0198-0211/92/1304-0188$03.00/0 & ANKLE Copyright © 1992 by the American Orthopaedic Foot Society, Inc.
FOOT
Plantar Fasciotomy for Intractable Plantar Fasciitis: Clinical Results and Biomechanical Evaluation* Peter J. Daly, M.D.,t Harold B. Kitaoka, M.D.,:j: and Edmund Y. S. Chao, Ph.D.§ Rochester, Minnesota
excision,6,10,34,36,37 Steindler stripping,9,21,35 rotational calcaneus osteotomy." countersinking calcaneus osteotomy." calcaneal drilling oecornpresslon.t":" neurolysis of the nerve to the abductor digiti minimi muscle,4,8 calcaneus nerve neurolysis." calcaneal nerve neurectomy," ,30 and general decompression. 6,22,29 In a recent review of various heel operations on 527 feet, the results were described as good or excellent in 91 % of cases." We reviewed the Mayo Clinic experience with plantar fasciotomy for intractable plantar fasciitis over an 11year period and analyzed the results clinically, roentgenologically, and biomechanically.
ABSTRACT Thirteen consecutive patients underwent plantar fasciotomy in 16 feet for intractable plantar fasciitis and had follow-up from 4.5 to 15 years. Plantar fasciotomy was successful (good or excellent results) for 71% of the 14 feet operated on and for which follow-up data were available. However, time to full recovery was prolonged, additional treatment was frequently required, and abnormalities of foot function persisted. Flattening of the longitudinal arch occurred. Dynamic force-plate studies showed differences in peak vertical, fore-aft, and lateralmedial forces between pathnts and matched controls. More rapid progression of weightbearing along the longitudinal axis of the foot during stance phase in patients indicated avoidance of heel loading.
MATERIALS AND METHODS Patient Profile
INTRODUCTION
Thirteen patients (16 feet) underwent surgical treatment for plantar fasciitis from September 1975 through March 1986. Six patients were male and seven were female; the mean age was 45 years (range 14-61 years). Two patients could not be located for follow-up. Ten (13 feet) of the remaining 11 patients returned for examination and for roentgenographic and force-plate studies. Follow-up was by interview for one patient (one foot). Preoperatively, all of the patients had heel pain and tenderness of the plantar fascia and one had dysesthesia. No patient had neurologic deficit as determined by physical examination. There was roentgenographic evidence of heel spur in seven patients. Prolonged nonsurgical treatment, including orthoses, injections, casting, anti-inflammatory medications, and gait aids (cane), failed in all the patients. The mean duration of symptoms preoperatively was 20 months (range 5-60 months). Only patients who had not previously undergone operation on the heel were included in our study.
Pain of the plantar heel in the central to medial subcalcaneal region is a common foot complaint. It may be due to chronic inflammation of the plantar fascia secondary to microscopic fascial tears from repetitive trauma." Other causes that have been proposed are calcaneal spur." increase in intraosseous calcaneal pressure," nerve entrapment,":":" penosntls," and degeneration of the tat-pad." Several investigators have advocated plantar fasciotomy for intractable symptoms. 15,20.23.25,28,32,33,37 Other procedures, usually done in combination with plantar fasciotomy, also have been advocated: calcaneal spur • Presented at the Annual Meeting of the American Orthopaedic Foot and Ankle Society, Anaheim, California, March 10, 1991. t Senior Resident in Orthopedics, Mayo Graduate School of Medicine, Rochester, Minnesota, 55905. :j: Consultant, Department of Orthopedics, Mayo Clinic and Mayo Foundation, and Assistant Professor of Orthopedics, Mayo Medical School; Rochester, Minnesota. To whom requests for reprints should be addressed at the Department of Orthopedics, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. § Consultant, Section of Biomechanical Research, Mayo Clinic and Mayo Foundation, and Professor of Bioengineering, Mayo Medical School, Rochester, Minnesota.
Operative Technique
Incision was made medial or plantar oblique along the anterior margin of the heel pad. Although there was 188
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some variation in technique (heel spur excision in two, calcaneal drilling in four, Steindler stripping in two, and division of the nerve to the abductor digiti minimi muscle in one), division of the central component of the plantar fascia (plantar fasciotomy) was performed in each foot in a standard fashion. A postsurgical shoe was applied in four cases and a short leg cast in 10. Evaluation of Results
Clinical results were determined by using graded subjective and objective factors (Table 1). Results were rated as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor «70 points). Standing lateral roentgenograms were obtained to measure soft tissue shadow, 1 to evaluate occurrence of calcaneal heel spurs, and to assess any changes in longitudinal arch alignment, such as the development of pes planus. The longitudinal arch alignment was evaluated by comparing preoperative and postoperative measurements of the lateral talometatarsal-1 angle, arch height, and ratio of arch height to arch length in standing lateral foot roentqenoqrarns.':" Magnification artifact with this technique is less than 1%.27 Measurements were repeated to assess interobserver and intraobserver error. TABLE 1 Clinical Scoring System (100 Points Total) for Evaluating Results of Plantar Fasciotomy Operation" Characteristic Pain
Activity limitations
Footwear or orthotic requirement
Plantar heel tenderness Neuropathy
Antalgic gait
None Mild, occasional Moderate, frequent Severe, constant None Minor, no limitation of daily activities Major, limitation of daily and recreational activities No footwear Iimitations, orthoses not required Minor limits of footwear, orthoses occasionally used Modified shoes required, orthoses required Absent Present None, sensation intact Present, hypesthesia, Tinel's sign Absent Present
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Force-plate studies were performed on 10 patients (13 feet), but one patient (one foot) was excluded because of a recent pelvic fracture that affected gait. Each patient walked at a free velocity along a 5-meter level walkway containing a custom-made (61 x 61 cm) piezoelectric force ptate." Load cells in the force plate measured the resultant three-dimensional ground reaction force vector while the foot was in contact with the plate (Fig. 1). Instantaneous vertical and horizontal shear forces (expressed as a percentage of body weight) and the linear X (medial-to-lateral) and Y (anteroposterior or longitudinal) progression of the center F3
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Fig. 1. Ground reaction force peaks and timing of peak forces. A, Vertical force peaks, Fj - F3 • B, Fore-aft force peaks, F4-F6 • C, Mediallateral force peaks, F7-Fa. BW., body weight. (Reprinted with permission from Katoh, Y., Chao, E.Y.S., Laughman, R.K., Schneider, E., and Morrey, B.F.: Biomechanical analysis of foot function during gait and clinical applications. Clin. Orthop., 177:23-33, 1983. By permission of J. B. Lippincott Company.)
