ultrasound-guided plantar fascia release technique · table 1. effectiveness of conservative...

Journal of the American Podiatric Medical Association • Vol 99 • No 3 • May/June 2009 183

Insertional heel pain with or without the spur is mostcommonly related to mechanical factors.1-4 Otherproposed causes of heel pain include bursitis, perios-titis, nerve entrapment, trauma, degeneration of theplantar heel fat-pad, and seronegative arthridities.5-13

Up to 90% of patients can receive complete relief ofsymptoms with conservative therapy alone (Table1).1-9, 11-31 When conservative methods, including ex-tracorporeal shockwave therapy, fail to alleviate heelpain, surgical intervention may be indicated. Themost widely used surgical technique used today waspopularized by DuVries.32 Variations of this proce-dure are based on the location of the incision and theamount of fascia and bone that is resected (Table 2;

Fig. 1).9, 16, 17, 32-37 Alternative surgical techniques in-clude endoscopy and coblation.3, 8, 38 The endoscopicplantar fascia release technique has been reported tobe an effective alternative to relieving plantar heelpain.3 The coblation technique for repair of inflamedand degenerated tendon, ligament, and fascia offerspromise for treatment of the plantar fascia, but long-term studies are needed.39 Advancement in diagnostictechnology has enabled the ultrasound to become areliable, cost-effective, diagnostic, and therapeutic in-strument for visualizing foot pathology.40-42 These ad-vancements have sparked interest in the use of ultra-sound to assist the surgeon in the management ofplantar fascia pain (Figs. 2 and 3). The rationale forthe technique is based in part on a previous ultra-sound study that positively correlated the thicknessof the medial, central, and lateral plantar fasciabands with heel pain (Table 3).2 Hence, the purposeof this ultrasound study is to determine the effective-ness of the ultrasound-guided plantar release in re-lieving heel pain.

Background: Ultrasound-guided plantar fascia release offers the surgeon clear visualiza-tion of anatomy at the surgical site. This technique uses small arthroscopic dissecting in-struments through a 0.5-cm incision, allowing the surgeon to avoid the larger and more tis-sue-disruptive incision that is traditionally used for plantar heel spur resection and plantarfascia releases.

Methods: Forty-one patients (46 feet) were selected for the study. The mean patient agewas 47 years. Twenty-nine were considered obese with a body mass index greater than30 kg/m2. Patients were functionally and subjectively evaluated 4 weeks after surgery usingthe American Orthopedic Foot and Ankle Society Ankle and Hindfoot Rating Scale.

Results: Results from the study show a significant improvement (P = .05 confidence level) 4weeks postoperatively for the 41 patients (46 feet), compared to their preoperative condition.The mean pretest score was 33.6 (range 10–52); this score improved to 88.0 (range50–100), 4 weeks postoperatively. There were no postoperative infections or complications.

Conclusions: The ultrasound-guided plantar fascia release technique is a practical surgi-cal procedure for the relief of chronic plantar fascia pain because the surgeon is able toclearly visualize the plantar fascia by ultrasound. In addition, there is minimal disruption tosurrounding tissue because small instruments are passed through a small 0.5-cm incision.The traditional open method of heel spur surgery, in contrast, uses a larger skin incision of3 to 5 cm, followed by larger instruments to dissect to the plantar fascia. (J Am Podiatr MedAssoc 99(3): 183-190, 2009)

*Private practice, Plainfield, IL.†Department of Surgery, Northport Veterans Affairs Med-

ical Center, Northport, NY.Corresponding author: Christopher J. Japour, DPM, MS,

Department of Surgery, Northport Veterans Affairs MedicalCenter, 79 Middleville Rd, Northport, NY 11738. (E-mail:[email protected])

Ultrasound-guided Plantar Fascia Release Technique A Retrospective Study of 46 Feet

