Original Article With Video Illustration. Endoscopic Surgery for Plantar Fasciitis: Application of a Deep-Fascial Approach

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1 Original Article With Video Illustration Endoscopic Surgery for Plantar Fasciitis: Application of a Deep-Fascial Approach Fumito Komatsu, M.D., Ph.D., Masato Takao, M.D., Ph.D., Ken Innami, M.D., Wataru Miyamoto, M.D., and Takashi Matsushita, M.D., Ph.D Purpose: The purpose of this study was to determine the clinical results of deep-fascial medial and lateral portals in performing endoscopic surgery for plantar fasciitis. Methods: In 10 feet in 8 patients who were treated conservatively for more than 6 months with failure to relieve their symptoms, endoscopic surgery was performed. After the patient was placed in the supine position, a medial portal was made 5 mm deep to the plantar fascia and 10 mm anterior to its origin on the calcaneus under fluoroscopy. The lateral portal was established by placing a blunt trocar deep and perpendicular to the plantar fascia. A 2.7-mm-diameter arthroscope was passed through the deep-lateral portal, and the operative devices were inserted through the deep-medial portal. A motorized shaver was used for making a working space to excise the fat tissue along with a portion of the flexor digitorum brevis muscle. If a heel spur existed, it was resected to establish a clear view of the plantar fascia by use of an arthroscopic burr. After exposure of the plantar fascia, its medial half was removed with electric devices such as an Arthro-Knife (ConMed Linvatec, Largo, FL). Results: The mean score on the American Orthopedics Foot and Ankle Society Ankle Hindfoot Scale was points before surgery and points at 2 years after surgery (P.0001). The mean duration to full weight bearing after surgery was days. All patients returned to full athletic activities by a mean of weeks. Conclusions: Endoscopic surgery for plantar fasciitis through a deep-fascial approach allows a wide field of vision and working space, permitting reliable resection of the plantar fascia and heel spur. Level of Evidence: Level IV, therapeutic case series. Plantar fasciitis is known as a degenerative syndrome, without inflammation 1-3 of the plantar fascia, resulting from repeated trauma at the medial process of the calcaneal tubercle, and it is one of the major causes of heel pain. 4-6 More than 90% of cases From the Department of Orthopaedic Surgery, Teikyo University, Tokyo, Japan. The author reports no conflict of interest. Received June 26, 2010; accepted February 24, Address correspondence to Fumito Komatsu, Department of Orthopaedic Surgery, Teikyo University, Kaga, Itabashi, Tokyo, Japan. fumito@crest.ocn.ne.jp 2011 by the Arthroscopy Association of North America /10382/$36.00 doi: /j.arthro Note: To access the video accompanying this report, visit the August issue of Arthroscopy at respond to conservative treatment including nonsteroidal anti-inflammatory drugs, stretching, night splint use, foot orthosis use, physical therapy, and extracorporeal shock-wave therapy. However, the remaining 5% to 10% of patients do not improve with conservative treatment and may be candidates for surgical treatment. 7,8 If nonsurgical treatment fails, a partial plantar fasciotomy has generally been performed to remove a portion of less than the medial half of the plantar fascia. Treatment may be divided into 3 procedures: (1) percutaneous release, (2) open surgery with plantar medial incision, 9-12 and (3) endoscopic surgery Percutaneous release is a less invasive surgery but is not a reliable method to release the plantar fascia. Although open surgery is more common, there have been reported complications including skin trouble, infection, nerve disturbance, and Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 8 (August), 2011: pp

1106 F. KOMATSU ET AL. FIGURE 1. The first branch of the lateral plantar nerve (LPNFB) passes directly over the top of the medial process of the calcaneal tuberosity.

