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Treatment of recalcitrant plantar fasciitis by sonographically-guided needle fasciotomy
Foot and Ankle Surgery 11 (2005) 211–214 www.elsevier.com/locate/fas
Treatment of recalcitrant plantar fasciitis by sonographically-guided needle fasciotomy Y. Folmana,*, G. Bartalb, A. Breitgandb, S. Shabatc, N. Rona a
Department of Orthopaedic, Hillel Yaffe Medical Center, Hadera 38100, Israel b Department of Imaging, Hillel Yaffe Medical Center, Hadera 38100, Israel c Department of Orthopaedic Surgery, Meir Medical Center, Kefar Sava, Israel Received 25 January 2005; revised 8 August 2005; accepted 15 August 2005
Abstract Plantar fasciotomy was carried out in 32 patients who had typical heel pain that had persisted for three months or longer. Following induction of local anesthesia, an 18-gauge needle was guided toward and into the plantar fascia by real-time sonography. The criterion for operative success was the appearance of an acoustic window within the plantar fascia. Pain intensity was graded on an 11-point visual analog scale (VAS). Questionnaires combining the VAS and a 0–100 point Daly score were filled out after treatment to determine the effectiveness of the procedure. The follow-up averaged 13.5 months. 78% were overweight (BMIO25). The mean pain score decreased by 6.72 points, a 73G21% improvement (P!0.001). The mean post-operative Daly score was 88.3G16.2. There were no complications during or after the procedure. Sonographically-guided needle fasciotomy is a safe and effective method for the relief of conservatively unmanageable heel pain due to plantar fasciitis. q 2005 European Foot and Ankle Societ. Published by Elsevier Ireland Ltd. All rights reserved. Keywords: Clinical trial; Plantar fasciotomy; Ultrasound
1. Introduction The entity known as plantar fasciitis is manifested by heel pain that occurs whenever weight-bearing is resumed after a period of rest. It is characteristically associated with point tenderness over the calcaneal tuberosity [1–3]. The pathogenesis of this entity is unknown. The pain has been ascribed to calcaneal periostitis or bursitis, plantar nerve entrapment, fat pad atrophy etc. However, the prevailing theory is fatigue failure of the plantar fascia resulting in chronic inflammation at its insertion on the medial tubercle of the calcaneus [2,3]. For many years, heel pain of a similar nature was often attributed to a calcaneal spur when this common lesion was discovered by X-ray [3,4]. In recent years, this notion has been challenged. While a few authors have suggested bone scintigraphy for diagnosis [5,6], the * Corresponding author. Tel./fax: C972 4 6304738. E-mail address: [email protected] (Y. Folman).
bulk of recent publications on the subject of heel pain advocate sonographic investigation as the final arbiter in problem cases. The sine qua non is a thickened, hypoechogenic plantar fascia [7–9]. The symptoms of plantar fasciitis remit spontaneously in the majority of patients, however, the average time for pain relief was reported to be as long as 6 months [10]. In the hope of inducing remission, several methods of conservative treatment have been devised and subjected to trial but their results, as analyzed, did not improve upon the natural history of the condition [10–13]. Recent randomized, controlled trials assessing conservative treatment of plantar fasciitis showed limited evidence of the effectiveness of low-energy exatracorporeal shock-wave therapy [14,15] and of plantar fascia-stretching exercise [16]. Approximately 10% of the cases develop recalcitrant symptoms [17] and are offered various forms of surgical intervention, including open plantar fasciotomy with resection of calcaneal spur, if present [1–3,18], endoscopic plantar fasciotomy [19,20] and neurolysis of the medial
1268-7731/$ - see front matter q 2005 European Foot and Ankle Societ. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.fas.2005.08.001
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calcaneal nerve [21] or of the nerve to the abductor digiti minimi [22–24]. All of these have inherent side effects that are potentially more disabling than the condition they are designed to relieve. The simplest and the least traumatic surgical procedure reported to date consists of percutaneous, plantar fasciotomy [25]. We report herein our experience with this method as applied in conjunction with ultrasound imaging as an intraoperative control modality.
