Plantar Fascia Release

Why this approach — at MOS

Plantar fascia release is not appropriate for every patient who has had plantar fasciitis for 6 months. Before recommending surgery, I confirm the diagnosis with ultrasound (which I can perform in the office) or MRI to verify that the fascia is genuinely thickened and degenerated — not just tender. I also exclude other causes of heel pain through examination and imaging, because surgery does not help pain caused by tarsal tunnel syndrome, calcaneal stress fracture, or lateral plantar nerve entrapment.

I consistently use the endoscopic technique because the evidence for EPFR is strong — equivalent outcomes to open release, fewer wound complications, and faster return to walking. The critical technical point is how much fascia to release. I release the medial third to one-half of the fascia — enough to eliminate the pathologic tension, not enough to flatten the arch. Patients who develop arch pain after plantar fascia release almost always had too much released. I prioritize conservative release.

Patients presenting from throughout Montgomery County with chronic heel pain who have exhausted conservative options deserve a clear explanation of what surgery involves and realistic expectations about recovery, including the fact that early post-operative soreness and gradual return to activity are normal.

Who is a candidate?

Indications

• Plantar fasciitis with persistent heel pain for 6 months or more despite compliance with conservative treatment
• MRI or ultrasound confirming thickened, degenerated plantar fascia at the calcaneal origin
• Failure of all of the following: dedicated calf and plantar fascia stretching program, orthotics or arch-supportive footwear, physical therapy, and at least one cortisone injection
• Functional impairment limiting daily activities, work, or exercise
• Diagnosis confirmed — other causes of heel pain (tarsal tunnel syndrome, stress fracture, fat pad atrophy, nerve entrapment) have been excluded

Contraindications

• Conservative treatment has not been completed for at least 6 months — surgery should not be the first or second treatment
• Active heel infection or skin condition
• Peripheral neuropathy — sensation must be assessed before surgery
• Inflammatory arthritis (e.g., psoriatic arthritis, ankylosing spondylitis) — the underlying systemic condition must be managed first

Conservative Treatment First

The conservative treatment program for plantar fasciitis is extensive and must be genuinely completed before surgery is considered. The core program includes:

Stretching: Calf stretching and plantar fascia-specific stretching (towel stretch, toe extension stretching) performed multiple times daily. The first morning stretch before standing is particularly important because the fascia is tight after overnight rest.

Footwear and orthotics: Supportive footwear with arch support and heel cushioning at all times — including the first steps of the morning (no barefoot walking on hard floors). Custom or prefabricated orthotics reduce tension at the plantar fascia attachment.

Physical therapy: Targeted strengthening of intrinsic foot muscles, manual therapy, and modalities such as ultrasound or iontophoresis.

Cortisone injection: A fluoroscopy-guided or ultrasound-guided injection into the plantar fascia attachment provides temporary relief and confirms the diagnosis. Relief lasting weeks to months is common. Repeat injections are used judiciously — more than two to three injections risk plantar fascia rupture.

Night splint: Dorsiflexion night splint keeps the calf and plantar fascia stretched overnight, reducing morning pain.

Shockwave therapy (ESWT): Extracorporeal shockwave therapy is a non-surgical, office-based treatment available for patients who have failed the above measures and are trying to avoid surgery. Studies show meaningful benefit in a significant proportion of patients.

The procedure

What Is Plantar Fascia Release?

Plantar fascia release is surgery for chronic plantar fasciitis that has failed at least 6 months of conservative treatment. The procedure cuts a portion of the tight plantar fascia at its heel attachment to relieve tension and eliminate pain. The endoscopic technique (EPFR) uses a small camera through two tiny incisions, avoiding a large open incision.

The plantar fascia is a thick band of fibrous tissue that runs along the bottom of the foot from the heel bone (calcaneus) to the bases of the toes. It acts as a bowstring that supports the arch during walking and running, absorbing the tension forces that occur with each step. When this tissue becomes chronically inflamed and degenerated — a condition called plantar fasciitis or plantar fasciosis — the heel attachment becomes thickened and painful, causing the characteristic stabbing heel pain with the first steps in the morning.

Plantar fasciitis affects approximately 2 million people in the United States annually and is the most common cause of heel pain. The vast majority of cases resolve with conservative treatment over 6–18 months. Surgery is reserved for the minority of patients — approximately 5–10% — who have persistent, functionally limiting pain despite a genuine sustained effort at non-surgical management.

Endoscopic plantar fascia release (EPFR) is the standard surgical technique. It provides equivalent results to open release with a smaller wound, lower risk of wound complications, and faster return to weight-bearing. The procedure releases the medial third to one-half of the plantar fascia — enough to relieve tension, but not enough to destabilize the arch. Releasing too much of the fascia is why surgical judgment matters: complete fascia release can flatten the arch and create a new, different problem.

What Happens During Plantar Fascia Release?

Plantar fascia release is performed as an outpatient office or surgery center procedure under local anesthesia.

Anesthesia: Local anesthetic is injected at the heel — into the area where the portals will be placed. No IV sedation or general anesthesia is required for most patients, making this one of the few foot surgeries that can be done under local alone.

Positioning: The patient lies on their back or side with the operative foot accessible. A tourniquet may be applied to the ankle.

Portal placement: Two small incisions (approximately 5 mm each) are made on either side of the heel — one medial and one lateral.

Endoscope insertion: A small cannula (sleeve) with an attached camera is inserted through the medial portal into the space beneath the plantar fascia. The surgeon views the underside of the fascia on a monitor.

Fascia release: A small hook-bladed cutting instrument is inserted through the lateral portal. Under direct visualization through the scope, the medial one-third to one-half of the plantar fascia is released from its calcaneal attachment. Cutting is stopped well before the middle of the fascia — partial release is deliberate. Only the plantar fascia is cut; the abductor hallucis muscle and adjacent plantar nerves are protected throughout.

Confirmation: The released fascia ends are visualized to confirm the adequacy of release. The heel spur, if present, is not routinely removed — it is not the cause of pain and its removal adds risk without improving results in most cases.

Closure: Portal incisions are closed with a single suture each. A compressive dressing is applied.

Recovery timeline

Frequently Asked Questions