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of pressure during the entire stance phase were determined. Ground reaction force components and the progression of the center of pressure (V-progression) were assessed at 10%, 25%, and 75% stance phase to determine the rate of progression of force from the hindfoot to the forefoot. The magnitude of ground reaction peak forces (F1-Fg) was determined":" (Fig. 1), as was the timing of peak forces (T1 - Tg) . The gait variables of the patients were compared with those of matched control subjects. The opposite foot was not used as a control because patients exhibit a "crossover" phenomenon in which abnormalities such as gait and foot breaking on the involved side affect the opposite extremity. RESULTS
Follow-up evaluation (mean 8 years; range 4.5-15 years) was obtained for 11 patients (14 feet). The clinical results are shown in Table 2. Ten of the 14 feet had no or mild pain and nine had no activity limitations, but footwear limitations or orthoses were required for 11 of 14 feet. There was tenderness of the plantar heel in five feet, and paresthesias were elicited with percussion along the medial incision (medial calcaneal nerve) of one foot. Three patients (four feet) had a discernible limp. Ankle and subtalar motion was unrestricted in all the patients, and hindfoot deformity was not observed in any of them. The only complication, delayed wound healing, occurred in one patient and resolved uneventfully. The patient had a poor clinical result. Clinical results were excellent for eight feet, good for two, and poor for four. The two patients who had good results had mild pain in the foot and one had minor restrictions of activity; they used orthoses. For three of
the four poor results, the patients had severe pain, major limitations of activity, tenderness of the heel, and an antalgic gait. One of these patients underwent another operation. The other patient who had a poor result had moderate pain, minor limitations of activity, heel tenderness, and an antalgic gait. The operations performed in the patients (four feet) who had poor results were plantar fasciotomy only (three feet) and plantar fasciotomy with Steindler stripping, spur removal, and calcaneal drilling (one foot). We were unable to find a correlation between obesity and clinical results. Only one of the five feet of patients considered obese was a poor clinical result. 26 Seven patients (eight feet) were satisfied with the results, two were satisfied but with reservations, and four were dissatisfied. Satisfaction correlated with clinical results. The seven patients (eight feet) who had excellent results according to the scoring system were all satisfied. The two patients with scores that indicated good results were satisfied but with reservations, and the patients with scores that indicated poor results were dissatisfied. Additional treatment was required in seven patients: one underwent neurolysis (poor result) and six had nonsurgical treatments, such as anti-inflammatory medications, injections, orthoses, and nerve block procedures. The average time to maximal clinical improvement was 10.5 months postoperatively (range 1.5-24 months). Roentgenologic evaluation of longitudinal arch alignment demonstrated that the difference in arch height preoperatively and postoperatively was -4.1 ± 2.8 mm and was significant (P < .01). The length of the arch increased an average of 1.7 ± 2.7 mm, but not signifi-
TABLE 2 Clinical Results of Plantar Fasciotomy Operation Based on the Clinical Scoring System Compared with Patient Satisfaction" Patient
2
3 4 5 6 7
e 9 10 11b
Age
Sex
Side
Pain
Activity limitations
Footwear limitations
43
M
R
0 0 0 50 50 50 30 50 50 50 40 40 50 40
0 0 0 10 10 10 5 10 10 10 5 10 10 10
0 0 0 5 5 5 0 10 10 10 5 5 5 5
41 43
F F
61 49 50 53 41
F F
14 36 45
F F
M M F
M
L R R L R R R L R L R L L
Heel tenderness
Neuropathy/ Tinel's sign
Antalgic gait
0 0 0 10 10 10 0 10 10 0 10 10 10
10 10 0 10 10 10 10 10 10 10 10 10 10
0 0 0 10 10 10 0 10 10 10 10 10 10
NA
NA
NA
Graded result Poor Poor Poor Exc. Exc. Exc. Poor Exc. Exc. Exc. Good Good Exc. Exc.