Praveen K. Vohra, DPM*Christopher J. Japour, DPM, MS†

ORIGINAL ARTICLES

184 May/June 2009 • Vol 99 • No 3 • Journal of the American Podiatric Medical Association

Ultrasound imaging is based on the recorded echoof transmitted sound waves from a given object, suchas tendon, bone, or foreign material. The transmittedsound wave is reflected back as an echo to a trans-ducer and the signal is then received and processedby the machine. The ultrasound image visualized onthe monitor is produced from acoustic impedancemismatches at the interface between objects. For ex-ample, when sound waves encounter an object ofhigh-mass density (eg, bone), a high acoustic imped-

ance mismatch is produced and object images willappear hyperechoic or brighter on ultrasound (Fig.3). An object with lower-mass density (eg, air, blood,abscess, inflammation) will produce a low acousticimpedance mismatch when sound waves are encoun-tered, and such objects will appear hypoechoic orblack on the ultrasound image. Painful plantar fasciais often inflamed, thickened, and appears black or hy-poechoic. The noninflamed plantar fascia bands willappear thinner and remain hypoechoic. Therefore, the

Table 1. Effectiveness of Conservative Treatment Modalities in Various Studies

Treatment Total No. Percentage Authors Treatment Modalities Time (mo) of Patients Receiving Relief

Japour19 Acetic acid iontophoresis 0.25–8.2 35 94Campbell and Inman20 Orthoses 1–3 33 94Chang and Miltner21 Shoe modification, rest, cast, hot pack 3–9.6 25 68Furey22 Shoe modification, injection, nonsteroidal 2–5 116 98

anti-inflammatory drugsAmis et al23 Orthoses, shoe modification 6 43 72Kenzora24 Shoe modification, injection, nonsteroidal 0.25 Not published 90

anti-inflammatory drugsLapidus and Guidotti25 Injection, nonsteroidal anti-inflammatory drugs 0.25 364 100OʼBrien and Martin26 Orthoses, injection Not published 58 71Shikoff et al27 Orthoses, injection, nonsteroidal 5 195 65

anti-inflammatory drugsSnook and Chrisman28 Rest, injection, nonsteroidal 0.25 27 81

anti-inflammatory drugsLutter29 Physiotherapy 1–9 182 95

Table 2. Surgical Treatment of Heel Spur

Total No. Percentage of Patients Authors Year Treatment Type of Patients Receiving Relief

Vohra and Japour 2004 Ultrasound-guided release 41 95(current study)

Vohra et al37 1999 Open 42 81Vohra et al37 1999 Endoscopic plantar fasciotomy 17 88Barrett and Day3 1991 Endoscopic plantar fasciotomy 62 95Gormley and Kuwada33 1992 Open 87 95Gormley and Kuwada33 1992 Fascial release 9 100Lewis et al34 1991 Open (plantar approach) 22 95Kenzora24 1987 Open 6 100Lutter29 1986 Fascial release 4 50Ali35 1980 Open 52 87Ali35 1980 Fascial release 38 74Contompasis36 1974 Fascial release 38 74Contompasis36 1974 Open 115 43DuVries32 1957 Open 37 100Chang and Miltner21 1934 Open 35 83


difference in the plantar fascia band thickness guidesthe surgeon to select the appropriate thicker band toresect.

Methods

Patients with plantar fasciitis who underwent 6 monthsof unsuccessful treatment were included in this study.Forty-one patients (14 males and 27 females) with amean age of 47 years were clinically diagnosed withplantar fasciitis and met the study inclusion criteria.Each patient was evaluated with the American Ortho-pedic Foot and Ankle Society Ankle and HindfootRating Scale at the time of surgery and 4 weeks post-operatively. The scale was modified to rate heel painand measured both functional and subjective out-

Figure 1. Lateral radiograph of calcaneus with calca-neal spur showing resected medial band of plantarfascia.

Figure 2. Longitudinal sonogram of a symptomatic in-flamed medial band of plantar fascia.

Figure 3. Longitudinal sonogram of an asymptomaticmedial band of plantar fascia.

Table 3. Ultrasound Measurements of Symptomatic Versus Asymptomatic Plantar Fascia

Mean Thickness of Author Study Year Mean Age (y) No. of Patients No. of Feet Plantar Fascia (mm)

Patients with Plantar Fascia Pain (Symptomatic)

Vohra et al37 1999 47.6 109 211 5.4

Wall et al43 1993 49.2 19 38 5.6

Cardinal et al44 1996 45.0 17 19 5.2

Patients without Plantar Fascia Pain (Asymptomatic)

