Surgery Should be the Last Resort for Treatment of Plantar Fasciitis

We advise you not to let anyone perform surgery on your heel unless you have seen us first for a consultation.

With proper treatment of plantar fasciitis, heel pain surgery is almost never necessary. We don’t have exact numbers but in our clinic at most about 1 out of 1000 heel pain patients will need surgery.   

You can learn about all of the conservative treatments for plantar heel pain in our Guide to Plantar Heel Pain.

We recommend that you give conservative treatment at least six  to twelve months to work before considering surgery.  If surgery has been recommended for your plantar fasciitis, see us for a second opinion first.

If surgery should be necessary, we will provide you with comprehensive, state-of-the-art care. When it is needed surgery is about 85% successful but does not guarantee your symptoms will resolve after surgery.  Studies indicate that surgery for heel pain tends to require longer recovery periods for those who are overweight.1-3

After Conservative treatment, but Before Surgery: 

Certain treatments that involve injections or special equipment are often used before surgery, or even marketed as “surgery”  while not entirely qualifying as a surgical procedure. Out of all of these procedures, we use the most up to date research to determine which we should use. Be sure to see our Chronic & Severe Heel Pain page, or the links to the specific treatments below, for an outline of the indications for these procedures: 

• • Shockwave therapy
  • Dry needling
  • Ultrasound Guided Corticosteroid Injections
  • Platelet Rich Plasma Therapy – We have not been impressed with the outcome studies on platelet rich plasma for treatment of plantar heel pain. Patients do show improved symptoms at 1 month but, unfortunately,  not at 6 months when compared with control.⁶ 
    
  • Topaz/Tenex Coblation – Topaz in our practice has been replaced by newer procedures. Some physicians billing Tenex  as a fasciectomy but the fascia is not actually cut through and through. 
  • Radiofrequency Ablation – only for nerve issues. 
  • Cryotherapy – not a common procedure.

Plantar Fasciitis Surgery Guide

Despite only being necessary much less than 1% of the time, plantar fasciitis surgery is common in the United States and many different types exist. 

Not all plantar fasciitis surgeries are performed directly on the plantar fascia. While all procedures are designed to treat the same pain and symptoms, they have varying indications and effectiveness. 

Two people with plantar fasciitis may require completely different surgeries depending on:

• • what part of the plantar fascia is causing pain,
  • nerve involvement,
  • how long the pain has been present and
  • the biomechanics of your feet and legs.

There are three major types of Plantar Fasciitis Surgery:

1. 1. Endoscopic Plantar Fasciotomy
   2. Open Plantar Fasciotomy 
   3. Gastrocnemius Recession alone or with other procedures

We’ll also talk about Heel Spur Surgery, and Baxter’s Nerve Release which can be added to certain plantar fasciitis surgical approaches when necessary. 

 

Endoscopic Plantar Fasciotomy

This procedure is performed for severe plantar fasciitis when the area causing pain has been identified by an physical exam and possibly ultrasound imaging. 

During this procedure a small 1-2 cm cut is made on the inside and outside of the heel. Using a small tube, and a tiny video camera the plantar fascia is identified and the fascia is partially or completely cut. No tissue or bone is removed. The skin is sewn together, and a bandage is placed over the surgical site.

This surgery is very popular in treatment for plantar fasciitis, and Dr Hale at the Foot and Ankle Center of Washington was among the first to use it in the Seattle area. It has since grown tremendously in popularity and our extensive experience with this less invasive procedure sets us apart from other providers. 

While your individual results may vary, many people feel relief from their plantar fasciitis pain after the endoscopic plantar fasciotomy and as such the surgery is regarded as a good option for treating resistant severe plantar fasciitis. Remember that surgery never provides a pain free guarantee, and that is why we choose to exhaust all conservative options prior to considering surgey.4

It takes a skilled surgeon to determine which procedure to perform. Thus, it is important for you to choose your surgeon wisely. 

 

Open Plantar Fasciotomy

An open plantar fasciotomy is perhaps one of the oldest and most heavily performed surgical procedures for plantar fasciitis. Performed on the right person, by the right surgeon, it can be a useful last resort in the treatment of severe plantar fasciitis pain.

During this procedure a larger 3-5cm cut is made on the inside and bottom of the foot. The surgeon directly identifies the plantar fascia and makes the necessary cuts. This may involve cutting just a portion of the plantar fascia, or the entire plantar fascia depending on the location of your pain. Several modifications to the open plantar fasciotomy exist and, if indicated, can be added. It is important to minimize scarring. 

The Open Plantar Fasciotomy has nearly identical benefits to the endoscopic fasciotomy. The larger incision may take longer to heal than the endoscopic plantar fasciotomy, however it allows for additional procedures to be added during the same surgery. 

