Today on Doc On The Run podcast we’re talking about everything that runners should need to know about surgery on the plantar fascia.
Today we’re talking about surgical options for chronic plantar fasciitis and not every runner needs to listen to this but if any of you have had chronic heel pain and you’re considering surgery, it’s really important that you understand what all the different surgical procedures mean in terms of the procedures themselves but also what that mean to you as a runner. I personally believe that my entire job is to help runners continue running and so I have a perspective that’s a little different than some other surgeons. So we are going talk all of the special considerations that you need to take into account if you’re considering surgery on the plantar fascia.
The first thing to consider is…why are you thinking about surgery anyway? If you think about this from a psychological standpoint the fact is that when people get frustrated they start looking for solutions. If you’ve tried a lot of different treatments and it seems like you’re not getting better you probably want to fix it as fast as possible. This is only human nature. With the current onslaught of advertisements about medications and surgical procedures, it’s not surprising that it seems like surgery could fix just about anything.
As somebody who is trained as a foot and ankle surgeon, I like the idea of fixing things. When I raced motorcycles, I found it gratifying when I could take a motorcycle that had been virtually destroyed in a crash and then fix it, get back on it and still win a race.
But human beings are relatively complicated machines. Its one thing if your car starts making a noise…you may be able to simply replace a part so it doesn’t make a noise anymore. If you have chronic knee pain you can even replace that part too, you could get a total knee replacement. That may allow you to walk without pain. But it’s not your normal anatomy and I don’t believe there is anyone, not even your orthopedic joint replacement surgeon, who is going to argue that an artificial replacement is going to work as perfectly as your natural anatomy.
All doctors are on a mission to make you feel better by helping you manage diseases and deformities that interfere with your lifestyle. So if we get to the point that we think we cannot cure your issue with conventional measures (without surgery) we start thinking of surgical solutions.
One thing you have to understand is that almost all doctors will agree that surgery is traumatic and damaging. Almost no doctor is going to recommend surgery to you as the very first option.
In fact many years ago, when I was a medical student I went to the annual conference of the
American College of Foot and Ankle Surgeons. During one of the lectures I remember one of the speakers explaining the process of surgical consent and documentation.
He said that when he talks to a patient with virtually every condition that he sees, he explains that the patients have basically three options:
Most of the time when I have patients read their consent form and we discuss all of these risks, they look at me and say, “But that’s not going to happen to me right?”
Well, I certainly hope not, but there’s absolutely no guarantee. Surgical complications do happen.
There are a wide variety of surgical procedures that can be performed to treat chronic plantar fasciitis. But I think it is helpful for any runner to understand the difference between these various surgical procedures. The more you understand about the different options, the better informed you will be when you have a discussion with your foot surgeon so that you can make the best choice for you.
Certainly the most commonly performed surgery on the plantar fascia is open plantar fascia release surgery. This is likely been performed more times than any other type of surgical procedure in an attempt to cure chronic plantar fasciitis.
When we say this is an “open” procedure what we mean is that the surgeon makes an incision on the bottom of the foot or the side of the foot in order to gain access to the plantar fascia.
Then, once the surgeon has dissected down to the plantar fascia, the surgeon will use a scalpel or surgical scissors to cut through a portion of the plantar fascia and “release” the plantar fascia.
In most cases the surgeon will only release the medial band of the plantar fascia. The “medial band” is the portion of the plantar fascia that starts at the heel bone, passes under the arch and continues out to the big toe. This is the portion of the plantar fascia that has the most tension on it and it is the part that typically causes most of the discomfort in cases of chronic plantar fasciitis.
Once the surgeon cuts through the medial band of the plantar fascia she will simply irrigate the incision and then close the skin with sutures. But there are no stitches in the plantar fascia. That is one point that you have to understand.
The surgeon does not actually “fix” or truly repair the plantar fascia. The goal with open plantar fascia release surgery is to simply cut through the portion of the plantar fascia that has the most tension. The idea is that by relieving the tension the pain will decrease overtime.