Satisfaction Dis. Dis. Dis. Sat. Sat. Sat. Dis. Sat. Sat. Res. Res. Sat. Sat. Sat.
• See Table 1 for details of scoring system. Dis., dissatisfied; Exc., excellent; NA, not available; Res., satisfied but with reservations; Sat., satisfied. b Only SUbjective data available.
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PLANTAR FASCIOTOMY
cantly (P = .14). Although arch height and length are related, it probably is not a linear relationship, because rotation also occurs with the development of pes planus. The ratio of arch height to arch length difference was -0.03 ± 0.02, which was significant (P = .01). The talometatarsal-1 angle difference was -4.7 0 ± 5.1 0, which was significant (P = .05). These measurements, made on standard weightbearing lateral foot roentgenograms, showed a measurable flattening of the longitudinal arch after plantar fasciotomy (Fig. 2). Postoperative measurements1 of the soft tissue shadow of the
191
heel were not significantly different from preoperative measurements (P = .52). Peak values (F1-Fg) of floor reaction forces (Fig. 1) were studied. Vertical force peaks F1 and F3 were significantly less (Table 3) in the patients than in the matched control subjects (P < .01), but vertical force peak F2 was significantly greater than in control subjects (P < .001). These differences in vertical force indicate a less energetic pattern of walking in the patients. Fore-to-aft shear force peak (Fs) was less in patients than in control subjects (P < .05), indicating a
Fig. 2 Lateral weightbearing radiographs of a patient A, before and B, after plantar fasciotomy. Solid lines form the tarsometatarsal-1 angle. Dashed lines show the talar height measurement.
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TABLE 3 Ground Reaction Peak Forces (F 1-Fg) and Clinical Result and Comparison Between Patients and Control Subjects Patient
Sex
Side
M
R L
R R
2 3
F F
4 5 6 7 8
F F M M F
L L
9
F
R R
L
R R R
Patients Mean SO Control subjects Mean SO
F,
F2
F3
F:
F5•
Fs•
Fl
Feb
Fgb
122 127 103 107 106 104 111 113 118 104 103 119
74 65 83 85 85 85 88 71 73 78 81 73
121 129 96 114 115 105 108 101 115 112 108 117
-5.7 -4.1 -1.4 0.3 1.0 -2.0 -4.1 -7.9 -8.4 -2.6 -2.3 -3.2
15.2 17.6 7.9 14.8 12.4 12.8 14.6 10.7 14.0 12.5 14.7 14.2
-12.9 -22.2 -20.0 -20.4 -19.5 -16.8 -23.4 -18.5 -19.8 -21.3 -17.8 -18.7
3.1 4.4 4.3 6.3 3.1 3.5 1.8 6.5 3.6 1.9 2.2 5.5
-5.3 -6.9 -2.9 -1.8 -5.2 -4.0 -4.9 -3.5 -5.9 -4.5 -4.9 -7.9
-5.1 -4.5 -2.2 -1.1 -4.3 -2.5 -1.6 -1.6 -6.7 -5.8 -3.0 -3.1
111c
78 c 7.2
111C
-3.4 2.9
13.5c
2.5
-20.0 1.9
3.9 1.6
-4.8 1.6
-3.5 1.8
66 9.5
120 10
-2.7 3.2
18.3 5.4
-22.3 5.3
4.7 2.0
-5.0 1.7
-4.1 1.8
8.3 119 13
8.9
Clinical result Poor Poor Poor Exc. Exc. Exc. Poor Exc. Exc. Good Exc. Good
• Fore-aft forces directed anteriorly are negative, and ones directed posteriorly are positive. b Medial-to-Iateral forces directed medially are negative, and ones directed laterally are positive. c p < .05 for difference from control. TABLE 4 Comparison of Ground Reaction Force Components Between Patients and Control Subjects Component (% stance phase) Vertical"
Fore-aft"
Medial-tolateral"
TABLE 5 Comparison of Center of Pressure Progression (Y-Component) Between Patients and Control Subjects Percentage of stance phase
Patients. (% body wt)
Controls" (% body wt)
10 25 75 10 25 75 10
75.0 ± 12.1 108.0 ± 10.8 108.5 ± 7.6 10.1 ± 2.7 9.4 ± 3.0 -11.5±1.4 1.1 ± 1.9
71.5 ± 12.8 118.0 ± 2.4 118.8 ± 9.6 11.0 ± 3.4 13.9±5.1 -13.9±5.1 3.3 ± 2.9
.52 .003 .02 .54 .007 .35 .02
25 75
-3.9 ± 1.6 -2.7 ± 1.4
-4.6 ± 1.8 -3.3 ± 2.0
.35 .18
• Mean ± SO. b P < .05 for difference from normal. c Vertical forces are positive. d Fore-aft forces directed anteriorly are negative, and ones directed posteriorly are positive. " Medial-to-Iateral forces directed laterally are positive, and ones directed medially are negative.
lower "braking force" decelerating the center of mass. The timing of peak ground reaction forces (T1- T9) was studied, and vertical peak pressure (F3 ) occurred earlier in stance phase (T3) in patients than it did in control subjects (P < .05). Comparison of vertical, anteroposterior, and medialto-lateral forces and the progression of the center of pressure at 10%, 25%, and 75% stance phase revealed a number of significant differences (P < .05) between patients and control subjects (Tables 4 and 5). There
10 25 75
Patients"
(% body wt)
Controls" (% body wt)
pb
30.1 ± 6.0 48.9 ± 6.5 90.5 ± 5.6
19.1 ± 13.2 32.2 ± 17.0 73.8 ± 22.8
.02 .003 .02
• Mean ± SO. b P < .05 for difference from normal.