 

Additional procedures that can be added to an open plantar fasciotomy:

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Heel Spur Surgery

Before any plantar fascia surgery your surgeon will take an x-ray of your foot. It’s common for a heel spur to be present on this x-ray right where the plantar fascia originates off your heel bone.

There is good medical  research to prove that the heel spur is not the cause of your heel pain, but rather a symptom of continuous stress on the plantar fascia. 

Many people without plantar fasciitis have heel spurs, and many people with plantar fasciitis don’t have heel spurs. It’s a very popular misconception that the spur is the single cause of your pain. 

For more information be sure to see the informative Heel Spur Pain video on our Plantar Fasciitis page.

Removing a heel spur during an open plantar fasciotomy will remove the place that the plantar fascia attaches, and decreases the likelihood that the plantar fascia will heal back together. It can also remove a prominent bump which may have chronically inflamed fascia attached. 

No additional incisions are needed to perform this procedure. 

You may need to be non-weight bearing for a longer period of time if you have a heel spur removed. Years ago heel spur surgery was common but now a rare procedure. 

Baxter’s Nerve Release

 Below the plantar fascia, and between the muscles of the foot there is a nerve called first branch of the lateral plantar nerve/Baxter’s nerve (a.k.a. the Inferior Calcaneal Nerve). Baxter’s nerve controls a muscle in your foot, as well as feeling to part of the foot. 

This nerve can be pinched by several possible structures including the inflamed plantar fascia, enlarged foot muscles, large calcaneal spur, or excess body weight. When it’s pinched we call that Baxter’s Nerve Entrapment. The symptoms are often very similar to plantar fasciitis, and may contribute to the failure of conservative plantar fasciitis treatment.

To diagnose Baxter’s Nerve Entrapment extra studies may need to be performed before surgery, sometimes including  nerve conduction studies, diagnostic injections or MRI. 

During a Baxter’s Nerve Release the nerve is identified and the surgeon creates space around the nerve by skilled dissection. Certain cuts in the muscle and tissue surrounding the nerve may be necessary, but not always. We do not recommend cutting the nerve unless as a last resort. 

The added dissection for the Baxter’s Nerve Release will take longer during surgery, and your recovery will also take longer.  In very rare cases the nerve may start to become more painful after surgery. 

Gastrocnemius Recession (a.k.a. Gastroc Recession)

One thing that most people overlook is the interaction between the leg and the foot. 

Sometimes your heel pain is caused by the strong Achilles tendon pulling up on the calcaneus, flattening the arch and stretching the plantar fascia. 

One of the muscles causing the Achilles tendon to pull on the heel bone is called the Gastrocnemius muscle. 

A gastrocnemius/gastric recession simply refers to cutting part of the Gastrocnemius muscle to lengthen the Achilles tendon and reduce the strain it places on the heel. 

Conservative treatments that involve stretching the Achilles tendon and calf muscles results in significantly less pain at the plantar fascia. When stretching of the tendon is not enough, the muscle attached to the tendon itself can be lengthened with the gastrocnemius recession surgery. 

There is evidence to support the use of a gastrocnemius recession for treating plantar fasciitis.⁵ 

At the Foot & Ankle Center of Washington we have more than 20 years of experience performing the gastrocnemius recession procedure. We have seen good success addressing heel pain with the gastrocnemius recession alone and in addition to other plantar fascia procedures. 

The gastrocnemius recession can be added to any combination of plantar fascia surgeries to increase their effectiveness when applicable. 

The gastrocnemius recession is performed on the mid-calf area of the leg and involves a 2-5cm incision. The junction between the gastrocnemius muscle and the tendon is cut.

The tension on the plantar fascia may be relieved by reducing the pull on the heel bone from the Achilles.

Most patients see pain relief in their plantar fascia after recovering from the procedure and returning to activity. However, the procedure does not directly involve the plantar fascia and like all heel surgeries not a guarantee of pain relief. 

You may notice after a gastrocnemius recession that you have decreased push off strength in the affected leg. This strength can be restored over time and is often significantly outweighed by the pain relief patients experience. 

 It takes an excellent surgeon to determine what procedures your unique foot will need, and we have many success stories treating plantar fasciitis both conservatively and surgically. 

Plantar Fasciitis Surgery Recovery: 

Recovery will depend on which procedures you have performed. After any procedure you will want to rest for 1-2 weeks following the surgery. You will ice, elevate and protect the foot for this time and you will not place any weight on the foot. 

Proper shoes and orthotics to reduce pressure on the heel will help in the healing process.

Endoscopic and Open Plantar Fasciotomy Recovery

For the endoscopic and open plantar fasciotomies, you will not be able to place any weight on the foot for 4-6 weeks, and you may not be able to drive depending on which foot is operated on. We limit early weight bearing due to higher complications

Around 4-6 weeks you will start transitioning to your normal shoes and increasing the amount of weight you place on the foot. This gradual return to activity helps ease the trauma on the operation site, and is crucial to the success of the recovery. 