2 1106 F. KOMATSU ET AL. FIGURE 1. The first branch of the lateral plantar nerve (LPNFB) passes directly over the top of the medial process of the calcaneal tuberosity. (FDB, flexor digitorum brevis; PF, plantar fascia.) persistent pain associated with prolonged recovery time. 10,17 Recently, endoscopic partial plantar fasciotomy has been developed for treating plantar fasciitis to decrease the occurrence of surgical complications and shorten the duration to return to initial level of activities. Although patients have tended to report subjective satisfaction with these procedures, 18,19 there remain several issues. The lateral and medial portals have been made at the superficial level of the plantar fascia in all of these procedures. Because that location is between the skin and the plantar fascia and fills with fat tissue, it has been difficult to obtain a sufficient field of vision and working space, so we needed to use a hook probe and slotted cannula system. Furthermore, a calcaneal spur cannot be resected through these portals because it exists deep to the plantar fasciitis in most cases. To resolve these issues, we have introduced deep-fascial medial and lateral portals in performing endoscopic surgery for plantar fasciitis. The purpose of this study was to determine the clinical results of this approach. We hypothesized that endoscopic surgery with a deep-fascial approach is effective for the treatment of plantar fasciitis and enables patients to return to full athletic activities. showed localized tenderness to palpation at the insertion of the plantar fascia and a positive Windlass test. 20 In 10 feet in 8 patients who did not respond to a minimum of 6 months (range, 6 to 13 months) of routine conservative treatment (nonsteroidal antiinflammatory drugs, stretching, night splint use, foot orthosis use, and physical therapy), endoscopic surgery was performed. There were 5 male and 3 female patients, with a mean age at surgery of 38.2 years (range, 14 to 66 years). Preoperative standard radiography showed a plantar calcaneal spur in 8 feet. Surgical Technique The patient is placed in the supine position to elevate the operative foot approximately 15 cm with a leg holder. Preoperative antibiotics are administered. A pneumatic tourniquet applied to the thigh is inflated to a pressure of 250 mm Hg. Because the first branch of the lateral plantar nerve passes directly over the top of the medial process of the calcaneal tuberosity, there is a risk of injuring it when a medial portal is made (Fig 1). To prevent this, a medial portal is made by use of the following procedures. Under fluoroscopy, a deepmedial portal is made 5 mm deep to the line that links the medial calcaneal tubercle to the plantar side of metatarsal head and 10 mm anterior to the medial calcaneal tubercle (Fig 2). The incision is made only in the skin, and blunt dissection is done to only the deep-medial aspect of the plantar fascia. The deep- METHODS This is a retrospective case series study on 8 patients who were treated by endoscopic plantar fasciotomy after conservative treatment. Between April 2005 and February 2008, 53 patients with plantar fasciitis visited our institution. Plantar fasciitis was diagnosed by history, physical examination, and radiographic investigation. All patients typically had heel pain that was more severe upon the first step in the morning. On physical examination, all patients FIGURE 2. Fluoroscopic image confirming the placement of the needle 5 mm deep to the plantar fascia and 10 mm anterior to its origin on the calcaneus.

ENDOSCOPIC SURGERY FOR PLANTAR FASCIITIS 1107 Evaluation The clinical results of all patients were assessed with the American Orthopedics Foot and Ankle Society Ankle Hindfoot Scale (AOFAS score) 21

Lateral view of left foot. The lateral portal is made on the lateral aspect of the heel at the tip of the trocar passed from medial to lateral.

3 ENDOSCOPIC SURGERY FOR PLANTAR FASCIITIS 1107 Evaluation The clinical results of all patients were assessed with the American Orthopedics Foot and Ankle Society Ankle Hindfoot Scale (AOFAS score) 21 before surgery and at 2 years after surgery. The duration to full weight bearing after surgery and the duration to returning to full athletic activity were also examined. RESULTS FIGURE 3. Lateral view of left foot. The lateral portal is made on the lateral aspect of the heel at the tip of the trocar passed from medial to lateral. lateral portal is established by placing a blunt trocar deep and perpendicular to the plantar fascia, and the skin, tented by the trocar, is incised vertically (Fig 3). A 2.7-mm-diameter (30 ) arthroscope is passed through the deep-lateral portal, and the surgical devices are inserted through the deep-medial portal (Fig 4, Video 1 [available at A motorized shaver is used for making a working space to excise the fat tissue and a plantar portion of the flexor digitorum brevis muscle, as minimally as possible, to obtain good visualization. First, the plantar surface of the calcaneus and the calcaneal attachment of the plantar fascia should be identified for a landmark (Fig 5A). (If there was a heel spur, the authors resected it to establish a clear view of the plantar fascia using an arthroscopic burr [Fig 5B].) After exposure of the plantar fascia, its width is measured with a probe, and an area of less than the medial half of the plantar fascia is resected with an Arthro-Knife (ConMed Linvatec, Largo, FL) (Fig 5C). Care should be taken never to allow the fiber of the plantar fascia to remain. The plantar fascia should be removed until the plantar fat tissue is exposed, which is the sign that the plantar fascia has been resected completely toward its superficial layer (Fig 5D). After closure of the portals with No. 4-0 nylon mattress suture, the pneumatic tourniquet is released and a compressive dressing is placed on the foot. Active range-of-motion exercise of the foot and ankle is performed 1 day after surgery. Partial weight bearing is allowed 3 days after surgery and gradually increases to full weight bearing in accordance with patient tolerance. The mean AOFAS score was points before surgery and points at 2 years after surgery (P.0001). In the categories of the AOFAS score, pain was improved significantly: points before surgery and points at 2 years after surgery (P.0001). The mean duration to full weight bearing after surgery was days (range, 3 to 27 days). All patients returned to full athletic activities by a mean of weeks (range, 6 to 14 weeks). Three patients had paresthesia on their sole after surgery, but the symptom disappeared within 2 months after surgery. There were no cases of infection, venous thrombosis, residual heel pain, or arch collapse. DISCUSSION An endoscopic procedure has been developed in orthopaedic surgeries for decreasing the occurrence of surgical complications and shortening the duration to FIGURE 4. An arthroscope is passed through the superolateral portal, and the surgical devices are inserted through the superomedial portal.

