Percutaneous fenestration of the anteromedial aspect of the

calcaneus for resistant heel pain syndrome

Freih Odeh Abu Hassan F.R.C.S. (Eng.), F.R.C.S. (Tr. & Orth.)*

Department of Orthopedics Surgery, Jordan University Hospital, P.O. Box 73, Jubaiha 11941, Amman, Jordan

Received 28 May 2008; received in revised form 13 August 2008; accepted 13 August 2008

Abstract

Introduction: The failure of conservative treatment of chronic heel pain might cause prolonged disability from continued discomfort and

pain, which mandates a further treatment modality.

Aim of study: The presentation of the results of percutaneous fenestration of the anteromedial aspect of the calcaneus for symptomatic relief

of resistant heel pain syndrome.

Material and methods: Between September 2001 and August 2006, 34 patients (38 feet) with chronic heel pain syndrome reported an

unacceptable level of pain despite intensive conservative treatment. There were 23 females and 11 males with an average age of 41 years (25–

59 years). The average follow-up was 46 months (range, 14–84 months). Clinical evaluation of the intensity of pain (VAS score system),

walking distance, standing duration, fascial tenderness, and ankle and subtalar joint motion were evaluated preoperatively and at regular

follow-up.

Results: The preoperative pain score level was 8.4 (range, 6–10). The mean postoperative VAS for pain at 4 weeks was 5.89 (range, 3–9), at 8

weeks the value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at 8 months 1.7 (range, 0–3) and at 12 months zero. A clinical

improvement was seen in all patients irrespective of the duration of symptoms ( p = 0.0041). Three heels (7.9%) had partial relief of pain, but

after 43 weeks had complete subsidence of pain. Complications include three transient paraesthesias at the distribution of the medial calcaneal

nerve that resolved spontaneously after 8 weeks post-surgery.

Conclusion: The results suggest the technique of percutaneous fenestration is a significantly effective treatment modality for patients with

recalcitrant heel pain syndrome after failed conservative treatment.

The described technique may provide a useful method for treating refractory heel spur syndrome without resorting to invasive surgical

techniques and warrants further study.

# 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Keywords: Foot; Heel pains; Fenestration; Calcaneal spur; Fasciitis

www.elsevier.com/locate/fas

Available online at www.sciencedirect.com

Foot and Ankle Surgery 15 (2009) 90–95

1. Introduction

Heel pain is a frequent orthopaedic problem encountered

in daily practice and plantar fasciitis forms the most common

aetiology, affecting 10% of the population, which may lead to

significant morbidity and place strict activity limitations on

the patient [1]. The heel pain syndrome includes a continuum

of three different entities, including plantar fasciitis, calcaneal

periostitis and the calcaneal spur [2].

* Tel.: +962 6 5240 346; fax: +962 6 5240 346.

E-mail address: freih@ju.edu.jo.

1268-7731/$ – see front matter # 2008 European Foot and Ankle Society. Publ

doi:10.1016/j.fas.2008.08.006

The aetiology is not known but it is believed to be the

result of chronic repetitive injury as a result of the nature of

upright human activity leading to repetitive tensile and

compressive stress of the fascia that has a cumulative ability

to damage or transform the tissue, causing a chronic

degenerative/reparative process with or without inflamma-

tory changes, which may include fibroblastic proliferation at

the calcaneal interface [3,4].

The majority of patients can be treated initially by a

combination of one or more of the following in a therapeutic

regimen: heel cord stretching, plantar fascia stretching, arch

support, heel pads, custom orthosis, taping, non-steroidal

anti-inflammatory drugs (NSAIDs), physiotherapy, ice,

ished by Elsevier Ltd. All rights reserved.