was significantly less medial-to-Iateral shear force in patients (P = .02) at 10% stance phase, significantly less vertical force (P < .01) at 25% stance phase, and less fore-to-aft shear force (P < .01) at 25% stance phase. The center of pressure was significantly different between patients and control subjects (Table 5). This finding and the significantly less vertical force at 25% stance phase in patients indicated that the patients progressed through stance phase faster (thus spending less time on the heel) and applied less vertical force than control subjects did. A typical example is shown in Figure 3. DISCUSSION
The prolonged course and intractable nature of plantar fasciitis often can be a frustrating dilemma for patients and physicians alike. Nonsurgical treatment usually is successful within 6 to 12 months of the onset of symptoms." Most of the operations that have been
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Foot & Ankle/Vol. 13, No. 4/May 1992
193
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194
Foot & Ankle/Vol. 13, No. 4/May 1992
DALY ET AL.
reported for intractable symptoms 4 ,6,9,11-13,15,20,22,24,35 included plantar fasciotomy, which was performed on all our patients, Only 71% of the feet had excellent or good results, which is not as good an incidence as in most reports, There may be several reasons for this. We report longterm results (mean 8 years) of consecutively treated patients, nearly all of whom had follow-up (11 of 13 patients, or 85%). The patients were assessed more critically in this series, but the poor results would be considered failures, using any of the published grading methods. The duration of symptoms (mean 20 months) was longer in our patients than in those of other studies. We were unable to find a correlation between duration of symptoms preoperatively and final result. Also, our patients required longer times (mean 10.5 months) postoperatively to reach maximal clinical improvement. This is in contrast to the 6-month postoperative period reported by others. 2o ,37 A limited number of operations for intractable plantar fasciitis performed at our institution during the 11-year period and the long duration of preoperative symptoms reflected the careful selection of patients. Several hundred patients were treated nonoperatively during this period. Patients in our group may be different from those treated earlier by surgeons with a propensity toward operative treatment. Although patients were not followed at regular intervals (e.g., yearly assessment), it is our impression that progressive deterioration clinically did not occur during the time the patients were followed (mean follow-up 8 years). Two of the seven feet that preoperatively had roentgenologic evidence of heel spurs underwent spur excision. In one of the feet, the result was excellent, and in the other, it was poor. The results were excellent or good in the other five patients who did not undergo spur removal but who had roentgenologic evidence of heel spurs. We could not determine a difference between patients treated with postsurgical shoe and patients treated with cast immobilization. Release of the plantar fascia may have a detrimental effect on function. It is recognized that the plantar fascia and such structures as joint capsules, various intertarsal ligaments, extrinsic and intrinsic muscles, and bone and joint architecture assist in the stabilization of the longitudinal arch. Sellman31 reported the development of flatfoot in patients after spontaneous rupture of the plantar fascia. All of these patients had had injections of cortisone in the plantar fascia for plantar fasciitis, and this was believed to have contributed to the rupture. Most of these patients did have complete resolution of heel pain, but had persistent symptoms of foot weakness, arch pain, increased foot length, and leg strain. In our study, there was a change in arch height and the ratio of arch height to arch length and a
decreased talometatarsal-1 angle, which indicates that the arch alignment is maintained to some degree by the plantar fascia. The remaining soft tissue and bony structures apparently achieved adequate stability, so that a severe flatfoot deformity did not develop. In fact, deformity was not recognized by any of the patients. We recognized, with the use of objective gait analyses, functional abnormalities in patients who had good or excellent clinical results. These abnormalities were similar to those reported in other patients with heel pan." Patients appeared to walk less energetically and to place less force on the heel than control subjects. Also, our patients appeared to walk at a faster rate and, thus, spend less time on the heel. Further study is needed to determine the clinical and biomechanical factors that are most important for defining foot function. Surgical treatment for plantar fasciitis was successful for 71% of the feet evaluated at long-term follow-up. The time to full recovery was prolonged, and additional treatment was often required. Force-plate studies indicated persistent abnormalities in foot function despite satisfactory clinical results.
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obesity: National Institutes of Health consensus development conference statement. Ann. Intern. Med., 103:147-151, 1985. Nestor, B.J., Kitaoka, H.B., IIstrup, D.M., Berquist, T.H., and Bergmann, A.D.: Radiologic anatomy of the painful bunionette. Foot Ankle, 11:6-11, 1990. Polisner, R.I.: Early ambulation after minimal incision surgery for calcaneal spurs. Clin. Podiatry, 2:497-502,1985. Przylucki, H., and Jones, C.L.: Entrapment neuropathy of muscle branch of lateral plantar nerve: a cause of heel pain. J. Am. Podiatry Assoc., 71:119-124, 1981. Savastano, A.A.: Surgical neurectomy for the treatment of resistant painful heel. R.1. Med. J., 68:371-372, 1985. Sellman, J.R.: Plantar fascia rupture associated with corticosteroid injection. Presented at the Sixth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Banff, Canada, June 22,1990. Snider, M.P., Clancy, W.G., and McBeath, A.A.: Plantar fascia release for chronic plantar fasciitis in runners. Am. J. Sports Med., 11:215-219,1983. Snook, G.A., and Chrisman, 0.0.: The management of subcalcaneal pain. Clin. Orthop., 82:163-168,1972. Steindler, A.: Stripping of the os calcis. J. Orthop. Surg., 2:8-
12,1920. 35. Steindler, A., and Smith, A.R.: Spurs of the os caicts. Surg. Gynecol. Obstet., 66:663-665,1938. 36. Tanz, S.S.: Heel pain. elin. Orthop., 28:169-178,1963. 37. Ward, W. G., and Clippinger, F.W.: Proximal medial longitudinal arch incision for plantar fascia release. Foot Ankle, 8:152-155, 1987.
