Heel Pain - Surgical Treatment Options
Published Thursday, August 12, 2004
by Dr. Leonard E. Vekkos
In this last of a three part series on heel pain, we will be reviewing the possible surgical options for the treatment of chronic heel pain. As I wrote in the second article of this series, in my professional experience, over 90% of heel pain responds and can be successfully treated through conservative means. However, in those cases where conservative care fails to alleviate the pain to an acceptable level, then surgical treatments need to be considered.
The time period after which conservative treatment fails and surgery should be considered is still open to debate. I feel all attempts at conservative care should be exhausted to the satisfaction of both the patient and the doctor, but often this occurs after anywhere from 3-6 months of conservative treatment or at the time that both the patient and doctor agree to move on to surgical options.
A little review of the history of heel pain surgery is appropriate at this time. In the past, during the course of our initial evaluation of heel pain, x-rays are always taken to rule out the formation of a heel spur. The correlation was made that heel pain and the formation of a heel spur was due to the attachment of the ligament (plantar fascia) onto the bottom of the heel. This ligament would pull on the heel causing inflammation which would then calcify resulting in the heel spur. Therefore, in approaching this surgically, it made sense to not only release the ligament, but also remove the heel spur. The nature of this particular procedure, while successful, resulted in a more significant post-operative recovery period due to the extensive nature of the surgical procedure.
In the past ten to fifteen years, several investigative studies into heel pain and its anatomical causes revealed that the plantar fascia's attachment was more on the direct bottom of the heel and NOT into the heel spur. While attachments of the plantar fascia were found onto the spur, the heel spur formation was actually due to the muscles on the bottom of the foot. As well, it was not uncommon for patients to present with heel pain on one side, but heel spurs on x-ray on both feet. Because of these findings and observations, there was a shift in the approach to surgical treatment of heel pain.
In the 1990's attention was concentrated on the plantar fascia as the culprit for heel pain, not the heel spur. In developing procedures to address this new focus, not having to remove the heel spur significantly reduces post-operative swelling and recovery time. It now became apparent through studies and research that if the plantar fascia is released from it's attachment to the heel, the stress associated with it pulling on the heel is reduced and the pain resolved. From this realization procedures were developed that could be performed through small incisions on both sides of the heel and using a small video camera and specialized blades, the plantar fascia would be cut from the inside bottom part of the heel. This procedure is called an Endoscopic Plantar Fasciotomy (EPF). I have been performing these procedures for the past ten years with excellent results.
The advantages of the EPF include a much quicker return to regular showgear, only 2-3 stitches per incision and less work missed. Return to physical activity is encouraged much sooner as well with very few complications. This procedure has made the traditional heel spur removal almost unnecessary and obsolete. It must be understood that in rare cases, the traditional method is still the procedure of choice.
And, of course, medicine would not be medicine without further advances and the surgical treatment of heel pain is no different. Most recently, studies initially performed in Europe and now in the United States have developed another significant advancement in the treatment of heel pain using a very well-established technology for another well-known problem...kidney stones. The procedure known as lithotripsy uses very powerful sound waves through a technique called Extracorporeal Shock Wave Therapy (ECSWT) to break down kidney stones so they may be easily passed by the patient.
As more intense investigation into heel pain continued, a theory was developed that heel pain, while the result of excessive pulling of the plantar fascia on the bottom of the heel, resulted from a lack of adequate blood supply to the tissues at the insertion due to the build up of scar tissue known as fibrosis. This tissue is very dense and has poor blood vessel development. Because of the nature of lithotripsy was to break up tissue in the form of stones, it was theorized that such a medium could be used to break up scar tissue and adhesions to stimulate new blood vessel formation and create a healing environment at the heel pain origin; i.e. the plantar fascia insertion.
With the development of proper instrumentation and equipment designed specifically to deliver the proper amount of energy to the heel area, studies showed significant results in reducing heel pain without the need for any incisions and cutting or removal of tissue or bone. As well, the procedure allows the patient to walk out of the procedure in a regular shoe and go back to work that day. While certain limitations exist and precautions have to be followed before and after the procedure, the advantages are significant and this has become the procedure of choice for many patients as a surgical option.
It is important that with any surgical procedure that the patient be educated and informed. Any successful surgical procedure is the result of proper workup, effective communication between the patient and surgeon, and complete confidence of both the surgeon and patient in the entire process. NEVER be afraid to ask your surgeon anything. A compliant and satisfied patient is an informed one.