Mrs D is a delightful 49 year old lady who was referred to Dr Touzell after an eight year history of intractable plantar fascia pain. Mrs D used to be a competitive ballet dancer and is also a busy Mum to three children. Mrs D had, in her words, 'tried bloody everything'. This included:
custom orthotics
shockwave therapy
physiotherapy and achilles stretching exercises
change of runners
two ultrasound guided corticosteroid injections with an experienced musculoskeletal ultrasonographer and radiologist
On examination, she had a subtle cavovarus foot type. She was tender to palpation over the plantar fascia insertion but her achilles tendon was non-tender. Her ankle and subtalar joint were mobile and non tender, and she had generalised ligamentous laxity. There was no evidence of tarsal tunnel syndrome (an occasional cause of intractable heel pain).
An MRI scan demonstrated severe plantar fasciitis and bone oedema within the plantar aspect of the calcaneus suggestive of chronic traction of the plantar fascia (see below).
Mrs D had exhausted her non-operative treatment, so the option of surgery was discussed. An endoscopic plantar fascia release is a minimally invasive method of treating this condition, and the risks and benefits of the procedure were discussed.
Mrs D was very keen to proceed with surgery due to frustration with non-operative treatment measures and ongoing difficulty walking and night pain. The procedure, performed as a day case, was uneventful. She was partial weight bearing in a CAM boot for two weeks after surgery and the commenced weight bearing as tolerated in a normal shoe. She felt immediate relief from the procedure and was delighted with the outcome. Two years post-operatively, she has lost 15kg in weight as she felt she was able to exercise more easily, although also made some positive dietary changes that have contributed to her overall health.
Discussion
Intractable plantar fasciitis is a frustrating condition for health clinicians to treat due to its protracted post-operative course and occasional resistance to standard treatment methods. Common non-operative treatment modalities includes steroid injections and orthotics. An excellent randomised controlled trial by podiatrist Dr Glenn Whittaker PhD comparing a pre-fabricated orthotic (costing approximately $60) with a steroid injection demonstrated more improvement four weeks post treatment with an injection, but increased improvement with a pre-fabricated orthotic twelve weeks post treatment. Surgery for this condition is also supported by the literature for cases where non-operative treatment has not been successful. There is some research that suggests an endoscopic plantar fascia release is of benefit for severe plantar fasciitis but we are yet to have a high-quality randomised controlled trial to support this. Ethically, financially and practically, well-powered, randomised controlled trials for surgical interventions are difficult to execute. Surgery for severe plantar fasciitis can have a role but the importance of optimisation of non-operative management cannot be overlooked. Taping, a pre-fabricated orthotic and corticosteroid injection are all low-cost, relatively minimal risk treatments that may help patients with plantar fasciitis. An endoscopic plantar fascia release (like most surgical procedures) should be offered when non-operative treatment has failed.
Key Learning Points:
Plantar fasciitis is extremely common.
Non-operative treatment includes taping, stretching, change of footwear, a pre-fabricated orthotic and corticosteroid injection.
An endoscopic plantar fascia release is a reasonable surgical procedure if non-operative measures fail.
All cases have been shared with discussion and written permission from the patient involved.
*costs are a rough estimate only and reflect what is charged by Podiatry at South East Orthopaedic Surgery, and costs will vary between individual practices.