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Plantar Fasciotomy for Intractable Plantar Fasciitis: Clinical Results and Biomechanical Evaluation* Peter J. Daly, M.D.,t Harold B. Kitaoka, M.D.,:j: and Edmund Y. S. Chao, Ph.D.§ Rochester, Minnesota
excision,6,10,34,36,37 Steindler stripping,9,21,35 rotational calcaneus osteotomy." countersinking calcaneus osteotomy." calcaneal drilling oecornpresslon.t":" neurolysis of the nerve to the abductor digiti minimi muscle,4,8 calcaneus nerve neurolysis." calcaneal nerve neurectomy," ,30 and general decompression. 6,22,29 In a recent review of various heel operations on 527 feet, the results were described as good or excellent in 91 % of cases." We reviewed the Mayo Clinic experience with plantar fasciotomy for intractable plantar fasciitis over an 11year period and analyzed the results clinically, roentgenologically, and biomechanically.
ABSTRACT Thirteen consecutive patients underwent plantar fasciotomy in 16 feet for intractable plantar fasciitis and had follow-up from 4.5 to 15 years. Plantar fasciotomy was successful (good or excellent results) for 71% of the 14 feet operated on and for which follow-up data were available. However, time to full recovery was prolonged, additional treatment was frequently required, and abnormalities of foot function persisted. Flattening of the longitudinal arch occurred. Dynamic force-plate studies showed differences in peak vertical, fore-aft, and lateralmedial forces between pathnts and matched controls. More rapid progression of weightbearing along the longitudinal axis of the foot during stance phase in patients indicated avoidance of heel loading.
MATERIALS AND METHODS Patient Profile
INTRODUCTION
Thirteen patients (16 feet) underwent surgical treatment for plantar fasciitis from September 1975 through March 1986. Six patients were male and seven were female; the mean age was 45 years (range 14-61 years). Two patients could not be located for follow-up. Ten (13 feet) of the remaining 11 patients returned for examination and for roentgenographic and force-plate studies. Follow-up was by interview for one patient (one foot). Preoperatively, all of the patients had heel pain and tenderness of the plantar fascia and one had dysesthesia. No patient had neurologic deficit as determined by physical examination. There was roentgenographic evidence of heel spur in seven patients. Prolonged nonsurgical treatment, including orthoses, injections, casting, anti-inflammatory medications, and gait aids (cane), failed in all the patients. The mean duration of symptoms preoperatively was 20 months (range 5-60 months). Only patients who had not previously undergone operation on the heel were included in our study.
Pain of the plantar heel in the central to medial subcalcaneal region is a common foot complaint. It may be due to chronic inflammation of the plantar fascia secondary to microscopic fascial tears from repetitive trauma." Other causes that have been proposed are calcaneal spur." increase in intraosseous calcaneal pressure," nerve entrapment,":":" penosntls," and degeneration of the tat-pad." Several investigators have advocated plantar fasciotomy for intractable symptoms. 15,20.23.25,28,32,33,37 Other procedures, usually done in combination with plantar fasciotomy, also have been advocated: calcaneal spur • Presented at the Annual Meeting of the American Orthopaedic Foot and Ankle Society, Anaheim, California, March 10, 1991. t Senior Resident in Orthopedics, Mayo Graduate School of Medicine, Rochester, Minnesota, 55905. :j: Consultant, Department of Orthopedics, Mayo Clinic and Mayo Foundation, and Assistant Professor of Orthopedics, Mayo Medical School; Rochester, Minnesota. To whom requests for reprints should be addressed at the Department of Orthopedics, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. § Consultant, Section of Biomechanical Research, Mayo Clinic and Mayo Foundation, and Professor of Bioengineering, Mayo Medical School, Rochester, Minnesota.