Vohra et al37 1999 49.6 16 32 2.7

Wall et al43 1993 45.5 20 40 3.6

Cardinal et al44 1996 Not reported Not reported 30 2.9


prior to anesthesia with a linear 7.0-MHz ultrasoundtransducer (Accustom128XT; Acuson Corp, MountainView, California). Ultrasound examinations were per-formed while the patients were positioned supinewith their feet hanging over the edge of the examina-tion table. A bead of acoustic gel was applied to thecover of the head of the transducer, which was thenplaced longitudinally on the plantar aspect of the foot(Fig. 4). Ultrasound scanning was performed duringdynamic dorsiflexion of the toes to stretch the plantarfascia, allowing its margins to be delineated. Imageswere recorded on emulsion film with a multi-imagecamera (Fuji Corp, Hyogo-ken, Japan). Transversesonograms were also obtained to determine the loca-tion of the symptomatic plantar fascia bands proxi-mally near insertion into the calcaneus (Figs. 5–7).

Surgical Technique

Prior to intervenous and local anesthesia, the sympto-matic region of plantar fascia is marked. Then thefoot is anesthetized by an infiltrative block, with a50/50-combination mixture of 0.5% plain bupivacaineand 2% plain lidocaine. The foot is then exsanguinat-ed and hemostasis maintained with the inflation of apneumatic ankle tourniquet. Attention is then direct-ed to the medial aspect of the heel, to a point slightlyanterior and inferior to the attachment of the plantarfascia. The plantar fascia bands are identified by directultrasound and thickness measurements are taken. A

comes (Table 4). Patients were used as their owncontrol, and during the 4 weeks after surgery, theywere evaluated for surgical complications such as in-fection, hypoesthesia of the heel, or heel pain duringweightbearing.

Five patients with bilateral plantar fasciitis and 36with unilateral plantar fasciitis were included in thisreview. A diagnosis of plantar fasciitis was initiallybased on the patient’s history of poststatic dyskinesiaand physical findings of pain on palpation of the plan-tar fascia at its calcaneal insertion. Patients were ex-cluded if they had any of the following: 1) a history ofinflammatory arthritis, 2) a connective-tissue disor-der, 3) recent trauma to the heel or plantar fascia, 4) acongenital defect of the lower extremity, 5) previousheel surgery, 6) nonsteroidal anti-inflammatory med-ication use within 2 weeks, or 7) a corticosteroid heelinjection within the previous 2 weeks. If the plantarfascia pain was not alleviated conservatively, ultra-sound examination was performed in the office to lo-cate symptomatic and asymptomatic plantar fasciabands. The same examination was also performed

Table 4. Modified 100-point American Orthopedic Footand Ankle Society Scale for Ankle and Hindfoot

A. Pain (40 Points)None 40Mild, occasional 30Moderate, daily 20Severe 0

B. Function (30 Points)Activity limitations

No limitations 10Some limitations of daily activities 5including recreational and leisureactivities (shopping, employmentrequirements)

Severe limitation of daily and 0recreational activities

Footwear requirementsNo restrictions 10Restricted to sneakers, wide shoes 5Restricted to many types 0

Walking/RunningCompletely satisfied 10Nonpainful, limited motion 5Painful, restricted, motion 0

C. Physical Findings (20 Points)Callus

None or present and nonpainful 10Painful 0

EdemaNone 10Slight 8Constant 0

D.Patient Satisfaction (10 Points) Percent/100Figure 4. Longitudinal placement of the ultrasoundtransducer on the plantar medial surface of the foot.


0.5-cm long linear plantar medial incision is made,which is gently retracted and widened with a bluntdissecting probe. The foot is then dorsiflexed and areverse cutting knife with direct ultrasound visualiza-tion is used to transect a portion of the fascia from alateral to medial direction (Figs. 8–12). When the fas-cia is transected, the defect created allows the firstlayer of plantar muscles to be identified with the ul-trasound device. The reverse cutting knife is then re-moved. The incision site is irrigated with copiousamounts of sterile saline. All areas are visualized withdiagnostic ultrasound to ensure complete release ofband fibers. Skin edges are reapproximated with 4-0simple nylon sutures, and 0.25 mL of dexamethasonesodium phosphate (4 mg/mL) is then infiltrated intothe surgical site. Poviodine topical solution (10%) andnonadhering petroleum gauze are placed on the inci-sion site, and a dry sterile compressive dressing isthen placed around the foot to support the medialarch (Fig. 13). Sutures are removed between 10 and 14days postoperatively. In addition, after surgery, pa-tients are placed into a CAM walker (Zinco Industries,Inc, Pasadena, California) and allowed to bear weightas tolerated for up to 2 weeks and then placed in asurgical shoe for 2 weeks. Patients are returned toregular shoe gear as tolerated. Physical therapy be-gins 4 weeks postoperatively and includes stretching,whirlpool, phonophoresis, and use of night splints.