2. Subjects and methods From January 2001, 32 consecutive patients with unremitting typical heel pain, attributed to plantar fasciitis and present for three months or longer, were treated as outpatients by sonographically-guided needle fasciotomy. These patients had failed trials of conservative therapy that included shock absorbing shoe insoles, physical therapy, nonsteroidal anti-inflammatory drugs and a single trial of local infiltration with 40 mg methylprednisolone acetate. We excluded patients who had generalized polyarthritis, significant foot deformity with loss of longitudinal arch, neuropathic arthropathy, a bleeding disorder or a behavioral abnormality that could impair cooperation. Following induction of local anesthesia (lignocaine, 2%, 2 ml), an 18-gauge needle was inserted into the plantar fascia aiming at an intersection of a perpendicular line drawn from the anterior border of the medial malleolus and an horizontal line bridging the calcaneal tuberosity, and the head of first metatarsal bone (Fig. 1). This anatomic landmark prevented a potential injury to the plantar neurovascular bundle, while an inadvertent entry of the needle into the flexor digitorum brevis muscle caused no morbidity. The needle was advanced under continuous sonographic guidance, employing a linear array US, 10 MHz transducer. Once introduced into the plantar fascia, the forefoot was dorsiflexed and the needle moved forwards and backwards intersecting the fascia under direct palpation. The sign of successful
fasciotomy and the end-point of the procedure was the appearance of an acoustic window within the plantar fascia spanning 70–80% of its width. All the procedures were performed by a single team of a clinician (NR) and a radiologist (AB) in a radiology suite. Outcome was assessed independently by a research fellow, who had not been involved in the selection of patients or their treatment. Before treatment, pain intensity was scored on a visual analog scale (VAS). The effectiveness of the procedure was determined by repeat scoring at 2, 6 and 12 months, and by Daly’s scoring questionnaire at the final evaluation [26]. On the latter occasion, each patient was asked whether he/she felt the procedure had been worthwhile and his or her answer was recorded. The paired t-test was applied to determine the significance of differences as between mean VAS scores pre- and postoperatively.
3. Results The patient cohort consisted of 12 men and 20 women; aged 30–74 years (mean 49G11.7 years). Seventy-eight percent of the patients were overweight (body mass indexO 25 Kg/m2). All patients reported unilateral symptoms or clear predominance of pain in one heel. The mean duration of preoperative symptoms was 4.5 months (range, 3–10 months). By definition, sonography showed the plantar fascia to be thickened as compared to that of asymptomatic foot. However, as the exact location of the measurement could not be reproduced, we were unable to reach definitive statistical conclusions. There were no untoward events or complications during or following needle fasciotomy. Successful fasciotomy was verified by the appearance of an acoustic window within the plantar fascia in every one of the patients (Fig. 2). No patients were lost to follow-up which averaged 13.5 months (range 10.3–16.2 months). Mean values for VAS were 9.2G1.0 before treatment and 2.5G2.02 two months
Fig. 1. Entrance point at intersection of lines drawn perpendicularly from the anterior border of medial malleolus and horizontally from calcaneal tuberosity to the head of first metatarsal. (A) Plantar fascia and flexor digitorum brevis muscle. (B) Plantar artery and nerve.
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condition that may seriously hinder mobility and recreational activities. We found US imaging highly useful for real-time navigation of the needle, which ensures partial (70–80%) release of the fascia. We were impressed that partial fasciotomy is highly effective in terms of pain relief; and this accords with earlier reports [3,25,27]. Furthermore, it has been shown by others that partial fasciotomy, as opposed to total disconnection, has a minimal affect on the plantar arch collapse [28] and the consequent changes in gait pattern [18,27,29]. In our group of patients, US control ensured maximal safety with regard to the potential complication of neurovascular injury and was comparable in this regard to endoscopic plantar fascia surgery [19,20]. All things considered, sonograhically-guided needle fasciotomy would appear to be a safe and effective surgical procedure for heel pain due to recalcitrant plantar faciitis.
References
Fig. 2. Plantar fascia following treatment by needle fasciotomy. Arrow points to the acoustic window spanning 80% of the plantar fascia width (the cross indicates the depth of penetration).
later and remained stable thereafter up to final follow-up (P!0.001 for differences between means). The mean Daly score at final follow-up was 88.3G16.2. Twenty-nine patients (90.6%) stated that “the procedure had been worthwhile”.