F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95 91

massage, lithotripsy, cast immobilization, activity modifica-

tions, night splints or steroid injections. Independent of the

mode of therapy used, if at all, 10–15% of patients fail to

respond to conservative treatment [5–9]. There is limited

evidence for the superiority of corticosteroid injections over

orthotic devices, stretching exercises and heel pads over

custom-made orthoses in people who stand for more than 8 h

per day [10]. Extracorporeal shock wave therapy is

ineffective in the treatment of chronic plantar fasciitis

[10,11]. Despite the used multiple modalities of treatment, it

takes a long time to heal. Many surgical techniques have

been tried with non-response rates varying from 2 to 35%

[12,13].

The aim of this study is to assess the effectiveness of

percutaneous fenestration of the anteromedial aspect of the

calcaneus at the insertion of the plantar fascia as a treatment

modality for chronic heel pain syndrome, to abate the

painful symptoms and to allow a rapid return to ordinary

activity, on the assumption of the degenerative and calcaneal

periostitis process as factors playing a role in the

pathogenesis of plantar fasciitis [2–4].

2. Material and methods

Between 2001 and 2006, 34 patients (38 feet) were

treated for their chronic heel pain syndrome after the

failure of conservative methods, using percutaneous

fenestration. There were 23 females and 11 males, with

an average age of 41 years (25–59 years). The left heel

was affected in 17 patients, the right heel in 13 and the

problem was bilateral in 4 patients; all were treated with

the same technique by the author. All the patients

diagnosed with painful plantar fasciitis were questioned

concerning the type of pain, site of pain, duration of pain,

walking distance, standing duration, extent of conserva-

tive therapy, previous surgical treatment and past medical

history. All the patients had an assessment of the range of

motion of the ankle and subtalar joints actively

and passively, and they were checked for gait pattern.

Each patient was treated for 3 months with conservative

methods, including physical therapy, Achilles tendon

and plantar fascia stretching, icing, heel pads and

NSAIDs. If the patient was not improving, an 8-week

course of additional therapy, including three courses of

ultrasound of six sessions each, and continued heel

pads and NSAIDs were prescribed before considering

surgery.

All the patients had weightbearing lateral radiographs of

the feet. Our inclusion criteria were the following: the

presence of a chronic pain of at least 6 months duration

(range 6–43 months) at the proximal insertion of the plantar

fascia at the anteromedial of the heel, which failed to

respond to a trial of conservative treatment. None of the

patients had symptoms of inflamed joints, tendon attach-

ments, inflammatory back pain, iritis, blood or mucus per

rectum, urethritis or skin problems as a manifestation of the

underlying inflammatory process.

Pain was evaluated using the subjective 11-point visual

analogue scale (VAS), where 10 represented unbearable

pain and 0 absence of pain. Patients were checked for any

signs of inflammation at the entry point of the fenestration

and impaired sensation of the sole using a pinprick. Pain and

gait pattern were evaluated preoperatively, 4 weeks, 8

weeks, 4 months, 8 months and 12 months after the

fenestration procedure. We defined the clinical results as

follows: excellent, patients who reported a subjective

decrease in pain ranging from 100 to 80% (VAS), no

complications and normal gait; very good, a decrease from

80 to 60% (VAS), no complications and minimal short-term

antalgic gait; good, a decrease of less than 60–40% (VAS),

minor complications and/or antalgic gait; and poor, a

decrease of less than 40–0% (VAS), major complications

and/or impossible gait.

2.1. Surgical technique

Under general anesthesia, the patient is placed in the

supine position with a sand bag under the opposite buttock

and the leg placed in external rotation. Without using the

tourniquet, the foot and ankle are draped. After a betadine

preparation of the skin, localization of the entry point is

performed under an image intensifier, followed by a

medial single 5 mm stab incision. Using the image

intensifier, the Steinmann pin is introduced through the

incision at the anteromedial aspect of the calcaneus and

multiple bone fenestration for about 1 cm made from the

same single hole in the superolateral direction, then

withdrawn slightly and directed posteriorly then anteriorly

and finally towards the lateral side perpendicular to the

calcaneus (Figs. 1 and 2).