Operative Technique
Incision was made medial or plantar oblique along the anterior margin of the heel pad. Although there was 188
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some variation in technique (heel spur excision in two, calcaneal drilling in four, Steindler stripping in two, and division of the nerve to the abductor digiti minimi muscle in one), division of the central component of the plantar fascia (plantar fasciotomy) was performed in each foot in a standard fashion. A postsurgical shoe was applied in four cases and a short leg cast in 10. Evaluation of Results
Clinical results were determined by using graded subjective and objective factors (Table 1). Results were rated as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor «70 points). Standing lateral roentgenograms were obtained to measure soft tissue shadow, 1 to evaluate occurrence of calcaneal heel spurs, and to assess any changes in longitudinal arch alignment, such as the development of pes planus. The longitudinal arch alignment was evaluated by comparing preoperative and postoperative measurements of the lateral talometatarsal-1 angle, arch height, and ratio of arch height to arch length in standing lateral foot roentqenoqrarns.':" Magnification artifact with this technique is less than 1%.27 Measurements were repeated to assess interobserver and intraobserver error. TABLE 1 Clinical Scoring System (100 Points Total) for Evaluating Results of Plantar Fasciotomy Operation" Characteristic Pain
Activity limitations
Footwear or orthotic requirement
Plantar heel tenderness Neuropathy
Antalgic gait
None Mild, occasional Moderate, frequent Severe, constant None Minor, no limitation of daily activities Major, limitation of daily and recreational activities No footwear Iimitations, orthoses not required Minor limits of footwear, orthoses occasionally used Modified shoes required, orthoses required Absent Present None, sensation intact Present, hypesthesia, Tinel's sign Absent Present
189
Force-plate studies were performed on 10 patients (13 feet), but one patient (one foot) was excluded because of a recent pelvic fracture that affected gait. Each patient walked at a free velocity along a 5-meter level walkway containing a custom-made (61 x 61 cm) piezoelectric force ptate." Load cells in the force plate measured the resultant three-dimensional ground reaction force vector while the foot was in contact with the plate (Fig. 1). Instantaneous vertical and horizontal shear forces (expressed as a percentage of body weight) and the linear X (medial-to-lateral) and Y (anteroposterior or longitudinal) progression of the center F3
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Fig. 1. Ground reaction force peaks and timing of peak forces. A, Vertical force peaks, Fj - F3 • B, Fore-aft force peaks, F4-F6 • C, Mediallateral force peaks, F7-Fa. BW., body weight. (Reprinted with permission from Katoh, Y., Chao, E.Y.S., Laughman, R.K., Schneider, E., and Morrey, B.F.: Biomechanical analysis of foot function during gait and clinical applications. Clin. Orthop., 177:23-33, 1983. By permission of J. B. Lippincott Company.)
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190
of pressure during the entire stance phase were determined. Ground reaction force components and the progression of the center of pressure (V-progression) were assessed at 10%, 25%, and 75% stance phase to determine the rate of progression of force from the hindfoot to the forefoot. The magnitude of ground reaction peak forces (F1-Fg) was determined":" (Fig. 1), as was the timing of peak forces (T1 - Tg) . The gait variables of the patients were compared with those of matched control subjects. The opposite foot was not used as a control because patients exhibit a "crossover" phenomenon in which abnormalities such as gait and foot breaking on the involved side affect the opposite extremity. RESULTS
Follow-up evaluation (mean 8 years; range 4.5-15 years) was obtained for 11 patients (14 feet). The clinical results are shown in Table 2. Ten of the 14 feet had no or mild pain and nine had no activity limitations, but footwear limitations or orthoses were required for 11 of 14 feet. There was tenderness of the plantar heel in five feet, and paresthesias were elicited with percussion along the medial incision (medial calcaneal nerve) of one foot. Three patients (four feet) had a discernible limp. Ankle and subtalar motion was unrestricted in all the patients, and hindfoot deformity was not observed in any of them. The only complication, delayed wound healing, occurred in one patient and resolved uneventfully. The patient had a poor clinical result. Clinical results were excellent for eight feet, good for two, and poor for four. The two patients who had good results had mild pain in the foot and one had minor restrictions of activity; they used orthoses. For three of
the four poor results, the patients had severe pain, major limitations of activity, tenderness of the heel, and an antalgic gait. One of these patients underwent another operation. The other patient who had a poor result had moderate pain, minor limitations of activity, heel tenderness, and an antalgic gait. The operations performed in the patients (four feet) who had poor results were plantar fasciotomy only (three feet) and plantar fasciotomy with Steindler stripping, spur removal, and calcaneal drilling (one foot). We were unable to find a correlation between obesity and clinical results. Only one of the five feet of patients considered obese was a poor clinical result. 26 Seven patients (eight feet) were satisfied with the results, two were satisfied but with reservations, and four were dissatisfied. Satisfaction correlated with clinical results. The seven patients (eight feet) who had excellent results according to the scoring system were all satisfied. The two patients with scores that indicated good results were satisfied but with reservations, and the patients with scores that indicated poor results were dissatisfied. Additional treatment was required in seven patients: one underwent neurolysis (poor result) and six had nonsurgical treatments, such as anti-inflammatory medications, injections, orthoses, and nerve block procedures. The average time to maximal clinical improvement was 10.5 months postoperatively (range 1.5-24 months). Roentgenologic evaluation of longitudinal arch alignment demonstrated that the difference in arch height preoperatively and postoperatively was -4.1 ± 2.8 mm and was significant (P < .01). The length of the arch increased an average of 1.7 ± 2.7 mm, but not signifi-
TABLE 2 Clinical Results of Plantar Fasciotomy Operation Based on the Clinical Scoring System Compared with Patient Satisfaction" Patient
2
3 4 5 6 7
e 9 10 11b
Age
Sex
Side
Pain
Activity limitations
Footwear limitations
43
M
R
0 0 0 50 50 50 30 50 50 50 40 40 50 40
0 0 0 10 10 10 5 10 10 10 5 10 10 10
0 0 0 5 5 5 0 10 10 10 5 5 5 5
41 43
F F
61 49 50 53 41
F F
14 36 45
F F
M M F
M
L R R L R R R L R L R L L
Heel tenderness
Neuropathy/ Tinel's sign
Antalgic gait
0 0 0 10 10 10 0 10 10 0 10 10 10
10 10 0 10 10 10 10 10 10 10 10 10 10
0 0 0 10 10 10 0 10 10 10 10 10 10
NA
NA
NA
Graded result Poor Poor Poor Exc. Exc. Exc. Poor Exc. Exc. Exc. Good Good Exc. Exc.