Results

The 4-week postoperative Ankle and Hindfoot RatingScale for all patients represents a significant improve-ment (P = .05 confidence level) regardless of weightcompared to their preoperative levels. The mean pre-test score of 33.6 (range, 10–52) improved to 88.0(range, 50–100). There were no incidents of postoper-ative complications.

Figure 5. Transverse placement of the ultrasoundtransducer on the plantar surface of the foot at the ori-gin of the bands of plantar fascia.

Figure 6. Ultrasound anteroposterior view of the calca-neus depicting the medial calcaneal tubercle as the me-dial imaging plane (A), the calcaneal sulcus as thecentral imaging plane (B), the lateral tubercle as the lat-eral imaging plane (C), and the plantar fascia band (D).

Figure 7. Illustration of Figure 6. (Courtesy of AnneErickson, MA, CMI, Veterans Affairs Medical Center,Brooklyn, New York.)


Figure 8. Blunt probe used to isolate plantar fascia. Figure 9. Triangular knife used to release inflamedbands of the plantar fascia.

Figure 10. Surgical release of plantar fascia bands.The foot is dorsiflexed to place tension on the plantarfascia. Longitudinal placement of the ultrasound trans-ducer at the proximal origin of the plantar fascia is ac-complished to visualize the inflamed plantar fasciaband and to release it.

Figure 11. Plantar view illustration of the surgical re-lease of the plantar fascia bands. (Courtesy of AnneErickson, MA, CMI.)

Figure 12. Lateral view illustration of the surgical re-lease of the plantar fascia bands. (Courtesy of AnneErickson, MA, CMI.)

Discussion

Ultrasound-guided plantar fascia release offers thesurgeon visualization of the local anatomy at the sur-gical site and enables more precise anatomical dissec-tion. In addition, there is minimal tissue trauma to theadjacent anatomy surrounding the plantar fascia be-cause of the small size of the dissecting instruments.

In the present review, there were no postoperativecomplications of infection, hypoesthesia, or sharpheel pain. However, some complications have beenreported by other authors. Lester and Buchanan45

noted that 42% of patients had heel hypoesthesia post-operatively. Their procedure consisted of spur resec-tion, release of all first-layer plantar musculature, andfascial release. Such extensive dissection may haveresulted in transaction of the abductor digiti quintimuscle and the calcaneal nerve branches. Baxter andThigpen46 report 18% of patients continued to haveheel pain with weightbearing after open neurolysisprocedures were performed. Leach et al47 performedopen fascial release, resection of the fascia, or both


for chronic plantar fascial pain and reported unre-solved heel pain in 7% of patients. Similarly, Snider etal48 performed fascial release and calcaneal osteoto-mies and reported 11% of patients with unresolvedheel pain. Postoperative complications for endoscopicplantar fascia release procedures and have been re-ported by Barrett and Day,49 who reported complica-tions in 19% of patients, and by Jerosch,50 who report-ed complications in 11% of patients.

It is recommended that patients either begin orcontinue using custom orthoses after surgery to pre-vent excess strain placed on the plantar fascia andadjacent structures. Additionally, physical therapy isimportant postoperatively to help strengthen the re-maining nontransected bands of plantar fascia.

Because there is minimal trauma, excellent visibili-ty of the plantar fascia, and a high patient satisfactionrate, we believe that the ultrasound-guided instep plan-tar fasciotomy technique is a practical procedure forthe relief of plantar fasciitis. A drawback to this studywas the inability of many of the original group of pa-tients to return to the office for a long-term follow-upexamination using the American Orthopedic Footand Ankle Society Ankle and Hindfoot Rating Scale.

Acknowledgment: Cheri Mettler, AA, for technicalassistance; Anne Erickson, MA, CMI, for Medical Il-lustration; Mike Yu, BS, William Collwell, JamieKanger for imaging; the Danville, Illinois Veterans Af-fairs Library Staff for literature assistance; and BrianKincaid, DC, for sonographic assistance.Financial Disclosure: None reported.Conflict of Interest: None reported.

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