4. Discussion Sixty two and a half percent of our patients were female, 78% were overweight, a typical profile of a population prone to plantar fasciitis [10,21,23,25]. We restricted the conservative regime to shoe insoles, physical therapy (plantar fascia stretching) and a solitary local injection of glucocorticoid. Steroid injection, which is recommended most frequently among the conservative modalities was shown to have a poor success rating [10]. We recommend the procedure to patients who failed to recover after a minimum period of 3 months, whereas other authors recommended a waiting period of 6–35 months [1–3,10,23,24,27]. Timing of surgical treatment for recalcitrant plantar fasciitis has a philosophical aspect. While taking into consideration that the vast majority of patients may improve within a few months, it could also be inappropriate to deny an effective and safe surgical option, for a period of over 6 months, with regard to a benign
[1] Lester DK, Buchanan JR. Surgical treatment of plantar fasciitis. Clin Orthop 1984;186:202–4. [2] Shepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. Etiology, treatment, surgical results and review of the literature. Clin Orthop 1991;266:185–96. [3] Tountas AA, Fornasier VL. Operative treatment of subcalcaneal pain. Clin Orthop 1996;332:170–8. [4] Tanz SS. Heel pain. Clin Orthop 1963;28:169–72. [5] Heim M, Goshen E, Chechick A, Cohen I, Azaria M. Adult nontraumatic plantar heel pain: do initial X-rays enhance or detract from the diagnosis? IMAJ 2000;2:244–5. [6] Tudor GR, Finlay D, Allen MJ, Belton I. The role of bone scintigraphy and plain radiography in intractable plantar fasciitis. Nucl Med Commun 1997;18:853–6. [7] Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiol 1999;28:21–6. [8] Kane D, Greaney T, Bresnihan B, Gibney R, FitzGerald O. Ultrasound guided injection of recalcitrant plantar fasciitis. Ann Rheum Dis 1998; 57:383–4. [9] Tsai WC, Chiu MF, Wang CL, Tang FT, Wong MK. Ultrasound evaluation of plantar fasciitis. Scand J Rheumatol 2000;29:255–9. [10] Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle 1994;15:97–102. [11] Buchbinder R, Ptashnik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis. A randomized controlled trial. J Am Med Assoc 2002;18:1364–72. [12] Gill LH, Kiebzak GM. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int 1996;17:527–32. [13] Probe RA, Baca M, Adams R, Preece C. Night splint treatment for plantar fasciitis. A prospective randomized study. Clin Orthop 1999; 386:190–5. [14] Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg 2002;84A:335–41. [15] Weil Jr. LS, Roukis TS, Weil Sr. LS, et al. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy. J Foot Ankle Surg 2002;41:166–72.
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[16] Di Giovanni BF, Nawochenski DA, Lintal ME. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. J Bone Joint Surg 2003;85A:1270–7. [17] Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int 1994;15:531–5. [18] Brown DN, Roberts S, Taylor M, Paterson RS. Plantar fascia release through a transverse plantar incision. Foot Ankle Int 1999; 20:364–7. [19] Barrett SL, Day SV, Piguetti TT, Robinson LB. Endoscopic plantar fasciotomy: a multi-surgeon prospective analysis of 652 cases. J Foot Surg 1995;34:1–7. [20] Hofmeister EP, Elliot MJ, Juliano PJ. Endoscopic plantar fascia release: an anatomical study. Foot Ankle Int 1995;16:719–23. [21] Savastano AA. Surgical neurectomy for the treatment of resistant painful heel. Rhode Island Med J 1985;68:371. [22] Baxter DE, Thigpen CM. Heel pain: operative results. Foot Ankle 1984;5:16–25.
[23] Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int 1999;20:803–7. [24] Sammarco GJ, Helfrey PB. Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle Int 1996;17:520–6. [25] Benton-Weil W, Borrelli AH, Weil Jr LS, Weil Jr LS. Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis. J Foot Ankle Surg 1998;37:269–72. [26] Daly PJ, Kitaoka HB, Chao EY. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle 1992;13:188–95. [27] Perelman GK, Figura MA, Sandberg NS. The medial instep plantar fasciotomy. J Foot Ankle Surg 1995;34:447–57. [28] Murphy GA, Pneumaticos SG, Kamaric E, Noble PC, Trevino SG, Baxter DE. Biomechanical consequences of sequential plantar fascia release. Foot Ankle Int 1998;19:149–52. [29] Arangio GA, Chen C, Kim W. Effect of cutting the plantar fascia on mechanical properties of the foot. Clin Orthop 1997;339:227–31.
