Is Plantar Fascia Release Surgery a Good Option?
When plantar fasciitis does not respond to non-surgical treatment options, the next option considered is a surgical release of the plantar fascia as a "last resort". There are other potential surgical options, however releasing the plantar fascia is by far the most common procedure.
The idea is that releasing the plantar fascia will reduce the stress placed on it and therefore alleviate the pain. Its a bit like cutting an elastic band that is under tension. Once its cut, the tension is released. This does seem to make sense, however what we need to consider is that the plantar fascia exists for a reason. Indeed, the plantar fascia is considered to have many vital roles in normal foot function and by cutting it, we not only release tension in it but also relieve it of its many important functions. This has the potential to create a knock on effect of other problems, since the plantar fascia plays an integral role in supporting the architecture of the foot. Some of the reported complications following plantar fascia release surgery include collapse of the arch of the foot, lateral column pain and secondary osteoarthritis in various joints.
Since plantar fascia release is the most common surgical procedure for plantar fasciitis, there has been a lot of published studies investigating the outcomes of this surgery. In fact, one of the first study published was in 1983 and since then over 45 additional studies have been published in the medical literature. This is just in the English language literature so there are probably a few more than this with studies published in other languages across the world.
To go through the details of each of those studies would make this a very dull read that will probably send you off to sleep! So I’m not going to do that. Instead, I am going to provide an overview of all the published studies, with a particular focus on the results in terms of pain relief as this is the main common goal for patients, as well as the complications and average recovery time after surgery.
So after I performed a literature review, I read through each independent study which was 46 studies in total and I documented key information such as patient demographics and outcomes. In total there 2220 patients where approximately 65% of patients were female and 35% were male. The average age of all patients was 46 years old. The average recovery time was 3 and a half months. This is the average amount of time for patients to return to their normal activities.
The average follow up time was 2.3 years. This is the average amount of time after surgery that patients were reviewed for their final follow up appointment to determine the outcome of their surgery.
Across all the studies there was a large range of various methods used to measure success of the surgery and it would have been very difficult to collate this information into something meaningful since some methods were only used in a single paper leading to very low levels of data.
So instead, I only documented studies that recorded the visual analogue scale (VAS). This is a scale ranging from 0 -10 with 0 representing pain free and 10 representing the worst pain imaginable. I also documented studies that looked at patient satisfaction.
For the visual analogue scales I only included studies that provided both pre-op AND post-op scores. If they didn’t have both then it wasn’t included in my analysis as I felt it was important to have pre-op and post-op scores to compare for each individual patient.
In total there were VAS scores documented for 669 patients. As previously mentioned there was a total of 2220 patients across all studies however only 669 of these patients had a VAS score documented.
There was more data available for patient satisfaction than for the VAS scores. In total there were 2082 patients that completed a patient satisfaction questionnaire.
Ok, lets move on to the results of the VAS scores then.The average pre-op VAS score was 8.0. and the average post-op VAS score was an impressive 1.5! That’s a significant reduction in pain. Looking at patient satisfaction 87% said they were satisfied with the plantar fascia release surgery. I think this is a very high number and prior to conducting this analysis, I did not expect it to be this high so I was pretty surprised at the results.
But lets not forget about complications as no surgery is without its complications. In total there were 268 complications reported. With a total of 2220 patients this gives us an overall complication rate of 12%. The complications were varied however the most common complications where arch pain, painful scarring, and lateral column pain which is pain on the outside of the foot.
So there you have it folks. These are the results in a nutshell. But before we finish up this episode there are few things that I think are worth a further mention.
Firstly, I think it is important that we interpret these findings carefully and consider the B word. That’s right, BIAS! And there is plenty of bias we need to consider across all these studies since the vast majority of studies were retrospective in nature which weakens the strength of the findings.
The reason why this weakens the findings is that it increases the potential to produce information that can be misleading or indeed bias. An example of this is the inconsistency of recording post-op complications and patient recall bias, where patients are asked to provide information about their pain levels at the pre-op stage but only documented many months after the surgery.
But lets not throw the baby out of the bath water just yet as I think there is still a lot of insightful information that can be drawn from this analysis providing we accept and understand the limitations in the quality of evidence.
From a personable point of view, whilst I accept that the overall quality of the evidence is low, the quantity of the evidence is actually high and the results are overwhelmingly positive in terms or patient reported outcome measures.
Some of you might be wondering how the plantar fasciotomies were performed in terms of surgical technique and the answer is lots of ways! Some studies performed a partial plantar fasciotomy by releasing 30% and some releasing 50% of the plantar fascia whilst other studies performed a fully release. Additionally some studies performed open surgery, others performed endoscopy and other included percutanous techniques. I’m afraid I can’t by more specific with numbers and percentages here as in a number of studies it was unclear exactly how the surgery was performed but overall the most common procedural technique seems to be endoscopy with a 30% release of the plantar fascia. Some surgeons opted to remove a calcaneal heel spur or reduce the prominence of them, however in the majority of cases, the heel spurs were left alone.
Food for Thought
So, after taking everything into consideration, is plantar fascia release something you would recommend to your patient if they aren’t responding to non-surgical treatment?
Have these results made you change your outlook on plantar fascia release surgery or maybe reinforced your existing beliefs?
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Thanks for reading and have a great day!