Should You Have Surgery For Plantar Fasciitis? My Opinion As a PT

What does surgery for plantar fasciitis involve?

There are different types of surgical procedures for plantar fasciitis. The two most commonly described are:

1. Plantar fasciotomy: a part of the plantar fascia is cut. This is usually done endoscopically without needing to make an open incision.
2. Proximal release of the medial gastrocnemius: a part of the calf muscle insertion on the heel is cut to release tension on the plantar fascia.

If you consult a surgeon for this condition, you can ask them which technique they prefer and why.

How long has it been practiced?

Academic publications on surgeries for plantar fasciitis for heel pain have been available since at least the 2000s, almost 25 years ago as of the time of writing.

🚨 International guidelines do not recommend surgery as a first-line treatment. They prioritize conservative treatment (non-surgical) for at least 6 to 12 months before considering surgery [MacRae 2022].

I have also written a comprehensive article on conservative treatments for plantar fasciitis.

What benefits can be expected?

Two different research teams have recently compiled all studies evaluating the effectiveness of surgery to draw conclusions. Here is a summary of their results:

A team from the United Kingdom 🇬🇧 [MacRae 2022] analyzed the results of 8 studies including a total of more than 300 people suffering from plantar fasciitis.

Here are their findings:

• All studies are at very high risk of bias;
• Three studies compared one type of surgery to another, showing largely little or no difference in results regarding pain, function, or quality of life;
• Five studies compared surgery to non-surgical interventions—three providing very low-certainty evidence that surgery might improve pain and function in the long term compared to non-surgical interventions, while two studies showed no long-term difference between the groups;
• The reporting of adverse events was inadequate, inconsistent, or absent in all studies.

Their conclusion:

Based on such evidence, it is not possible to formulate clinical recommendations.

People with plantar fasciitis should be informed of these gaps in current knowledge when considering surgery as a treatment option.

Regarding the other synthesis also from the 🇬🇧, it includes 17 studies involving 865 patients [Nayay 2023]. Its inclusion criteria are broader and include procedures that are not strictly surgical operations:

• Dry needling: involves inserting needles into the fascia;
• Microtenotomy by radiofrequency: under ultrasound guidance, a special needle is inserted into the plantar fascia. Radiofrequency energy is then applied to create micro-lesions.

The authors conclude with short- and medium-term efficacy of surgery. However, they are much less rigorous in analyzing the risk of bias and mix a lot more types of interventions.

➡️ In summary: it is reasonable to expect at least short-term pain relief after surgery. However, this relief might also occur without intervention, as pain often fluctuates in this condition.

What are the possible side effects?

Side effects are not always reported in studies. When they are, they include:

• Hematoma
• Prolonged pain and swelling
• Calf cramps
• Superficial infection or persistent wound drainage (which eventually stops)
• Numbness and paresthesias in the foot (which eventually disappear)

The occurrence of these events is described as infrequent.

Source: MacRae 2022

Is there an alternative to surgery?

Indeed, there are many alternatives to surgery. Some of these alternatives include:

• Waiting for the natural favorable progression
• Adapting physical activity levels to what the foot can tolerate based on pain
• Undergoing physical therapy sessions
• Performing plantar fascia stretches
• Adjusting footwear or wearing insoles

I have already dedicated a complete article to non-surgical treatments for plantar fasciitis, detailing the associated benefits and risks.

Should you undergo surgery?

As always here, my goal is not to tell you what you should do.

There is no single correct course of action when it comes to the various insights on surgeries for plantar fasciitis. It’s up to you to evaluate whether the potential benefits described are worth the associated risks, according to your personal perspective.

If you find it difficult to make this decision on your own, I encourage you to discuss these factual data with another healthcare professional besides a surgeon: your primary care physician or your physical therapist, for example.

Personally, however, I don’t think I would opt for surgery for this condition. Although it is always difficult to take a stance on a subject until one is directly confronted with it 🙂.