Common Surgical Procedures for Plantar Fasciitis
How Long To Recover From Plantar Fasciitis Surgery?
If you are undergoing an endoscopic plantar fasciectomy, full recovery should take 3 to 6 weeks as this surgery is considered a minimally invasive surgery. This form of surgery is also often termed arthroscopic plantar fasciectomy.
If you are undergoing a plantar fasciectomy via open surgey, full recovery should take 6 to 10 weeks though in rare cases, recovery may take 6 or 7 months.
Why Do Recovery Rates Vary?
Everyone is different! Soft tissue recovery time after surgery depends on a multitude of factors; some include overall health, age and blood circulation levels. Further to this, some diseases may also have a substantial effect on healing times, one example being diabetes.
What is the Goal of the Surgery?
Surgery is rarely undertaken unless it is has become clear that it is necessary - surgery for a soft tissue injury is a "last resort" option. The surgery performed to repair soft tissue usually involves one or more of the following surgical goals:
- Debridement - this is the removal of any loose fragments of bursa, scar tissue, bone or other debris from the area.
- Smoothing - the surgeon makes room so that tendons and muscles can function properly without being pinched (aka impingement). This sometimes results in shaving down of bony edges or spurs from bone so soft tissue can slide without fraying. The most common example of this in the foot would be a heel spur - a very common occurence for those suffering from plantar fasciitis.
- Stitching - torn fascia, ligament and/or tendon edges are sewn back together and reattached to the bone if needed.
- Tension Release - this is often a primary goal when dealing with plantar fasciitis. In such cases, the fascia is thickened and is possibly swollen. As a result, the thickened fascia has become less flexible and is causing strain (often near the attachment to the heel bone). to release tension, some of the fascia may be removed or cut.
What Requirements Are Considered For Me To Be a Candidate for Plantar Fasciitis Surgery?
First and foremost, you will likely only be considered for plantar fasciitis surgery after undertaking a course of conservative treatment options for at least 6 months. Other factors would likely include:
- Is Your Ability to Work Affected?
- Are You Still in Severe Pain, Despite Trying Conservative Treatment Options?
- Is This Condition Preventing You From Engaging In Physical Activity?
- Have You Been Diagnosed With Plantar Fasciitis? Have Other Conditions That Exhibit Similar Symptoms Been Ruled Out?
Around 90% of people who are diagnosed with plantar fasciitis will experience relief within one year of starting non-surgical therapy, and trying such options before considering surgery is recommended.
What Conditions May Affect Plantar Fasciitis Surgery Negatively?
There are many issues, ailments and conditions that could have a negative effect on surgery outcome. Some of these would include:
- Overall health. How healthy are you? Healthy bodies are generally more capable of handling the stress of surgery.
- Diabetes, and more specifically, lack of good blood flow to the foot. Lack of good blood flow to heal properly after surgery can lead to complications, predisposing you to many negative outcomes - even necrosis.
- Nerve disease "Sensory loss or paresthesias (uncomfortable sensations) due to nerve disease can predispose you to profound foot discomfort after surgical procedures involving your foot." [1.]
Aside from the conditions listed above, foot surgery will not be undertaken if you are currently experiencing an infection in the area.
If Surgery is Required
Regardless of what type of surgery is undertaken, there are both advantages and disadvantages for each. Once surgery is tabled as an option, speak with your physician and ensure you have a full understanding of the risks involved.
Surgery may be necessary if you have exhausted all forms conservative treatments, resting, cold, PT - and, you still find yourself in pain and have limited functionality in common daily activities. You and your doctor may decide to move forward and have you undergo surgery, triggering the next chapter of your injury recovery journey. A good point to remember is that your post surgery rehabilitation efforts will have an important impact on how soon you can return to living and enjoying your normal daily life.
The surgery that your surgeon will recommend for you will depend on the level of your pain, the type of injury you have, and the amount of damage there is in the area. Damage is typically determined from your physical exams, x-rays and MRI results. The length of time between the injury and the surgery is often also a determining factor in the type of surgery that will be required.
With acute (recent) tearing, the separation in your fascia is likely to be very minimal. If you have an acute tear you may qualify for less invasive surgery (such as a arthroscopic, open surgery or an mini-open procedure). Surgeons will always choose a shorter, less invasive procedure if it is possible to do so. Most surgeons know that a less complicated procedure will create less trauma to the area, resulting in a quicker rate of recovery after the surgery.