Treatment of recalcitrant plantar fasciitis by sonographically-guided needle fasciotomy Y. Folmana,*, G. Bartalb, A. Breitgandb, S. Shabatc, N. Rona a
Department of Orthopaedic, Hillel Yaffe Medical Center, Hadera 38100, Israel b Department of Imaging, Hillel Yaffe Medical Center, Hadera 38100, Israel c Department of Orthopaedic Surgery, Meir Medical Center, Kefar Sava, Israel Received 25 January 2005; revised 8 August 2005; accepted 15 August 2005
Abstract Plantar fasciotomy was carried out in 32 patients who had typical heel pain that had persisted for three months or longer. Following induction of local anesthesia, an 18-gauge needle was guided toward and into the plantar fascia by real-time sonography. The criterion for operative success was the appearance of an acoustic window within the plantar fascia. Pain intensity was graded on an 11-point visual analog scale (VAS). Questionnaires combining the VAS and a 0–100 point Daly score were filled out after treatment to determine the effectiveness of the procedure. The follow-up averaged 13.5 months. 78% were overweight (BMIO25). The mean pain score decreased by 6.72 points, a 73G21% improvement (P!0.001). The mean post-operative Daly score was 88.3G16.2. There were no complications during or after the procedure. Sonographically-guided needle fasciotomy is a safe and effective method for the relief of conservatively unmanageable heel pain due to plantar fasciitis. q 2005 European Foot and Ankle Societ. Published by Elsevier Ireland Ltd. All rights reserved. Keywords: Clinical trial; Plantar fasciotomy; Ultrasound
1. Introduction The entity known as plantar fasciitis is manifested by heel pain that occurs whenever weight-bearing is resumed after a period of rest. It is characteristically associated with point tenderness over the calcaneal tuberosity [1–3]. The pathogenesis of this entity is unknown. The pain has been ascribed to calcaneal periostitis or bursitis, plantar nerve entrapment, fat pad atrophy etc. However, the prevailing theory is fatigue failure of the plantar fascia resulting in chronic inflammation at its insertion on the medial tubercle of the calcaneus [2,3]. For many years, heel pain of a similar nature was often attributed to a calcaneal spur when this common lesion was discovered by X-ray [3,4]. In recent years, this notion has been challenged. While a few authors have suggested bone scintigraphy for diagnosis [5,6], the * Corresponding author. Tel./fax: C972 4 6304738. E-mail address: [email protected] (Y. Folman).
bulk of recent publications on the subject of heel pain advocate sonographic investigation as the final arbiter in problem cases. The sine qua non is a thickened, hypoechogenic plantar fascia [7–9]. The symptoms of plantar fasciitis remit spontaneously in the majority of patients, however, the average time for pain relief was reported to be as long as 6 months [10]. In the hope of inducing remission, several methods of conservative treatment have been devised and subjected to trial but their results, as analyzed, did not improve upon the natural history of the condition [10–13]. Recent randomized, controlled trials assessing conservative treatment of plantar fasciitis showed limited evidence of the effectiveness of low-energy exatracorporeal shock-wave therapy [14,15] and of plantar fascia-stretching exercise [16]. Approximately 10% of the cases develop recalcitrant symptoms [17] and are offered various forms of surgical intervention, including open plantar fasciotomy with resection of calcaneal spur, if present [1–3,18], endoscopic plantar fasciotomy [19,20] and neurolysis of the medial
1268-7731/$ - see front matter q 2005 European Foot and Ankle Societ. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.fas.2005.08.001
212
Y. Folman et al. / Foot and Ankle Surgery 11 (2005) 211–214
calcaneal nerve [21] or of the nerve to the abductor digiti minimi [22–24]. All of these have inherent side effects that are potentially more disabling than the condition they are designed to relieve. The simplest and the least traumatic surgical procedure reported to date consists of percutaneous, plantar fasciotomy [25]. We report herein our experience with this method as applied in conjunction with ultrasound imaging as an intraoperative control modality.
