrasound to make a hopefully clearer determination as to next 'step' to take.
Re: Remove spur or Cut fascia? Third opinionEd Davis, DPM on 9/07/03 at 00:21 (129001)
It is not clear to me that only the spur can be removed. While it may be true that not all of the fascia attaches to the spur, that part of the fascia that does need be removed so that one has access to the spur.
Re: Remove spur or Cut fascia? WAIT!!!!Ed Davis, DPM on 9/07/03 at 00:36 (129004)
I guess my advice didn't rate...
Re: Remove spur or Cut fascia? Third opinionDr. David S. Wander on 9/07/03 at 00:54 (129006)
In all due respect to Dr. Mercado, the results he reported were anecdotal, which represented his opinion based on his surgery, not a controlled, blind study. If you read his book, he also states 'a heel spur would be a rare finding in a thin individual with a sedentary occupation'. I strongly disagree with that statement, and would challenge that statement. Heel spurs are seen on all body types and activity levels, though heel pain is obviously exacerbated by being overweight and active. He also states that heel spurs are rarely found on patients with cavus foot types and the quote is 'if the practitioner reflects back on his personal experiences with heel spur patients, he will be hard pressed to find a heel spur in a cavus type foot'. I surely don't agree with this Dr. Z, do you?? I have a great amount of respect for Dr. Mercado, but his word is not gospel and just because he states that he has great results by only removing the spur, doesn't mean that those results are scientifically valid and certainly will not cause me to begin removing the spurs, since I believe the spur rarely causes any pain. And as Dr. Ed Davis so accurately stated, it is virtually impossible to simply remove the spur without disturbing any soft tissue attachments.
Re: Remove spur or Cut fascia? WAIT!!!!Dorothy on 9/07/03 at 03:05 (129007)
I'm not Mike, but I have been following this discussion, finding it very interesting and informative...and I think your advice did/does rate. My guess is that, because the discussion continued on to involve primarily Dr. Z and Dr. Wander, Mike simply acknowledged those closer to the end of the thread. I always find your comments and Dr. Wander's particularly informative. My guess is that Mike does, too.
Re: Remove spur or Cut fascia?Hilary G on 9/07/03 at 03:27 (129008)
Mike- If you haven't tried ART as of yet, I would encourage you to try it before having surgery done. My partner is a runner who had stopped running for over a yr due to PF. After 5 Active Release treatments she is running again. I am not a runner, but I did have PF for 20 yrs and was cured by Active Release. My chiro who performs this technique said it will work on PF with or without spur,. Please look at websites activerelease.com and drabelson.com. They are very informative and can help you locate a provider in your area. Just a suggestion from a happy person who suffered for many yrs. Hilary
Re: Remove spur or Cut fascia? Third opinionwendyn on 9/07/03 at 08:44 (129012)
Then I am a rare find.
But - I knew that already
Re: Remove spur or Cut fascia? WAIT!!!!BGCPed on 9/07/03 at 10:29 (129019)
Thanks Mike, think it over. I would try to post those pics or email them to me. May be something obvious, maybe not but thats an easy thing to do
Re: Remove spur or Cut fascia? Third opinionDr. Z on 9/07/03 at 10:32 (129020)
The only thing that I am trying to explain in my opinion is the location of the cutting of the fascia. The EPF is distal to the incision. The In-step Plantar fascia release is in the arch area is more distal. The fluoroscopic partial plantar fasciotomy with ostectomy is at the insertion area where the spurring is located.
When ( which is rare today) I cut the fascia I will perform an ostectomy at the calcaneal-plantar fascia junction. I truly believe that the location is what makes this works so well.. I have coined the term that in chronic insertional cases that this is a soft tissue mal-union condition similar to bone mal=unions. By cutting into the specific area that is not healing you knick start the healing process. This is why ESWT works. ESWT is used at the insertion only for pf and it works. Lemont's article gives points for this theory and may even prove it. I should get hold of his patient list that he used. I use to send him alot of specimens to his lab from my heel spur operation done at the pf/heel spur junction. They all comes back with similar descriptions from his article. Anyway. This will never be proven and alot of doctors will do different operations and some will remove spurs and some will only cut the pf. I think we all agree that the last thing you want to do is CUT the plantar fascia.
Re: Remove spur or Cut fascia? Third opinionDr. Z on 9/07/03 at 10:36 (129021)
I agree. I do feel that Dr. Mercado area of cutting was what was important . He cut at the junction of the pf and the heel bone
Re: DR Z, ED or Wander ?BGCPed on 9/07/03 at 10:55 (129023)
Dr Zingas here in Detroit did one of the FDA trials on ESWT. He wrote something, perhaps not related regarding the condition of the fascia. I never read the paper but heard it second hand. I was told it was a raher unique or unconventional finding. You guys know of it by any chance?
Re: DR Z, ED or Wander ?Dr. Z on 9/07/03 at 13:07 (129030)
Give me your e-mail address at (email removed). I will send you the article I have by Dr. Zingas.
Re: DR Z, ED or Wander ?BGCPed on 9/07/03 at 13:57 (129032)
will do, and thanks for the fast response. you have any opinions etc on the paper?
Re: Remove spur or Cut fascia? WAIT!!!!Mike P on 9/07/03 at 19:57 (129064)
I also thank you Dr Davis....I lost my place with all the posting for the question I raised. It is interesting to see all the activity. If I have surgery...do we cut the fascia or leave it alone?????????????
Re: Remove spur or Cut fascia? WAIT!!!!Dr. Z on 9/08/03 at 16:35 (129180)
So what about my comments.???