Arthroscopic Vs Open Surgery
Arthroscopic Surgery
Arthroscopy can be a minimally invasive surgical procedure that is used to diagnose and/or treat some conditions. If a doctor is unable to make a diagnosis following a physical exam, x-ray, and/or MRI, an arthroscopy may be performed to get a better look inside the injury area so a diagnosis can be made.
This type of surgery is normally used on joints of the body, like the shoulders or knees. Arthroscopic surgery is usually performed with the patient under general anaesthetic. During surgery, tiny incisions (1/4" - 1/3") are made to insert the surgical instruments, and a thin tube containing a camera and light.
Arthroscopic muscle surgery will provide the surgeon with a first hand look into the nature of the injury and what work must be done to fix the injury. If the damage is not extensive, the surgeon will be able to complete the repair through an arthroscopic procedure. This is a minimally invasive procedure so it may limit the amount muscle tissue damage from surgery, helping promote a more effective recovery.
Open Surgery
Traditional open surgery is used when there is substantial damage in the area and/or the surgeon needs to physically open up the area to better assess the damage. This could include damage to one or more of the following: muscle, tendon, cartilage, ligaments, fascia and/or bone fractures. During this procedure a sizable incision is made in the area of the injury.
Common Types of Plantar Surgery
Plantar Fascia Release (aka Plantar Fasciotomy)
The purpose of a plantar fascia release is to reduce the tension by making partial cuts in the plantar fascia. After surgery, as you heal, the fascia will experience new growth; the intent is for this new growth to help lengthen the fascia and reduce tension in the bottom of the foot over the long term. It is important to note for this surgery, the plantar fascia is not detached from the heel bone - only a portion of the fascia is cut. The fascia will be partially cut across the surface close to where it attaches at the heel bone.
After partial release of the fascia at the heel is done, the surgeon will determine if this is sufficient; if they feels the fascia is still 'tight', another incision will be made at the base of the ball of the boot (below the metatarsals) where more partial cuts will be made of the fascia. The surgeon will manually push your foot in an upward motion (basically push your toes toward your knee) to ensure the 'release' of the tissue.
Once the surgeon is satisfied, your incisions will be sutured up. You may be fitted with a non-weight-bearing cast or brace for 2 to 3 weeks to allow tissue in the foot to heal further before undergoing activity.
Plantar fascia release surgery can be done via open surgery or via arthroscopy; there are advantages and disadvantes to both:
Arthroscopic Plantar Fascia Release Surgery (also commonly termed as Endoscopic Plantar Fascia Release)
Due to massive improvents in both technology and techniques in the field of surgery, arthroscopic surgery has become the 'gold standard' for plantar release (fasciotomy). Normally, this type of surgery is considered a "day surgery" that only requires a local anesthesia. The surgeon will use one or two 1 cm small incisions on either side of the heel below the ankle bone. A small camera and scalpel are inserted and the surgeon will proceed with the partial fascia release. As stated above, if the surgeon is satisfied, they will close up and end the surgery - otherwise they will continue with the surgery at the base of the ball of the foot.
With this minimally invasive surgery, it is more likely that you can begin limited weight-bearing immediately and wearing normal shoes again as soon as you are comfortable. After a successful surgery, most people can return to normal activities in 3 to 6 weeks.
Advantages of Arthroscopic Plantar Fascia Release
There are two very big advantages of undergoing arthroscopic as compared to open surgery - only a local anesthetic is required, and the surgery is much less invasive than open surgery. This translates to the following:
- there is always a non-zero level of risk associated with being completely anesthetized (termed "general anesthesia"). Complications due to this, though not common, do arise.
- A minimally invasive surgery means there is less "damage" to soft tissue in the surgery location(s). This translates to less risk of infection, less risk of unintended damage (ie. nerve damage), and a much quicker recovery from the surgery.
Disadvantages of Arthroscopic Plantar Fascia Release
If the damage is too extensive, it may not be possible for the surgery to be successful. In such cases, open surgery may be required at a later date. Related to this issue is that removal of bone spurs or other problematic obstructions is not typically done during this minimally invasive surgery.