Plantar fascia release surgery results in a small gap between the portions of the plantar fascia that have been cut. As healing takes place scar tissue will fill in that gap. So in a sense, if all goes according to plan, the plantar fascia will be somewhat intact. But it is not the same structurally. In some cases the gap will not heal together completely. It is possible that some scarring will form between the sections to the plantar fascia that have been released. But in either case it is unlikely that the medial band of the plantar fascia will be as strong as it was prior to the plantar fascia release surgery.
Overall healing times from open plantar fascia release surgery can vary widely. One common routine is to place the patient in a cast or a fracture walking boot for a period of 4 to 6 weeks. It takes at least four weeks for any collagen formation to begin to add any sort of structural integrity to the release plantar fascia. So it’s very important that the foot remain in a fixed position while this healing takes place. Many surgeons will also recommend crutches during the initial healing period.
The plantar fascia will continue to heal for many months thereafter. The remodeling of the collagen that has formed and developed scar tissue where the plantar fascia had been cut will continue to change for many months. The remodeling process could go on for a year and a half.
I still very clearly remember a foot surgeon that I worked with when I was a student who had plantar fascia release surgery. I remember him telling me that it took approximately a year before all of his heel pain really went away. He of course, would also share this experience with patients when they were considering plantar fascia release surgery.
Minimal incision plan to release surgery is much like an open procedure except it is a smaller incision. In this case, the skin incision placement is similar but smaller.
Minimal incision surgery became very popular during the 1980s. The idea was that with less surgical dissection and soft tissue disruption the patient might have less swelling and faster healing after the surgical procedure.
When I was in residency working with the number of different surgeons I would often ask them their opinions about minimal incision surgery. Several of those surgeons joke that it should be called “minimal decision surgery” since the surgeon cannot actually see what she’s doing.
Very small incisions often equate to very poor visualization. And although plantar fascia release surgery is relatively simple procedure, there is no question that the surgeon can see less when working through a very small incision.
Many patients incorrectly assume that a smaller incision will always heal faster than a long incision. But the truth is skin heals from side to side, not from end to end. An incision on the top of the foot should be expected to take about two weeks to heal. This is true at the incision is one inch long or three inches long.
The skin on the bottom of the foot is thicker and it takes a little bit longer to heal. An incision on the bottom of the foot will often take about three weeks to heal. This is true at the incision is one inch long or three inches long.
The length to the incision really doesn’t make a difference in incision healing time.
An endoscope is basically a very small camera on the inside of a metal tube that is inserted inside the tissue to look around. You may be familiar with arthroscopic surgery. This is a common technique used in knee surgery. Some doctors call it a “knee scope.” The doctor can make very small incisions and stick instruments in through the hole in the skin and then use a very small camera to see what she is working on.
Endoscopic surgery is a lot like arthroscopic surgery. It’s basically the same technique. The only difference is that it’s just within the soft tissue and not within a joint.
Incisions are even smaller than those typically made through minimal incision surgery. An instrument with a camera is inserted through one side of the foot. An instrument with a scalpel is inserted through the other side of the foot. This procedure allows the doctor to look directly at the plantar fascia, cut through the plantar fascia and confirm that all of the collagen fibers has been released while maintaining very small incisions.
Depending upon the surgeon’s training she may not have been trained in arthroscopic or endoscopic surgery.
Although I have performed plantar fascia surgery using all of the above-mentioned techniques,
Endoscopic plantar fascia release is certainly my preferred method. I like the idea of very small incisions. I also believe there is a very low risk of developing a painful scar with this technique.
Because I see mostly patients who are runners and athletes I become very concerned when thinking about the possibility of a large potentially painful scar on the bottom of the foot.
Obviously if you have a painful scar on the bottom of your heel it could bother you when you’re running.
