- Anatomy:
-
plantar fascia:
-
plantar muscles of the foot: are arranged in four layers w/ the
FDB lying most superficially, just under
plantar fascia;
- medial and lateral branches of
tibial nerve pass superficial to
abductor hallucis
and the
quadratus plantae (w/ exception of 1st branch of lateral plantar nerve);
- at the quadratus plantae, these nerve branches changes direction from vertical to horizontal;
- first branch of lateral plantar nerve:
- is the only branch to course deep to the
abductor hallucis and
FDB;
- lies superficial to
quadratus as it courses laterally hugging the undersurface of the calcaneus and coursing underneath
the heel spur (embedded in the FDB), on its way to supply the quadratus, FDB, and
ADM;
- Surgical Considerations:
- complete release of the plantar fascia causes a severe drop in the medial and lateral columns;
- ultrasonography has shown thickening and inflammatory changes in the plantar fascia in patients with
plantar fasciitis vs those who do not have fasciitis;
- reference:
- Biomechanical consequences of sequential plantar fascia relase.
GA Murphy MD et al. Foot and Ankle Internation. Vol 19. No 3. March 1998. p 149.
- Differences in impulse distribution patterns in patients with plantar fasciitis.
S Harvinder. Foot and Ankle Vol 19. No 3. March 1998. p 153.
- Transverse Incision:
- consider transverse incision, along infero-medial aspect of heel, just distal to the weight bearing aspect of the heel;
- advantages: allows direct approach to
plantar fascia
- disadvantage:
- incision does not allow visualization of lateral branch of
tibial nerve;
- w/ severe
pes cavus, plantar fascia release may correct the deformity to the point that the wound edges gap open (preventing wound closure);
- in this case, tension must be taken off of the wound by allowing the foot to fall back into some cavus;
- in two weeks, serial casting can be started inorder to bring the foot out of cavus;
-
dissection:
- dissection thru subcutaneous tissues will reveal
plantar fascia;
- identify its medial edge and the fascia overlying the
abductor hallucis;
- attempt to identify the branches of the
tibial nerve;
- insert freer elevator on both sides of plantar fascia where it inserts onto calcaneus;
- w/ freer under plantar fascia, incise thru the fascia w/ # 15 blade scapel;
- Longitudinal Incision:
- advantages:
- allows visualization of the neurovascular bundle;
- wound edges will not gape open after correction of pes cavus;
-
dissection:
- dissection thru subcutaneous tissues will reveal
plantar fascia;
- identify its medial edge and the fascia overlying the
abductor hallucis;
- attempt to identify the branches of the
tibial nerve;
- insert freer elevator on both sides of plantar fascia where it inserts onto the calcaneus, and then insert a Kocher clamp across the fascia and clamp it across its lateral edge;
- w/ the Kocher clamped across the fascia, Metzembaum scissors are slightly opened and pushed across the fascia;
- attempt to transect fascia as proximally as possible to avoid transecting branches of the tibial nerve;
- Controversies:
-
neurolysis of nerve of the ADM muscle
-
abductor hallucis muscle is exposed and superficial fascia is exposed and AHM is elevated off of its deep fascia;
- muscle belly is retrated dorsally which exposes the deep fascia of AHM;
- a freer elevator is then placed beneath this deep fascia (of
AHM) which protects the nerve to the
ADM (first branch of the lateral plantar nerve);
- this deep fascia is then incised;
- the nerve to the ADM nerve is followed under the
FDB (and its associated fascia may also be released);
-
heel spur:
- if a heel spur is present at the origin of the
FDB, it may be removed w/ rounger;
Heel pain: operative results.
DE Baxter and CM Thigpen. Foot Ankle. Vol 5. 1984. p 16-25.
Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis.
Operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis.
Consequences of partial and total plantar fascia release: a finite element study.
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