Plantar Fascia Release Open Surgery (also commonly termed as Traditional Plantar Fascia Release Surgery)
Although there have been major technological advancements in the field of surgery, there are still times when open surgery is necessary. For this surgery, the surgeon makes an open incision approximately 4 centimeters long on the side of the foot. A surgical retractor is used to further widen the 'gap' of the incision, opening up the area for better access.
While the incision is open, the surgeon will also undergo the process of removing any calcium deposits and/or bone spurs from the heel area as they deem necessary. If the surgeon still feels the fascia is 'tight', they will make another small 2cm incision at the base of the ball of the foot. With this area exposed, more cuts will be placed in the fascia. Once the surgeon is satisfied, the incision will then be sutured closed. After a successful surgery, most people can return to normal activities in 6 to 10 weeks.
Advantages of Traditional, Open Surgery Plantar Fascia Release
There are two advantages of open surgery versus an arthroscopic/endoscopic method:
- With open surgery, the surgeon can remove calcium deposits, bone spurs and work on anything in the area that is likely beneficial to your recovery.
- Open surgery provides the surgeon with the best view of the problematic area. Micro-cameras, ultrasound, x-ray and MRI imaging are exceptional these days, but there can still be an advantage to the perspective provided by physically opening up the area.
Disadvantages of Traditional, Open Surgery Plantar Fascia Release
Open surgery comes at an increased risk of complications and infection when compared to a more minimally invasive surgery (arthroscopic). Further to this, "general anesthesia" will usually come with increased risk (however minimal) when compared to a "local anesthesia". However, anesthesia risk will depend on many factors and there are still risks associated with local anesthesia.
Percutaneous Fascia Surgery
This procedure can be done in 2 ways:
- Via regular (small) incisions
- or, "stab incisions" with a needle (this is most common)
Your surgeon may perform percutaneous surgery by using a surgical needle to repeatedly stab your tight and constricted fascia. These "stab incisions" will allow the surgeon to create small cuts in the fascia is abnormally tightened up (often from scar tissue). An argument could be made that the objective of percutaneous surgery on the fascia is much the same as a partial fascia release - only on a smaller scale and less minimally invasive. The surgeon will typically enable ultrasound imaging to direct needle placements. This type of surgery has been very successful in providing range of motion improvements. In most cases, the muscle in question has had open surgery with unsuccessful results and a build-up of scar tissue has further tightened the tissue.
Plantar Fasciectomy
If you are undergoing a plantar fasciectomy, the primary purpose of the surgery is to clean up the plantar fascia by removing damaged tissue with the intent of helping the foot heal better. Damaged tissue could mean scar tissue, inflamed tissue, dead tissue, infected tissue or contaminated tissue. The surgeon may also perform debridement by scraping down any calcium deposits (bone spurs) that may have formed on the bone.
A surgery that ends in "ECTOMY" implies the surgery objective is to remove tissue. A surgery that ends in "OTOMY" implies the surgery is to cut tissue.
Another Type of Surgery - A combination of open, arthroscopic and percutaneous surgeries
As another option - some surgeons will use a combination of the above types, making 1 to 3 incisions for smaller surgical implements to repair soft tissue while relying on imaging ultrasound to see your damaged tissue. During either procedure, the use of ultrasound imaging or endoscopic/arthroscopic techniques requires a very skilled surgeon.
Foot Stability Post Surgery
It is important to understand that surgery may not give you 100% functionality of your foot, but you should be able to return to most if not all of your pre-injury activities.
Surgical procedures (as outlined above) are often performed with very successful results. What truly makes a difference is your commitment to a doctor recommended rehabilitation program after surgery as there is always a possibility of re-injury even after a surgical procedure. One complication of surgical repair for soft tissue is that skin can become thin at the site of incision, and may have limited blood flow.
Ask any doctor and they will tell you that the success of your surgery depends on your level of dedication to your recovery. Most of our post-op clients have experienced positive results through adhering to a dedicated home conservative treatment regimen as oulined in the Foot Post Surgery Rehab page.
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Sources:
1. Plantar Fasciitis. The. (2023) Plantar Fascia Release: Preparation, Recovery, Long-Term Care. Retrieved April 04, 2023, from https://www.verywellhealth.com/surgery-for-plantar-fasciitis-2549873