Satisfaction Dis. Dis. Dis. Sat. Sat. Sat. Dis. Sat. Sat. Res. Res. Sat. Sat. Sat.
• See Table 1 for details of scoring system. Dis., dissatisfied; Exc., excellent; NA, not available; Res., satisfied but with reservations; Sat., satisfied. b Only SUbjective data available.
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cantly (P = .14). Although arch height and length are related, it probably is not a linear relationship, because rotation also occurs with the development of pes planus. The ratio of arch height to arch length difference was -0.03 ± 0.02, which was significant (P = .01). The talometatarsal-1 angle difference was -4.7 0 ± 5.1 0, which was significant (P = .05). These measurements, made on standard weightbearing lateral foot roentgenograms, showed a measurable flattening of the longitudinal arch after plantar fasciotomy (Fig. 2). Postoperative measurements1 of the soft tissue shadow of the
191
heel were not significantly different from preoperative measurements (P = .52). Peak values (F1-Fg) of floor reaction forces (Fig. 1) were studied. Vertical force peaks F1 and F3 were significantly less (Table 3) in the patients than in the matched control subjects (P < .01), but vertical force peak F2 was significantly greater than in control subjects (P < .001). These differences in vertical force indicate a less energetic pattern of walking in the patients. Fore-to-aft shear force peak (Fs) was less in patients than in control subjects (P < .05), indicating a
Fig. 2 Lateral weightbearing radiographs of a patient A, before and B, after plantar fasciotomy. Solid lines form the tarsometatarsal-1 angle. Dashed lines show the talar height measurement.
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TABLE 3 Ground Reaction Peak Forces (F 1-Fg) and Clinical Result and Comparison Between Patients and Control Subjects Patient
Sex
Side
M
R L
R R
2 3
F F
4 5 6 7 8
F F M M F
L L
9
F
R R
L
R R R
Patients Mean SO Control subjects Mean SO
F,
F2
F3
F:
F5•
Fs•
Fl
Feb
Fgb
122 127 103 107 106 104 111 113 118 104 103 119
74 65 83 85 85 85 88 71 73 78 81 73
121 129 96 114 115 105 108 101 115 112 108 117
-5.7 -4.1 -1.4 0.3 1.0 -2.0 -4.1 -7.9 -8.4 -2.6 -2.3 -3.2
15.2 17.6 7.9 14.8 12.4 12.8 14.6 10.7 14.0 12.5 14.7 14.2
-12.9 -22.2 -20.0 -20.4 -19.5 -16.8 -23.4 -18.5 -19.8 -21.3 -17.8 -18.7
3.1 4.4 4.3 6.3 3.1 3.5 1.8 6.5 3.6 1.9 2.2 5.5
-5.3 -6.9 -2.9 -1.8 -5.2 -4.0 -4.9 -3.5 -5.9 -4.5 -4.9 -7.9
-5.1 -4.5 -2.2 -1.1 -4.3 -2.5 -1.6 -1.6 -6.7 -5.8 -3.0 -3.1
111c
78 c 7.2
111C
-3.4 2.9
13.5c
2.5
-20.0 1.9
3.9 1.6
-4.8 1.6
-3.5 1.8
66 9.5
120 10
-2.7 3.2
18.3 5.4
-22.3 5.3
4.7 2.0
-5.0 1.7
-4.1 1.8
8.3 119 13
8.9
Clinical result Poor Poor Poor Exc. Exc. Exc. Poor Exc. Exc. Good Exc. Good
• Fore-aft forces directed anteriorly are negative, and ones directed posteriorly are positive. b Medial-to-Iateral forces directed medially are negative, and ones directed laterally are positive. c p < .05 for difference from control. TABLE 4 Comparison of Ground Reaction Force Components Between Patients and Control Subjects Component (% stance phase) Vertical"
Fore-aft"
Medial-tolateral"
TABLE 5 Comparison of Center of Pressure Progression (Y-Component) Between Patients and Control Subjects Percentage of stance phase
Patients. (% body wt)
Controls" (% body wt)
10 25 75 10 25 75 10
75.0 ± 12.1 108.0 ± 10.8 108.5 ± 7.6 10.1 ± 2.7 9.4 ± 3.0 -11.5±1.4 1.1 ± 1.9
71.5 ± 12.8 118.0 ± 2.4 118.8 ± 9.6 11.0 ± 3.4 13.9±5.1 -13.9±5.1 3.3 ± 2.9
.52 .003 .02 .54 .007 .35 .02
25 75
-3.9 ± 1.6 -2.7 ± 1.4
-4.6 ± 1.8 -3.3 ± 2.0
.35 .18
• Mean ± SO. b P < .05 for difference from normal. c Vertical forces are positive. d Fore-aft forces directed anteriorly are negative, and ones directed posteriorly are positive. " Medial-to-Iateral forces directed laterally are positive, and ones directed medially are negative.