1108 F. KOMATSU ET AL. FIGURE 5. Right foot with arthroscope inserted from lateral portal. (A) Endoscopic view of calcaneus and plantar fascia. (FDB, flexor digitorum brevis; PF, plantar fascia.

4 1108 F. KOMATSU ET AL. FIGURE 5. Right foot with arthroscope inserted from lateral portal. (A) Endoscopic view of calcaneus and plantar fascia. (FDB, flexor digitorum brevis; PF, plantar fascia.) (B) A heel spur is resected with an arthroscopic burr. (C) The medial half of the plantar fascia is resected with an Arthro-Knife. (D) The fat pad is visualized beneath the fascia to ensure complete removal. returning to initial activities. In treating plantar fasciitis, Barrett and Day 22 reported a single-portal endoscopic technique for plantar fascia in Thereafter several other authors published studies of endoscopic plantar fasciitis surgery. These reports showed passable clinical results with subjective satisfaction. O Malley et al. 23 reported on 20 feet treated with a 2-portal partial endoscopic plantar fascia release. The mean AOFAS score improved from 62 points to 80 points. Bazaz and Ferkel 19 reported that the mean AOFAS score improved from 66 points to 88 points. These reports introduced the portals located immediately anterior and superficial to the medial calcaneal tubercle and superficial to the plantar fascia. In their methods the cutting device was inserted and the plantar fascia released. In performing those procedures, it is difficult to obtain a sufficient field of vision and working space because of the fat tissue filling the space between the skin and the plantar fascia. Therefore there may be a possibility of some plantar fascia fibers remaining that should be resected completely and may cause residual heel pain after surgery. We introduce deep-fascial medial and lateral portals as a means to make possible a greater working space and better view than those of previously reported procedures. In this study the mean AOFAS score improved from 64.2 points to 92.6 points. Our results were equal or superior to those of past studies. Our better clinical results may have been obtained because of the complete resection of the plantar fascia under good visualization through the deep-fascial portals. It is now widely accepted that calcaneal spurs can occur with plantar fasciitis but that they are not the cause of heel pain. 11,24 Previous reports showed that there was no efficacy of pain reduction with calcaneal spur resection in cases of plantar fasciitis. 25 However, a previous article showed that there was connective tissue richly supplied with blood vessels and nerves between the spurs and plantar fascia. 2 Accordingly, we believe that there remains a possibility for the calcaneal spurs to lead to pain and they should be removed. Regarding the duration to returning to athletic activities, Saxena 26 reported the clinical results of uniportal endoscopic plantar fasciotomy performed in 16 athletic patients. The mean return-to-activity period