2. Subjects and methods From January 2001, 32 consecutive patients with unremitting typical heel pain, attributed to plantar fasciitis and present for three months or longer, were treated as outpatients by sonographically-guided needle fasciotomy. These patients had failed trials of conservative therapy that included shock absorbing shoe insoles, physical therapy, nonsteroidal anti-inflammatory drugs and a single trial of local infiltration with 40 mg methylprednisolone acetate. We excluded patients who had generalized polyarthritis, significant foot deformity with loss of longitudinal arch, neuropathic arthropathy, a bleeding disorder or a behavioral abnormality that could impair cooperation. Following induction of local anesthesia (lignocaine, 2%, 2 ml), an 18-gauge needle was inserted into the plantar fascia aiming at an intersection of a perpendicular line drawn from the anterior border of the medial malleolus and an horizontal line bridging the calcaneal tuberosity, and the head of first metatarsal bone (Fig. 1). This anatomic landmark prevented a potential injury to the plantar neurovascular bundle, while an inadvertent entry of the needle into the flexor digitorum brevis muscle caused no morbidity. The needle was advanced under continuous sonographic guidance, employing a linear array US, 10 MHz transducer. Once introduced into the plantar fascia, the forefoot was dorsiflexed and the needle moved forwards and backwards intersecting the fascia under direct palpation. The sign of successful
fasciotomy and the end-point of the procedure was the appearance of an acoustic window within the plantar fascia spanning 70–80% of its width. All the procedures were performed by a single team of a clinician (NR) and a radiologist (AB) in a radiology suite. Outcome was assessed independently by a research fellow, who had not been involved in the selection of patients or their treatment. Before treatment, pain intensity was scored on a visual analog scale (VAS). The effectiveness of the procedure was determined by repeat scoring at 2, 6 and 12 months, and by Daly’s scoring questionnaire at the final evaluation [26]. On the latter occasion, each patient was asked whether he/she felt the procedure had been worthwhile and his or her answer was recorded. The paired t-test was applied to determine the significance of differences as between mean VAS scores pre- and postoperatively.
3. Results The patient cohort consisted of 12 men and 20 women; aged 30–74 years (mean 49G11.7 years). Seventy-eight percent of the patients were overweight (body mass indexO 25 Kg/m2). All patients reported unilateral symptoms or clear predominance of pain in one heel. The mean duration of preoperative symptoms was 4.5 months (range, 3–10 months). By definition, sonography showed the plantar fascia to be thickened as compared to that of asymptomatic foot. However, as the exact location of the measurement could not be reproduced, we were unable to reach definitive statistical conclusions. There were no untoward events or complications during or following needle fasciotomy. Successful fasciotomy was verified by the appearance of an acoustic window within the plantar fascia in every one of the patients (Fig. 2). No patients were lost to follow-up which averaged 13.5 months (range 10.3–16.2 months). Mean values for VAS were 9.2G1.0 before treatment and 2.5G2.02 two months
Fig. 1. Entrance point at intersection of lines drawn perpendicularly from the anterior border of medial malleolus and horizontally from calcaneal tuberosity to the head of first metatarsal. (A) Plantar fascia and flexor digitorum brevis muscle. (B) Plantar artery and nerve.
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condition that may seriously hinder mobility and recreational activities. We found US imaging highly useful for real-time navigation of the needle, which ensures partial (70–80%) release of the fascia. We were impressed that partial fasciotomy is highly effective in terms of pain relief; and this accords with earlier reports [3,25,27]. Furthermore, it has been shown by others that partial fasciotomy, as opposed to total disconnection, has a minimal affect on the plantar arch collapse [28] and the consequent changes in gait pattern [18,27,29]. In our group of patients, US control ensured maximal safety with regard to the potential complication of neurovascular injury and was comparable in this regard to endoscopic plantar fascia surgery [19,20]. All things considered, sonograhically-guided needle fasciotomy would appear to be a safe and effective surgical procedure for heel pain due to recalcitrant plantar faciitis.
References
Fig. 2. Plantar fascia following treatment by needle fasciotomy. Arrow points to the acoustic window spanning 80% of the plantar fascia width (the cross indicates the depth of penetration).
later and remained stable thereafter up to final follow-up (P!0.001 for differences between means). The mean Daly score at final follow-up was 88.3G16.2. Twenty-nine patients (90.6%) stated that “the procedure had been worthwhile”.