lower "braking force" decelerating the center of mass. The timing of peak ground reaction forces (T1- T9) was studied, and vertical peak pressure (F3 ) occurred earlier in stance phase (T3) in patients than it did in control subjects (P < .05). Comparison of vertical, anteroposterior, and medialto-lateral forces and the progression of the center of pressure at 10%, 25%, and 75% stance phase revealed a number of significant differences (P < .05) between patients and control subjects (Tables 4 and 5). There
10 25 75
Patients"
(% body wt)
Controls" (% body wt)
pb
30.1 ± 6.0 48.9 ± 6.5 90.5 ± 5.6
19.1 ± 13.2 32.2 ± 17.0 73.8 ± 22.8
.02 .003 .02
• Mean ± SO. b P < .05 for difference from normal.
was significantly less medial-to-Iateral shear force in patients (P = .02) at 10% stance phase, significantly less vertical force (P < .01) at 25% stance phase, and less fore-to-aft shear force (P < .01) at 25% stance phase. The center of pressure was significantly different between patients and control subjects (Table 5). This finding and the significantly less vertical force at 25% stance phase in patients indicated that the patients progressed through stance phase faster (thus spending less time on the heel) and applied less vertical force than control subjects did. A typical example is shown in Figure 3. DISCUSSION
The prolonged course and intractable nature of plantar fasciitis often can be a frustrating dilemma for patients and physicians alike. Nonsurgical treatment usually is successful within 6 to 12 months of the onset of symptoms." Most of the operations that have been
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193
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194
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DALY ET AL.
reported for intractable symptoms 4 ,6,9,11-13,15,20,22,24,35 included plantar fasciotomy, which was performed on all our patients, Only 71% of the feet had excellent or good results, which is not as good an incidence as in most reports, There may be several reasons for this. We report longterm results (mean 8 years) of consecutively treated patients, nearly all of whom had follow-up (11 of 13 patients, or 85%). The patients were assessed more critically in this series, but the poor results would be considered failures, using any of the published grading methods. The duration of symptoms (mean 20 months) was longer in our patients than in those of other studies. We were unable to find a correlation between duration of symptoms preoperatively and final result. Also, our patients required longer times (mean 10.5 months) postoperatively to reach maximal clinical improvement. This is in contrast to the 6-month postoperative period reported by others. 2o ,37 A limited number of operations for intractable plantar fasciitis performed at our institution during the 11-year period and the long duration of preoperative symptoms reflected the careful selection of patients. Several hundred patients were treated nonoperatively during this period. Patients in our group may be different from those treated earlier by surgeons with a propensity toward operative treatment. Although patients were not followed at regular intervals (e.g., yearly assessment), it is our impression that progressive deterioration clinically did not occur during the time the patients were followed (mean follow-up 8 years). Two of the seven feet that preoperatively had roentgenologic evidence of heel spurs underwent spur excision. In one of the feet, the result was excellent, and in the other, it was poor. The results were excellent or good in the other five patients who did not undergo spur removal but who had roentgenologic evidence of heel spurs. We could not determine a difference between patients treated with postsurgical shoe and patients treated with cast immobilization. Release of the plantar fascia may have a detrimental effect on function. It is recognized that the plantar fascia and such structures as joint capsules, various intertarsal ligaments, extrinsic and intrinsic muscles, and bone and joint architecture assist in the stabilization of the longitudinal arch. Sellman31 reported the development of flatfoot in patients after spontaneous rupture of the plantar fascia. All of these patients had had injections of cortisone in the plantar fascia for plantar fasciitis, and this was believed to have contributed to the rupture. Most of these patients did have complete resolution of heel pain, but had persistent symptoms of foot weakness, arch pain, increased foot length, and leg strain. In our study, there was a change in arch height and the ratio of arch height to arch length and a
decreased talometatarsal-1 angle, which indicates that the arch alignment is maintained to some degree by the plantar fascia. The remaining soft tissue and bony structures apparently achieved adequate stability, so that a severe flatfoot deformity did not develop. In fact, deformity was not recognized by any of the patients. We recognized, with the use of objective gait analyses, functional abnormalities in patients who had good or excellent clinical results. These abnormalities were similar to those reported in other patients with heel pan." Patients appeared to walk less energetically and to place less force on the heel than control subjects. Also, our patients appeared to walk at a faster rate and, thus, spend less time on the heel. Further study is needed to determine the clinical and biomechanical factors that are most important for defining foot function. Surgical treatment for plantar fasciitis was successful for 71% of the feet evaluated at long-term follow-up. The time to full recovery was prolonged, and additional treatment was often required. Force-plate studies indicated persistent abnormalities in foot function despite satisfactory clinical results.
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14. Jay, R.M., Davis, B.A., Schoenhaus, H.D., and Beckett, D.: Calcaneal depression for chronic heel pain. J. Am. Podiatr. Med. Assoc., 75;535-537,1985. 15. Kahn, C., Bishop, J.O., and Tullos, H.S.: Plantar fascia release and heel spur excision via plantar route. Orthop. Rev., 14:222-
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