Heel pain is caused by the excessive pull of a ligament in the arch of the foot called the plantar fascia. Generally the pain can be treated successfully without the need for surgery. However there are instances where non-surgical treatment of heel pain may fail and surgery may be necessary. Very often, the patient with heel pain will demonstrate a heel spur on an x-ray. In the past, many of the surgeries that were performed to relieve heel pain were designed to remove the bone spur. An incision was made on the side of the heel or the bottom of the heel, the spur identified and removed. Unfortunately, the healing time was very protracted and continued pain following the surgery was not uncommon. Now that the cause of heel pain is better-understood the surgery is much more successful and the recovery time greatly diminished.
Most surgical procedures are aimed at detaching the plantar fascial ligament from its attachment into the heel bone. This may be accomplished with a small incision on the bottom of the heel or on the side of the heel. The procedure is performed by “feel”. The surgeon inserted the scalpel blade and felt for the plantar fascia. Once they were confident that they had identified the plantar fascia they would cut the ligament free from the heel bone.
In the mid 1990’s a new procedure was developed called the “Endoscopic Plantar Fascial Release”. This procedure developed by Dr. Steven Barrett DPM and Dr. Steven Day DPM of Houston, Texas uses technology similar to that used in arthroscopic surgery. A small incision is place on the side of the heel where a small cannula is placed allowing the insertion of an arthroscopic camera. The plantar fascial ligament is visualized and then cut using a small surgical blade. This allows the surgeon greater control during the surgery. The surgeon can control where and how much of the ligament is freed from the heel bone. Some surgeons still perfer to remove the spur at the time of surgery. This is the surgeon’s choice and based upon their training and experience.
The surgery is generally performed in an outpatient surgical center or hospital operating room. It can be performed under a local anesthesia, twilight anesthesia or a general anesthesia. At the completion of surgery a gauze dressing is applied and the patient placed in a post operative shoe or cast.
Most patients are allowed to walk on the foot immediately but they are encouraged to limit their activities. The first week it is recommended that they stay off their feet except to use the restroom or have something to eat. After the first 3 to 7 days the bandage is removed and Band-Aids placed over the incision site. At this point the patient may attempt to wear a good supportive walking shoe if allowed to by their surgeon. Some surgeons perfer to protect the foot with a cast or have the patient use crutches. In 10 to 14 days the sutures are removed and the patient is allowed to bath the foot. It generally takes a minimum of three weeks before the patient is able to walk normally, with minimal discomfort. The patient should return to wearing their orthotics as soon as they are comfortable to wear in their shoes. Because the surgery does not address the cause of the heel pain it is a good idea to wear orthotics following the surgery to reduce reoccurrence of the heel pain or other foot problems that might arise from excessive pronation of the foot.
The amount of time needed to be off from work depends upon the demands of the job and the type of shoes that must be worn. If a limited amount of walking is required for the job and the patient is able to return to work wearing a cast the patient may be able to return to work in one week. If the job requires a lot of time standing, walking climbing or kneeling the patient may be required to be off work for three weeks or longer. These are general guidelines and it is important that the patient follow their doctor’s instructions and guidance. Each surgeon has their own set of criteria to guide the patient through their surgery based upon their experience.
Overall this surgery has a very high success rate, but as with any surgical procedure there are possible complications. If the patient walks excessively on the foot during the healing period following the surgery, it may damage the weakened soft tissues in the area of the heel. This can lead to continued pain in the heel or in other areas of the foot, particularly on the top and outside of the foot. This is due to jamming of a joint in the area. Infection is another possible complication. The risk of infection will increase if the surgical site gets wet while the sutures are in place. In some instances a continuation of the pain may occur. This can be due to the ligament not being cut all the way through at the time of surgery. Another cause of continued pain might be the presence on a pinched or damaged nerve called a calcaneal neuroma. A calcaneal neuroma is relatively rare and not easily identified and may only be recognized with the failure of the initial surgery. Some instances of failure of the surgery cannot be identified. In these cases the initial cause of the heel pain maybe due to something other than abnormal foot mechanics. Unfortunately, there are no tests for identifying these other causes of heel pain. They are generally diagnosed as a matter of exclusion, rather than with direct diagnostic testing.