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surgical release of plantar fascia -- NEVER!

Posted by Ed Davis, DPM on 9/04/04 at 15:32 (159311)

Here is an article in the Journal of the American Podiatric Medical Assn. I just got off the phone with Dr. Cocheba, one of the authors, talikg with him for a good 30 minutes about this research:

http://www.japmaonline.org/cgi/content/abstract/93/6/429

The bottom line is that even a partial release of the fascia has DRAMATIC effects on the mechanics of the foot. It should be avoided whenever possible!
Ed

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 9/04/04 at 15:38 (159314)

I bet that another few 100 are scheduled for Tuesday in OR's throughout the USA.

Re: surgical release of plantar fascia -- NEVER!

Ed Davis, DPM on 9/04/04 at 15:44 (159317)

Incredibly, yes, because practitioners are doing what the insurance company wants to pay for instead of what is best for the patient. These insurance companies need to be held ACCOUNTABLE for the results. A Patient Bill of Rights is way overdue.

Sorry to be up on the soap box again but after discussing the issue with Dr. Cocheba, who has more research coming out on this, the operation simply should NOT BE PERFORMED except for very rare instances.
Ed

Re: surgical release of plantar fascia -- NEVER!

april l on 9/04/04 at 15:45 (159318)

Dr. Z,

I thought that you, yourself still do these surgeries?

Re: surgical release of plantar fascia -- NEVER!

Ed Davis, DPM on 9/04/04 at 15:57 (159322)

april:
My assumption is that Dr. Z has a similar philosphy about the surgeries as I, doing them as an absolute last resort. This is why we encourage ESWT as an alternative to surgery.
Ed

Re: surgical release of plantar fascia -- NEVER!

april l on 9/04/04 at 16:04 (159324)

Both times my doctors did surgery as a last resort, although not one of them ever told me about ESWT. I had one year of conservative treatments before having surgery on each foot. I don't even want to think about living in the kind of pain I was in prior to the surgeries.

Re: surgical release of plantar fascia -- NEVER!

Pauline on 9/04/04 at 16:14 (159329)

Dr. Ed,
I don't think it's just because the insurance companies will pay for it. I believe it's offered as an easy alternative and patients either agree to it or believe they will continue to live in pain.

Re: surgical release of plantar fascia -- NEVER!

Ed Davis, DPM on 9/04/04 at 16:14 (159330)

I hope that you did well with the surgeries. Doctors should always give patients all the reasonable options and alternative treatments available.

There is one little 'hole' in Dr. Cocheba's research in that he is looking at what happens to the foot after the fascia is cut but not considering the long term possibility of the fascia regrowing -- something that happens failry often, so the patient actually regains some of the lost function with an elongated fascia which is hopefully pain fee.
The time factor for this to happen can be quite long.
Ed

Re: surgical release of plantar fascia -- NEVER!

april l on 9/04/04 at 16:40 (159332)

Yes, both surgeries were completely successful after long recoveries. I thought that the fascia does grow back so to speak in an elongated position, that is how my doctor explained it to me. He said the surgery lengthens the fascia when scar tissue forms where the incision is made. My feet feel completely normal as though I never had PF in the first place. I wish everyone had the outcome that I have had with the surgeries. Living with the pain of PF was so awful that I was willing to take the risk of getting worse in hopes of getting better.

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 9/05/04 at 02:35 (159353)

April,

I have used ESWT for chronic pf since 1999. I will use a miminial incision pf release if ESWT fails to resolve heel pain

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 9/05/04 at 02:41 (159355)

Pauline,

How many times on this site have we heard patients say I am having pf surgery because my insurnce will cover this and ESWT isn't covered.??

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 9/06/04 at 11:22 (159416)

http://linkinghub.elsevier.com/retrieve/pii/S0268003304001251

Here is another article I just received . Gives us the same conclusion

Re: April

Pat on 9/06/04 at 19:39 (159443)

Hi April,
If your feet feel completely normal can I borrow them? LOL! I'm so sick of this PF that I can't stand it anymore.

Re: April

april l on 9/06/04 at 20:09 (159450)

Pat, I wish I could lend them to you! I know how awful living with PF is and I really wish all who suffer could be pain free.

Re: surgical release of plantar fascia -- NEVER!

A Manoli, MD on 9/06/04 at 21:36 (159461)

They studied a different effect on the foot of cutting the plantar fascia, but the conclusion was very similar. Here is our abstract:

Foot Ankle Int. 2003 Mar;24(3):245-50.

The effect of plantar fascia release on strain in the spring and long plantar ligaments.

Crary JL, Hollis JM, Manoli A 2nd.

