Evidence-based Sports Medicine

Evidence-based Sports Medicine12 months. 19 Plantar fasciotomy is often combined with a neurolysis ofthe nerve to the abductor digiti quinti. 37 Endoscopic and openfasciotomy appear to have similar results although this has only beenstudied utilising restrospective patient surveys. 38 Initial relief ofrecalcitrant heel pain after surgery is reported to be 70–90% in severalstudies. 37,38,39,40,41 Long term results are not as encouraging. Fasciotomyresults in a flattening of the longitudinal arch and a shifting of peakforces of ambulation from the heel to the mid foot. 40 This shift resultsin an increase in mid and forefoot problems following surgery. Davieset al found that despite initial satisfaction with surgical results, 48%of 43 patients who underwent fasciotomy were unhappy with theresults. 39 Although patients surveyed by Fishco et al as well as Sammarcoand Helfrey reported a higher level of satisfaction post-operative, onethird of these patients reported persistent mid and forefoot pain. 37,41MRI analysis of patients with persistent pain revealed recurrent plantarfasciitis, pathology related to arch instability and structural failure fromoverload as the most common abnormalities in patients with persistentor recurrent pain following plantar fasciotomy. 42RecommendationSurgical intervention should be reserved for patients with heel painresistant to all other more conservative measures. A significant numberof patient with plantar fasciitis may experience relief of symptoms aslate as one year following presentation without invasive interventions.Due to the likelihood of resolution of symptoms significant painshould be persistent for a minimum of six months, and more typicallyone year, before the patient is considered to have failed conservativetherapies. Although surgery is likely to provide short-term relief to thegreat majority of patients, long-term results are not as encouraging.Patients should be made aware of the potential for subsequent forefootproblems resulting from the lysis of the plantar aponeurosis prior toperforming surgery.SummaryHeel pain due to plantar fasciitis frequently prompts patients to seekmedical treatment (Figure 28.1). The diagnosis can in most cases bemade after a careful examination. Atypical history or physical findingsas well as heel pain in very young or very old patients should promptan evaluation for other causes of heel pain. Radiographs are of littlevalue for most patients. Once the diagnosis has been established aconservative treatment plan of rest, stretching and orthotics will554