When I perform surgery on runners my primary goal is to make sure that they will be able to run after they heal. However it seems like many doctors simply focus on the goal of getting the plantar fascia pain to go away. That’s not to say getting your pain to good away is not a worthy goal. But what if we get your plantar fascia pain to go away, yet you still have pain on the bottom of her heel or in your arch when you run…simply because you have a painful surgical scar? I think it would be very difficult to label that surgery a success.
Another option is the Tenex Health TXTM surgery (which some doctors may simply refer to as the TenexTM procedure). Although some doctors will say that this is an alternative to surgery, suggesting that it is noninvasive, it is actually a form of surgery. It is minimally invasive surgery.
Granted the incisions are very small (about 3mm) and the surgical instruments inserted are about the size of large needles or a toothpick. But it is still surgery.
The procedure was developed to help remove portions of diseased or damaged tissue.
Basically it is an irrigation and vacuum system that will remove debris as a large sharp needle cuts through and loosens disease portions of a tendon.
Because the plantar fascia is a large ligament made of collagen, much like a tendon the procedure is sometimes performed on the plantar fascia. Some doctors will perform this procedure to attempt to reduce the thickness of the plantar fascia in cases of chronic plantar fasciosis. Because these are very small incisions the doctor does not look directly at the tendon but instead is viewing the instrumentation via ultrasound guidance.
The TopazTM procedure is another minimally invasive procedure. Instead of cutting away pieces of tissue as is done in the TenexTM procedure the TopazTM procedure uses radio frequency waves that cause micro trauma to the scar tissue and areas of damage to the plantar fascia. The intention of the TopazTM procedure is that it will target the damaged areas of tissue and induce a healing process instead of the chronic degenerative process that takes place in cases of plantar fasciosis.
Cryosurgery is another form of minimal incision surgery. In this case instead of using sharp instruments or radio waves to break up the damage tissue an extremely cold probe is used. The
Cryoprobe that is inserted under the skin to the plantar fascia can reach temperatures of -70 C.
The nerve cells in the area are destroyed by the freezing process. It has been reported that the most common adverse effect of cryosurgery is that some patients will develop discomfort in a different location of their pain or arches. In that case I start to walk differently in order to compensate for the new areas of inflammation.
The TopazTM and TenexTM procedures are both usually performed in the operating room with the patient under sedation. Cryosurgery can be performed in a podiatrist’s office.
All three of these minimally procedures are still considered to be relatively experimental in comparison to conventional surgery and are not offered by all doctors. When considering any of these options is important to make certain that your doctor has experience with that particular procedure.
As mentioned earlier there are many potential risks of surgery: everything ranging from pain to death and everything in between. And as I explained, we don’t really think you’re going to die if we take you into the operating room, but it does happen. So there is a risk.
Possibly the biggest risk, or at least most talked about risk, is complete rupture of the plantar fascia. In some cases the plantar fascia will rip or tear all the way across the foot, even if only a portion of the fascia has been released by the surgeon. This is a known possible complication of plantar fascia release surgery.
If the plantar fascia tears all the way across it will no longer be able to support your foot at all.
You can then develop collapse of the arch and pain, particularly on the outside of the foot, because the bones on the outside of the foot get compressed as the arch collapses and pushes the toes out to the side. This is a serious problem. This sort of collapse can result in additional surgery including flat foot reconstructive surgery.
A collapse of the arch would be a complete and total disaster for a runner. Although I would not go so far to say that you would not be able to run again if this happen to you, I would say that I would expect it to change your running form and your experience of running permanently.
Believe it or not, there are special considerations that I think have to be taken into account when operating on runners. As a runner myself I believe the stakes are much higher for runners.
Again, the goal is to make sure that you can run without pain, not just to try to fix the plantar fascia or the heel pain.
There are really three special considerations that I believe are important to runners considering plantar fascia surgery. If you understand these risks you can make sure to discuss them at length with your surgeon before you sign a consent form and head for the operating room.
If you cut through a portion of the cables on the Golden Gate Bridge and then you patch it together you cannot expect the cable to have the same strength after it is been repaired. You have to remember that if you cut through the plantar fascia you’re cutting through little cables of collagen. It will never be the same.