Gastrocnemius Recession Recovery

After a gastrocnemius recession you may be placed in a below knee splint that prevents you from moving your ankle, and firing your calf muscles. You will need to use crutches or a knee scooter for 2-4 weeks after surgery.

Physical therapy following a gastrocnemius recession is common, and may be beneficial to recovery. If your doctor thinks it is necessary, they will prescribe you physical therapy. 

Plantar Fasciitis Surgery Results:

The goal of a Plantar fasciitis surgery is to reduce pain that is caused by the plantar fascia. At the Foot and Ankle Center of Washington we have excellent results treating plantar fasciitis conservatively, and as a last resort surgically. 

Ninety-nine percent of our patients can be treated conservatively, with only 1% needing surgical intervention. Of the patients who need surgery, 85% experience pain reduction after surgery. 

The most important factor affecting your plantar fasciitis surgery result is how closely you follow the instructions of your surgeon. You must be an active participant in your own health and recovery in order to have success. A well balanced diet, sleep schedule and adhering to the recovery plan your surgeon lays out is crucial. 

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Plantar Fasciitis Surgery Pain:

All surgery has the potential to be painful. During the operation you will be in a relaxed state and usually not feel any pain. Immediately following the operation for 8-10 hours the local anesthetic at the surgery site may block the pain. 

Following the surgery your pain will be handled using a custom built pain management plan from your surgeon. The closer you adhere to your surgeon’s advice, the less pain you will feel. This plan always involves resting, icing, elevating and protecting the limb. For a short period of time after surgery your pain may also be managed with narcotic medications carefully prescribed and monitored by your doctor. 

If you are experiencing pain after your surgery, always contact your doctor and notify them as soon as possible. 

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Plantar Fasciitis Surgery Cost: 

All surgery is expensive, and investing in every conservative option possible can help you avoid excessive or unnecessary spending. A well built pair of custom orthotics from the Foot and Ankle Center of Washington can be one of the best investments you can make in your plantar fasciitis treatment now and later. 

Most plantar fasciitis surgeries are covered by your insurance provider, and the facility where you choose to have your procedure can give you the most accurate quote of the price. 

Prices vary over time and by facility so a quote listed on this website may not be the most up to date or accurate quote available.

We recommend that if have questions about the price of the surgery, call the surgical facility and anesthesia provider prior to your operation.  We can provide you with the surgeon’s cost. 

Plantar Fasciitis Risks and Complications:

Surgery in general carries several common risks. These include:

• • Pain at the surgical site
  • Infection 
  • Failure of the wound to heal (known as wound dehiscence)
  • Injury to nerves or blood vessels near the surgical site 

Some risks unique to plantar fascia surgery include:

• • Continued plantar fasciitis pain
  • Painful thick scar on the bottom of the foot
  • Loss of sensation to part of the bottom of the foot
  • Arch of the foot flattening
  • Decreased push off strength with walking and running

You can reduce your risks in several ways. Remember, never have a surgery if it can be avoided. 

•  First is by picking the best surgeon for your procedure. We suggest a surgeon Board Certified in Foot Surgery and Reconstructive Rearfoot/Ankle Surgery.
• Second, follow your surgeon’s instructions before and after your surgery, including instructions to rest, not bear weight on the foot, and take the proper medications. 
• Third, attend physical therapy if prescribed, this helps you get back to your activities faster. 
• Use of custom orthotics after surgery to reduce force on the surgical site and decrease tension on the plantar fascia

Medical References on Heel Pain Surgery

1. Ficke B, Elattar O, Naranje SM, Araoye I, Shah AB. Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients. Foot Ankle Surg. 2018;24(6):471‐473. doi:10.1016/j.fas.2017.05.008
2. Agyekum EK, Ma K. Heel pain: A systematic review. Chin J Traumatol. 2015;18(3):164‐169. doi:10.1016/j.cjtee.2015.03.002
3. Salvioli S, Guidi M, Marcotulli G. The effectiveness of conservative, non-pharmacological treatment, of plantar heel pain: A systematic review with meta-analysis. Foot (Edinb). 2017;33:57‐67. doi:10.1016/j.foot.2017.05.004
4. Chou AC, Ng SY, Koo KO. Endoscopic Plantar Fasciotomy Improves Early Postoperative Results: A Retrospective Comparison of Outcomes After Endoscopic Versus Open Plantar Fasciotomy. J Foot Ankle Surg. 2016;55(1):9‐15. doi:10.1053/j.jfas.2015.02.005
5. Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthop. 2013;37(9):1845‐1850. doi:10.1007/s00264-013-2022-2
6. Arch Orthop Trauma Surg. 2012 May 4. 
   Platelets rich plasma for treatment of chronic plantar fasciitis.
   Ragab EM, Othman AM.