4. Discussion Sixty two and a half percent of our patients were female, 78% were overweight, a typical profile of a population prone to plantar fasciitis [10,21,23,25]. We restricted the conservative regime to shoe insoles, physical therapy (plantar fascia stretching) and a solitary local injection of glucocorticoid. Steroid injection, which is recommended most frequently among the conservative modalities was shown to have a poor success rating [10]. We recommend the procedure to patients who failed to recover after a minimum period of 3 months, whereas other authors recommended a waiting period of 6–35 months [1–3,10,23,24,27]. Timing of surgical treatment for recalcitrant plantar fasciitis has a philosophical aspect. While taking into consideration that the vast majority of patients may improve within a few months, it could also be inappropriate to deny an effective and safe surgical option, for a period of over 6 months, with regard to a benign
[1] Lester DK, Buchanan JR. Surgical treatment of plantar fasciitis. Clin Orthop 1984;186:202–4. [2] Shepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. Etiology, treatment, surgical results and review of the literature. Clin Orthop 1991;266:185–96. [3] Tountas AA, Fornasier VL. Operative treatment of subcalcaneal pain. Clin Orthop 1996;332:170–8. [4] Tanz SS. Heel pain. Clin Orthop 1963;28:169–72. [5] Heim M, Goshen E, Chechick A, Cohen I, Azaria M. Adult nontraumatic plantar heel pain: do initial X-rays enhance or detract from the diagnosis? IMAJ 2000;2:244–5. [6] Tudor GR, Finlay D, Allen MJ, Belton I. The role of bone scintigraphy and plain radiography in intractable plantar fasciitis. Nucl Med Commun 1997;18:853–6. [7] Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiol 1999;28:21–6. [8] Kane D, Greaney T, Bresnihan B, Gibney R, FitzGerald O. Ultrasound guided injection of recalcitrant plantar fasciitis. Ann Rheum Dis 1998; 57:383–4. [9] Tsai WC, Chiu MF, Wang CL, Tang FT, Wong MK. Ultrasound evaluation of plantar fasciitis. Scand J Rheumatol 2000;29:255–9. [10] Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle 1994;15:97–102. [11] Buchbinder R, Ptashnik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis. A randomized controlled trial. J Am Med Assoc 2002;18:1364–72. [12] Gill LH, Kiebzak GM. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int 1996;17:527–32. [13] Probe RA, Baca M, Adams R, Preece C. Night splint treatment for plantar fasciitis. A prospective randomized study. Clin Orthop 1999; 386:190–5. [14] Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg 2002;84A:335–41. [15] Weil Jr. LS, Roukis TS, Weil Sr. LS, et al. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy. J Foot Ankle Surg 2002;41:166–72.
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[16] Di Giovanni BF, Nawochenski DA, Lintal ME. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. J Bone Joint Surg 2003;85A:1270–7. [17] Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int 1994;15:531–5. [18] Brown DN, Roberts S, Taylor M, Paterson RS. Plantar fascia release through a transverse plantar incision. Foot Ankle Int 1999; 20:364–7. [19] Barrett SL, Day SV, Piguetti TT, Robinson LB. Endoscopic plantar fasciotomy: a multi-surgeon prospective analysis of 652 cases. J Foot Surg 1995;34:1–7. [20] Hofmeister EP, Elliot MJ, Juliano PJ. Endoscopic plantar fascia release: an anatomical study. Foot Ankle Int 1995;16:719–23. [21] Savastano AA. Surgical neurectomy for the treatment of resistant painful heel. Rhode Island Med J 1985;68:371. [22] Baxter DE, Thigpen CM. Heel pain: operative results. Foot Ankle 1984;5:16–25.
[23] Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int 1999;20:803–7. [24] Sammarco GJ, Helfrey PB. Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle Int 1996;17:520–6. [25] Benton-Weil W, Borrelli AH, Weil Jr LS, Weil Jr LS. Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis. J Foot Ankle Surg 1998;37:269–72. [26] Daly PJ, Kitaoka HB, Chao EY. Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. Foot Ankle 1992;13:188–95. [27] Perelman GK, Figura MA, Sandberg NS. The medial instep plantar fasciotomy. J Foot Ankle Surg 1995;34:447–57. [28] Murphy GA, Pneumaticos SG, Kamaric E, Noble PC, Trevino SG, Baxter DE. Biomechanical consequences of sequential plantar fascia release. Foot Ankle Int 1998;19:149–52. [29] Arangio GA, Chen C, Kim W. Effect of cutting the plantar fascia on mechanical properties of the foot. Clin Orthop 1997;339:227–31.