5 ENDOSCOPIC SURGERY FOR PLANTAR FASCIITIS 1109 after surgery was months. In our study all cases could walk normally within a mean of 2 weeks after surgery, but the duration to full athletic activity was a mean of 10.9 weeks, similar to past studies. We suppose that the reason for this longer period was the need to resect a portion of the flexor digitorum brevis muscle. Further development of new surgical tools to make possible good visualization without partial resection of the flexor digitorum brevis may be beneficial in terms of an earlier return to athletic activities. One of the limitations of this procedure is that it is difficult to observe the first branch of the lateral plantar nerve. However, this nerve is known as one of the causes of heel pain when entrapped around the calcaneal attachment of the plantar fascia. 27,28 Some reports have shown good clinical results after decompression of the first branch of the lateral plantar nerve, 29,30 but it is difficult to perform this through the current technique. Another limitation is the small number of patients and short-term followup. A long-term follow-up of more than 5 years is needed for adequate clarification. CONCLUSIONS Endoscopic surgery for plantar fasciitis through a deep-fascial approach allows a wide field of vision and working space, permitting reliable resection of the plantar fascia and heel spur. REFERENCES 1. Snider MP, Clancy WG, Mcbeath AA. Plantar fascia release for chronic plantar fasciitis in runners. J Am Sport Med 1983; 11: Kumai T, Benjamin M. Heel spur formation and the subcalcaneal enthesis of the plantar fascia. J Rheumatol 2002;9: Lemont H, Ammirati KM, Usen N. Plantar fasciitis: A degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003;93: McCarthy DJ, Gorecki GE. The anatomical basis of inferior calcaneal lesions. A cryomicrotomy study. J Am Podiatry Assoc 1979;69: Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 1999;20: Tisdel CL. Heel pain. In: Rechardson EG, Cohen BE, Jognson JE, et al, eds. Orthopaedic knowledge update: Foot and ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2003; Gill LH. Plantar fasciitis: Diagnosis and conservative management. Foot Ankle Int 1997;5: Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int 1998;19: Daly PJ, Kitaoka HB, Chao EY. Plantar fasciotomy for intractable plantar fasciitis: Clinical results and biomechanical evaluation. Foot Ankle 1992;13: Tomczak RL, Haverstock BD II. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg 1995;34: Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: How successful is surgical intervention? Foot Ankle Int 1999;20: Woelffer KE, Figura MA, Sandberg NS, Snyder NS. Five-year follow-up results of instep plantar fasciotomy for chronic heel pain. J Foot Ankle Surg 2000;39: Lundeen RO, Aziz S, Burks JB, Rose JM. Endoscopic plantar fasciotomy: A retrospective analysis of results in 53 patients. J Foot Ankle Surg 2000;39: Blanco CE, Leon HO, Guthrie TB. Endoscopic treatment of calcaneal spur syndrome: A comprehensive technique. Arthroscopy 2001;17: Boyle RA, Slater GL. Endoscopic plantar fascia release: A case series. Foot Ankle Int 2003;24: Hogan KA, Webb D, Shereff M. Endoscopic plantar fascia release. Foot Ankle Int 2004;25: Kinley S, Frascone S, Calderone D, et al. Endoscopic plantar fasciotomy versus traditional heel spur surgery: A prospective study. J Foot Ankle Surg 1993;32: Ogilvie-Harris DJ, Lobo J. Endoscopic plantar fascia release. Arthroscopy 2000;16: Bazaz R, Ferkel RD. Results of endoscopic plantar fascia release. Foot Ankle Int 2007;28: De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int 2003;24: Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15: Barrett S, Day S. Endoscopic plantar fasciotomy: Preliminary study with cadaveric specimens. J Foot Ankle Surg 1991;30: O Malley MJ, Page A, Cook R. Endoscopic plantar fasciotomy for chronic heel pain. Foot Ankle Int 2000;21: Williams PL, Smibert JG, Cox R, Mitchell R, Klenerman L. Imaging study of the painful heel syndrome. Foot Ankle 1987; 7: Anderson RB, Foster MD. Operative treatment of subcalcaneal pain. Foot Ankle 1989;9: Saxena A. Uniportal endoscopic plantar fasciotomy: A prospective study on athletic patients. Foot Ankle Int 2004;12: Baxter DE, Thigpen CM. Heel pain Operative results. Foot Ankle 1984;5: Chan LK, Lui TH, Chan KB. Anatomy of the portal tract for endoscopic decompression of the first branch of the lateral plantar nerve. Arthroscopy 2008;24: Conflitti JM, Tarquinio TA. Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis. Foot Ankle Int 2004;25: Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop Relat Res 1992:

Plantar heel pain is a common symptom in daily

Plantar heel pain is a common symptom in daily Subcalcaneal Bursitis With Plantar Fasciitis Treated by Arthroscopy Kotaro Yamakado, M.D., Ph.D. Abstract: We report the successful arthroscopic treatment of a case of subcalcaneal bursitis with plantar