Northwest Surgical Specialists, Vancouver, WA 98664, USA.

The effect of plantar fascia release on strain in the spring and long plantar ligaments was investigated in 11 cadaveric feet. Strain gauges were placed in the spring and long plantar ligaments of each specimen, and cyclic axial loading was applied until reproducible hysteresis curves were observed in the ligaments before and after plantar fascia release. After release of the plantar fascia, the average strain observed in the spring ligaments at 920N of axial load increased by 52% (p < .001) and in the long plantar ligaments by 94% (p = .04). Longer resting lengths of the ligaments were also observed. Release of the plantar fascia significantly changed force distributions in the foot which may explain the development of deformities and symptoms observed clinically following this procedure.

'I knew it wasn't the right thing to do, BUT I JUST COULDN'T HELP MYSELF...'

Sort of like giving all those cortisone shots into the feet....!!!!

AM2

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 9/07/04 at 16:20 (159512)

Hello,
What do you do when the patient presents with chronic plantar fasciosis that has failed to respond to any type of conservative treatment.?

Re: surgical release of plantar fascia -- NEVER!

Pauline on 9/08/04 at 07:52 (159551)

Amen and thank you Dr. Manoli.

Re: surgical release of plantar fascia -- NEVER!

A Manoli on 9/08/04 at 11:35 (159559)

i generally perform a gastroc slide, when all the nonoperative methods fail. most people i see have had trouble for 1-5 years.

i is particularly good as a salvage procedure for the failed heel spur/plantar fascial release situation. we have even had good success with it for plantar fibromatosis in a handful of cases..

am2

Re: To Dr. Manoli

Pauline on 9/08/04 at 14:54 (159569)

Dr. Manoli,
Have you spoken with Dr. Zingas about his use of ESWT in treating P.F.? Do you know if he is still using it? If so, any idea what his success rate has been curing P.F. cases since publishing his paper for the Dornier Study?
Thanks

Re: surgical release of plantar fascia -- NEVER!

Pauline on 9/09/04 at 08:10 (159583)

Dr. Ed,
Why do you still need to do a P.F. release in 1/2 your cases when you do a gastroc slide procedure? Do you do a different Gastrocmemius procedure than Dr. Manoli? From his post, it sounds like he repairs failed P.F. release surgeries using his procedure.

I would like to know why View Thread
Posted by Ed Davis, DPM on 2/17/03 at 14:20

About 50% of my plantar fascial releases are combined with a gastrocnemius recession or achilles lengthening, although with ESWT those numbers are now very small. I beleive that most doctors understand the need for a gastroc slide although the numbers are insufficient to support the idea that isolated gastroc slides can be used in lieu of plantar fascial releases.
Ed

Re: To Dr. Manoli

Dr. Z on 9/09/04 at 23:54 (159623)

He has his own Dornier Epos

Re: surgical release of plantar fascia -- NEVER!

Ed Davis, DPM on 9/10/04 at 20:36 (159706)

Pauline:

Many recaclitrant cases of PF remain so due to a tight gastrosoleus achilles complex. If that is the case, a gastroc. lengthening procedure may help. It does not sound like Dr. Manoli is 'repairing' failed PF releases but perhaps performing the extra step (ie. the gastroc. slide) that would have made the release more successful in the first place.

Gastoc. slide procedures are performed for many more reasons beyond PF.
The question is if a gastroc. slide alone is enough to treat intractable PF? I know of no studies are sufficient experience to bear this out. Perhaps Dr. Manoli has some personal stats he can share.
Ed

Re: surgical release of plantar fascia -- NEVER!

A Manoli MD on 9/15/04 at 07:51 (159930)

pauline,

thank you for all the nice comments.

we are currently doing a multi-center study of the use of the gastroc slide for plantar fasciitis. were looking them up currently, but i can only recall one case where the patient was not much improved, out of about 75 or so. but as you know, one must try to find them all.

i do the slide for a number of other things, including forefoot overload, mtp synovitis, midfoot arthritis, posterior tibial tendon insufficiency, some cases of achilles tendonosis, cavus reconstructions, peripheral neuropathy, multiple stress fractures, etc., when the gastroc is tight. we often couple it with multiprocedure cases, when necessary.

we have a paper coming out soon on the technique, with a look at the complications in 100+ cases. the complications are very minimal with the medial approach, and the strength returns in 6 mo. or so. it is particularly good for the prevention/ treatment of forefoot and midfoot ulcers in diabetics. we used to lengthen the achilles for this, but the slide is much better.