Re: Remove spur or Cut fascia? WAIT!!!!Mike P on 9/08/03 at 21:24 (129221)
Read Message # 128847
Re: Remove spur or Cut fascia? WAIT!!!!Dr. David S. Wander on 9/09/03 at 07:52 (129253)
Don't have surgery!. If you do, leave the spur alone(unless it's pointing directly downward which is VERY unusual) and have only the medial 1/3 of the fascia released. I believe that I've addressed the point of not removing the spur several times in some of the above posts. If you still are considering having the spur removed, you may want to re-read the posts.
Re: Remove spur or Cut fascia? WAIT!!!!Dr. Z on 9/09/03 at 13:11 (129288)
When doing miminial incision heel spur surgery you are cutting the fascia at the spur area. If any doctor has ever done mis plantar heel spur surgery they will realize that leaving the spur is just not logical. You are right there . The healing time frame is the same. The risk of infection etc is the same.
I can't speak for open fasciotomies surgery but for MIS take the spur out.
Re: Remove spur or Cut fascia? WAIT!!!!Dr. David S. Wander on 9/09/03 at 19:34 (129353)
You've got to be kidding. We're going to run through this again??? If that's your logic, why not do a nerve decompression 'while you're in there'? Any additional surgery, that does not NEED to be performed is ridiculous, especially when it involves disrupting the bone. Since the spur is part of the bone, additional complications can occur, including bone infection or stress fracture. If the spur isn't causing the pain, leave it alone, even if you're 'already in there'. You're treating the patient, not the x-ray.
Re: Remove spur or Cut fascia? WAIT!!!!Dr. Z on 9/09/03 at 20:20 (129367)
That's my point it needs to be done, in my opinion. The pain is caused by a fasciosis at the insertional junction between the fascia and the bone. This is why ESWT works and why it is done under ultrasound at this specific area. This has nothing to do with rays. A nerve decompression isn't done in this area and is impossible to do.. You are entitled to your view point and I am entitled by my view point.
I have done a few hundred mis heel spur procedures since 1979. I was probaby the first podiatrist in the USA to do a PLANTAR partial fasciotomy with ostectomy. At that time I was using a polariod x-ray. In 1985 I started using a fluroscopic portable x-ray unit. Over these 18 years I have never seen an infection and or a stress fracture. I have seen complications that are associated with any pf release thus my interest in ESWT.
You post sounds like this is some much more surgery . The time that is needed to do this procedure is about five minutes.
To say that this isn't needed is your opinion and that it find to say that the procedure I use is ridiculous isn't find. There is no reason to
express this attitude.
There are many ways to treat patient all find and not ridiculous but just different.
PS: I would like to again thank Dr. Harvey Pilsner who is passed away for introducing me to the MIS procedure I am talking about.
Re: Remove spur or Cut fascia? WAIT!!!!Dr. Z on 9/09/03 at 20:31 (129373)
I am not kidding or trying to be ridiculous. It is my opinion and from my experience of doing many MIS partial plantar fasciotomies to also do the ostectomy portion. This is a five minute procedure that in my 23 years of doing this procedure there hasn't been any infections and or stress fractures.
This is no reason to call my view point ridiculous or not needed. I have taught this exact procedure to doctors from around the world over the past 23 years. You are the first to call it ridiculous
It is very hard to have you see what I am talking about. My comment about being already in there was being to simplistic.
There is no way to prove either view point because no patient is going to go thru surgical procedures as a test.
Re: Remove spur or Cut fascia? WAIT!!!!Dr. Z on 9/09/03 at 20:45 (129379)
Here is one more thing that may make my opinion clear or may confuse this even more
Why specific procedures work
EPF. You are cutting the fascia distal to the heel bone. This will stop the traction completely so that the fasciosis heals, or prevents the fascia from pulling the insertional portion . If this happens the entire medial column has lost its function but you still will have no medial band heel pain.
Open heel plantar fascia= same thing. Stops the traction and in some cases prevents any pulling and lost of medial column support
MIS plantar approach with osteoctomy. Addresses the fasciosis at the insertion by cutting the area causing a trauma and a repair of the fasciosis at the areas that is located. This cutting is at the bone fascia interface, not distal
The plantar fascia isn't tight. It doesn't need to be lengthened. It can't be stretched. It is injuried at the insertion and this is why I am directing the cutting at the areas that Dr. Lemont describes as a fasciosis
By cutting at that junction you are directly address the fasciosis
I will also point out that by cutting and performing an osteotomy you are cutting less of the fascia and thus decreasing the chance of a calcaneal cuboid sydrome without reducing the sucess rate. The only procedure that completely ommits cal-cuboid syndrome is ESWT and that is why I start doing ESWT
Re: Remove spur or Cut fascia? WAIT!!!!Dr. David S. Wander on 9/10/03 at 13:52 (129456)
Dr. Z., First, I did not say that the MIS procedure you perform is ridiculous, I stated that the idea of doing something else just because you are already there is not a rationale answer. Your experience seems to based on the numerous MIS procedures you've performed. How many open procedures have you performed to compare? There are many ways to skin a cat, and performing an EPF, open procedure or MIS procedure still results in cutting of the fascia. The EPF fasciotomy is more distal, but many open, and small incision surgeries release the fascia at the site of the 'fasciosis'. The bottom line is that the fascia is still cut, which we both agree is usually not necessary. By whole point was that I don't agree with the statement that the spur should be removed 'while you are already in there'. We both agree that ESWT should be attempted prior to surgery of anykind. If ESWT fails and surgery is eventually indicated, I will not be removing the spur, no matter how I release the fascia.