No trial was made to break the plantar heel spur if

present. To infiltrate the heel at the end of operation, 5 ml

Marcaine local anesthesia is used. The entry site is not

sutured and a light, sterile compressive dressing with an

elastic bandage is applied.

2.2. Postoperative management

Postoperatively, the patient is given oral analgesia and

instructed for partial weight bearing for 7 days then to

continue with full weightbearing as tolerated. The dressing

is removed after 1 week and a small sterile dressing is

applied.

2.3. Statistical analysis

Statistical analysis of the data was performed by using a

PC program (SPSS 14 for Windows). Repeated measures

analysis (analysis of variance) was performed to compare

statistically pain ratings preoperatively, at 4 weeks, 8 weeks,

4 months, 8 months and 12 months.

F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–9592

Fig. 1. Serial clinical photographs of the fenestration technique.

Fig. 2. Serial radiological views of the fenestration technique.

F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95 93

Fig. 4. The clinical results obtained with the treatment using percutaneous

fenestration.

3. Results

The average follow-up was 46 months (range, 14–84

months). Five patients had diabetes mellitus, two hyperten-

sion, five carcinoma of the breast and four osteoarthritis of

the knee joints. In all cases, the exact cause of the plantar

fasciitis could not be defined. There were 23 heel spurs

noticed in the standing lateral plain radiograph of the foot.

Pain was graded by each individual patient preoperatively

and postoperatively.

Pain ratings before fenestration were significantly

reduced from the average pain ratings after the procedure.

The average pain score before fenestration was 8.4 (range,

6–10) on the VAS.

At regular follow-up, the mean postoperative VAS for

pain at 4 weeks dropped to 5.89 (range, 3–9), at 8 weeks the

value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at

8 months 1.7 (range, 0–3) and at 12 months zero (Fig. 3).

Based on the aforementioned parameters, we analysed the

results at 4, 8 and 12 months.

We had excellent results in 78.94% (30 feet), 92.09% (35

feet) and 100% (38 feet) at 4, 8 and 12 months, respectively.

Very good results were observed in 13.15% (5 feet) at 4

months; all become excellent at 8 months. Good results in

7.9% (3 feet) at 4 months become very good at 8 months and

excellent at 12 months (Fig. 4). None of our patients had

poor results. There was significant heel pain relief as

indicated by ( p = 0.0041). Pain distribution revealed that

92.09% (N = 35) of the heels had complete or substantial

relief of heel pain after an average period of 10 weeks (4–34

weeks), with a pain rating of 1.7 on the VAS 8 months after

the procedure. Three heels (7.9%) had partial relief, but after

43 weeks they had complete subsidence of pain.

All the patients had a limited walking distance

preoperatively and they used to avoid prolonged standing.

Patients were able to walk for an average of 0.76 km (range,

70–2.5 km) and stand for an average of 24 min (range, 15–

60 min). The average postoperative walking distance was

4.1 km (range, 1.5–8 km) and the average postoperative

standing period was 3.9 h (range, 2.5–8 h). We observed a

Fig. 3. The graph shows the mean value of pain (VAS) at the time of

preoperative and postoperative periods.

persistent improvement in heel pain as evidenced by

prolonged walking distance and an improvement in standing

period ( p = 0.033).

None of the patients had localized tenderness at the

insertion of the plantar fascia at 12 months postoperatively.

All the patients showed a normal range of motion in the

subtalar joint preoperatively, although there was a limited

dorsal flexion of the ankle joint in 21 of 38 feet (0–58 in 14

feet and 6–108 in the other 7 feet).

Clinical examination showed a normal postoperative

range of motion in the subtalar joint and ankle joint. Gradual

recovery of the sensation occurred in the three patients with

neuropraxia of the medial calcaneal nerve in an 8-week

period. None of the patients were sent for rehabilitation.