The plantar fascia is not a decorative element. It is a structural one. It does cover all of the muscles and deeper structures in your foot but it also provides architectural support. It helps stabilize your foot. If you cut through and release the plantar fascia it can result in instability of the foot.
Without getting into the biomechanical details just consider this. If you try to alter your running form you’ll notice soreness in different places. For example if you’ve been a chronic lifelong heel
striker and then you deliberately work on your running form to shift to more of a forefoot or midfoot striker you’ll notice, initially, you get intense soreness and the muscles on the inside of the foot. This is totally normal. Those muscles are just not used to supporting you in that way. So they get sore.
Some patients will actually get plantar fasciitis when they make the shift in their running form.
Some runners will get plantar fasciitis if they land as a heel striker. There are many ways that you can run and place stress on the plantar fascia.
But no matter what your running form, if you have released the plantar fascia it will not able to absorb as much of the force. It simply cannot carry its share of the weight anymore. You can never remove force. You can only move force somewhere else. So if the plantar fascia is not capable of absorbing its share of the work, all of that force gets distributed to other structures.
As a consequence of that shift, you could end up with a higher risk of other overuse injuries.
I have seen runners who developed very small scars that seemed like huge problems. Although it may seem like a Princess-and-the-Pea sort of phenomenon it’s a very real problem. If you put a very small rock on the inside of your shoe and you go for run you would probably find it very irritating. A little lump of collagen that develops as a result of scarring can be just as uncomfortable. The problem of course is that it’s much more difficult to remove.
I have treated patients in a few cases where I had to actually perform complicated rotational skin flap incisions using plastic surgical techniques that would change the position or location of the scar so it would not be as irritating. Because of those experiences I have always been very concerned about the potential for scarring.
Anytime you have a surgical incision you’re going to get a scar! In most cases of course the scar is not an issue. But a thick painful scar on your heel can become a serious impediment to running.
The one consideration that I don’t hear lots of physicians talk about in detail is the weakness and stiffness that is almost certain to occur after you have been recovering from surgery. This is not necessarily a direct result of the surgery but a consequence of the healing process.
Studies have shown that you can lose incredible amounts of fitness in very short period of time when you are immobilized in a cast and placed on crutches to protect an injured foot or ankle.
With most of the surgeries that we’ve been discussing here you have to expect a period of immobilization. In most cases you’ll also have a period of complete disuse of the foot and ankle because your foot is hanging in the air while you are hobbling around on crutches.
After immobilization, it takes a long time to get the strength back. And if you have any sort of complication that results in you being immobilized for an extended period of time, beyond the original expectation of your surgeon, you could end up with significant stiffness in the ankle,
Achilles tendon and all the supporting structures of the foot and ankle. That stiffness can become almost impossible to completely reverse.
In the simplest sense your foot is really just a lever attached to the end of your leg. If the whole thing is less pliable it is less capable of absorbing force. So a stiff, weak ankle is far less capable of absorbing the forces of running when you get back to activity and training. That of course puts you at higher risk of all sorts of overuse injuries like stress fractures and tendinitis.
So if you are a runner the big take-home message here is that you have to understand there are many potential complications from surgery. Surgery on the plantar fascia doesn’t really just fix the plantar fascia it just changes its structure so it has less tension. But it’s not a true “fix.” If plantar fascia surgery is your only option (because nothing else is helping) then it may be a great option. But you have to take into consideration the real risks that are unique to runners.
Make sure you discuss these risks with your doctor. Push your doctor to help you develop an early mobilization plan, early weight-bearing plan, or some other recovery strategy to mitigate the risk. If you and your doctor are thoughtful about the risks, and you really think about your end goal of running, you can have a better chance that when you get back to running you can continue to train and enjoy running just as much is you did before you started to develop plantar fasciitis.
Remember goal is not to just fix the plantar fascia. The goal is to run without pain.