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 9/15/04 at 08:03 (159933)

Dr. Manoli,
Thanks for this information. I look forward to reading your study. I find mid foot arthritis very difficult to treat unless this is a fusion procedures performed and that can be very for the patient to undergo..
On another note I would like to hear about your involvement with ESWT and what insight you could give us from your experience. I find ESWT to be a very valuable treatment option with chronic plantar fasciosis.

thanks

Dr. Z

Re: surgical release of plantar fascia -- NEVER!

Mark Evans on 9/15/04 at 16:21 (159955)

This is an interesting posting. Some of my UK colleagues slowly but increasingly are deploying an achilles tendon lengthening procedure to address an increasing range of fore and rearfoot related problems, when previously other procedures might have been favoured.

To the Podiatrist this is logical. Soft tissue ankle equinus unleashes probably the most severe abnormal forces on the foot. At least this is what I was taught in pod school! I would be interested to know from Dr. Manoli his surgical preference - e.g. incisional approach, which slide procedure, suture technique and preferences, and post-operative treatment protocol.

The one criticism of this approach I am aware of is that although the tendon strength gradually returns, it may take up to 12 months and full pre-operative strength may not be an achievable goal. So if you are an athlete, beware!

What this suggested to me is the procedure works by weakening the tendon so the patient can no longer propulse as effectively thereby reducing some of the pathological forces acting on the foot.

What are your thoughts, Dr M?

Re: surgical release of plantar fascia -- NEVER!

april l on 9/18/04 at 09:05 (160112)

My 13 yr. old son has tight achilles and was treated 4 yrs ago. We sought two opinions and decided to go with casting to stretch the achilles instead of surgery, which I believe would have been the gastroc slide. The casting worked for awhile, but now my son is back to toe walking. He also has flat feet. I am worried that he will get PF too eventually. I was afraid to have my son get surgery 4 yrs. ago. Now I feel it was a mistake to go with the casting. Is this gastroc slide an easy procedure? How long is recovery?

Re: surgical release of plantar fascia -- NEVER!

Mark Evans on 9/18/04 at 10:18 (160114)

April,

Has your son been examined for any underlying neurological problems? Does he have rigid or flexible flat foot? Did you follow up the casting with stretching excercises? Not everyone with flat feet will develop PF.

Re: surgical release of plantar fascia -- NEVER!

april l on 9/18/04 at 13:56 (160116)

yes. he had a thorough neurological exam...everything is normal. He just has tight heel cords, which I do also and so does my daughter. The casting and stretching worked, but it appears to have been temporary because they are tight again altho not as bad as before. Before treatment he could not stand up straight with his heels touching the floor. He had to lean forward to get the heels down. My daughter and I never had this problem to the extent that my son does. I know that not everyone with flat feel will get PF, and I had PF on both feet but have high arches. This is the first time I have heard that tight achilles has anything to do with PF, so I'm interested to hear that some doctors believe that a gastroc slide can cure PF. I once asked my pod if my tight achilles had anything to do with my PF and he said no.

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 9/18/04 at 14:01 (160118)

Maybe Dr. Manoli can give you some personal experience??. See his posts

Re: surgical release of plantar fascia -- NEVER!

Mark Evans on 9/19/04 at 09:15 (160162)

April - patients with thight achilles tendon usually have to continue with the stretching excercises. In my experience, once stretching stops, often tendon begins to contract again. This makes it very tedious for patients who need to build stretching into their daily routine.

Tight tendons have been strongly incriminated in PF but it will depend on how the foot compensates for the tightness.

Re: surgical release of plantar fascia -- NEVER!

april l on 9/19/04 at 19:58 (160182)

Thanks. I just wonder if we made the wrong decision going with the casting/stretching instead of surgery.

Re: surgical release of plantar fascia -- NEVER!

Margaret on 3/01/07 at 22:28 (223973)

Hi Dr. Manoli

I have had plantar fasciitis for 5 years and had many treatments including ESWT which didn't help. Four months ago i had a gastroc slide and radiofrequency ablation of the fascia. I am still off work because of burning pain in the lateral part of the heel about 1/2 an inch above the sole. My surgeon originally thought that the nerve had to lengthen to match the muscle but now says he doesn't know. The burning increases with weight bearing. Have you had any problems like this? Is there anything that will help? I have been to physiotherapy since surgery. Any advice would be appreciated. This new pain is worse than before surgery.

Re: surgical release of plantar fascia -- NEVER!

Dr. Z on 3/02/07 at 03:02 (223979)

Just so you know you are posting in a post that is years old by Dr. Manoli.
It sounds like you had a Topaz procedure. It is possible that you had the nerve injured with the ablation procedure. I would consider the treatment Cryotherapy if all procedures such as local steriod injection had been tried. Go to the cryotherapy board and take a look at this information