No infections, hypertrophic scar formations or vascular

complications occurred in our patients. Complications

include three patients having impaired sensation at the

plantar aspect of the heel; this resolved spontaneously in 8

weeks.

4. Discussion

Although this problem is common, patients’ heel pain

improves spontaneously, demonstrating that the condition

is self-limiting in some patients [10]. Most patients of

plantar fasciitis respond very well to conservative

treatment. There was conflicting, limited or no evidence

for the effectiveness of topical steroids, low-energy

extracorporeal shock wave therapy, night splints, ther-

apeutic ultrasound or low-intensity laser therapy in

altering the clinical course of plantar heel pain [10].

The first line of management is by non-steroidal anti-

inflammatory drugs and heel pads [14]. After the failure of

all conservative options and permanent pain, an indication

for surgical intervention should be considered. The

literature is plethoric with different methods of surgical

treatment, and it seems there is no agreement on a single

method as the curative remedy.

F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–9594

Conventional open fasciotomy, fluoroscopic-assisted

fasciotomy, neurolysis, denervation, osteotomy or drilling

of the posterior calcaneus were the described surgical

methods [13,15–18]. Considerable attention was paid to the

complications of such procedures: healing problems,

vascular and neural lesions, hypertrophic scars and even

fractures of the calcaneus [19]. Apart from this, bad

results after operations are always frustrating for both the

patient and the surgeon [17]. Uni- or bi-cortical drilling in

the posterior body of the calcaneus has been tried before

as another modality of treatment to decrease the intraoss-

eous vascular congestion, with a 75–94% success rate

[18,20,21].

Drilling can be performed with an open procedure

through making 7–10 separate holes that traverse the

calcaneus from the lateral to the medial cortex or

percutaneous drilling of the calcaneus can be performed

over the medial surface of the heel by making three separate

small holes in the medial cortex, without traversing the

lateral cortex.

The aim of all described methods of drilling to decrease

the high intraosseus pressure in the calcaneus. Our method

based on the degenerative and periostitis process at the

calcaneal interface of the plantar fascia as possible

pathogenesis of this condition, the technique enhance

healing process and accelerate resolution of this challenging

problem.

By performing fenestration at anteromedial aspect

of the calcaneal interface of the plantar fascia, a

process of inflammation can be induced which will be

followed by opening the channels of the blood to

the site of pathology where the reparative cells

produce healing of the degenerative insertion of the

plantar fascia.

Again the described methods of drilling are performed

through the posterior body of the calcaneus away from the

pathology site in the anteromedial aspect of the heel and may

be associated with calcaneal fracture or nerve injury

[18,20,21].

Our technique is directed to the site of the pathological

process at the insertion of the plantar fascia in the

anteromedial aspect of the calcaneus at the inferior

calcaneal tubercle, by one fenestration and four

different directions of the Steinmann pin penetration

without perforating the lateral cortex. Compared with

other surgical procedures, our technique disturbs

neither the normal anatomy nor the biomechanical

function of the hind foot. With resolved chronic heel

pain in all treated feet, the clinical results are better than

those found in the literature, whether local calcaneal

drilling, minimal invasive procedure or open fasciotomy

[19,20,22,23]. We believe that there is no risk of

permanent damage to the branches of the sural nerve or

the medial calcaneal nerve or fracture of the calcaneus,

despite the three cases of the neuropraxia of the medial

calcaneal nerve which could be attributed to slippage of

the Steinmman pin during the targeting of the site of the

plantar fascia insertion or an abnormal course of the

nerve.

5. Conclusion

Despite the successful outcome of our technique, the

suggested method of healing needs further confirmation by

other laboratory methods or histological studies. These

results from a small group of patients studied over a few

years indicate that the described technique may provide a

useful method for treating this challenging refractory heel

pain syndrome. A larger study combined with random

variables would be helpful in the elimination of such

limitations.

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