import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Multiple branches (average 3-5) cross operative field, arising 1cm proximal to calcaneal tuberosity **Protection**: Careful subcutaneous dissection, identify and retract branches, avoid cautery near nerves **Injury Consequence**: Painful neuroma, heel numbness, complex regional pain syndrome **Location**: Runs between FDB (superficial) and quadratus plantae (deep), crosses medial calcaneal tuberosity 5-10mm from plantar fascia insertion **Protection**: Stay superficial to muscle bellies during fascia release, direct visualization for decompression **Injury Consequence**: Burning heel pain, failed surgery, iatrogenic nerve entrapment **Location**: Runs deep between muscle layers, 10-15mm from medial plantar fascia border **Protection**: Limit lateral extent of release to medial 1/3-1/2, avoid deep dissection **Injury Consequence**: Lateral foot numbness, intrinsic muscle denervation, claw toes **Location**: Runs more medially beneath abductor hallucis, less at risk than lateral plantar nerve **Protection**: Identify as anatomical landmark, gentle retraction if exposed **Injury Consequence**: Medial forefoot numbness, motor loss to lumbricals **Location**: Lateral portion of plantar fascia extending to 5th metatarsal base **Protection**: NEVER release lateral fascia - palpate to confirm intact after medial release **Injury Consequence**: Arch collapse, lateral column overload, chronic lateral foot pain, disability ## Indications **Primary Indication** - Recalcitrant plantar fasciitis unresponsive to minimum 6-12 months conservative treatment - Significant functional impairment and quality of life impact - Failed comprehensive non-operative management **Conservative Treatment Requirements** 1. **Activity modification and rest periods** 2. **Stretching program** - gastrocnemius, soleus, plantar fascia specific 3. **NSAIDs** - minimum 4-6 weeks trial 4. **Orthotics and arch supports** - proper fitting required 5. **Night splints** - maintain dorsiflexion during sleep 6. **Corticosteroid injection** - maximum 2-3 injections 7. **PRP injection** - emerging evidence 8. **Extracorporeal shock wave therapy (ESWT)** - 3 sessions typical 9. **Physical therapy** - eccentric strengthening **Baxter's Nerve Decompression Indication** - Burning or radiating heel pain (not just plantar aching) - Tenderness over nerve course (medial to lateral heel) - Positive nerve percussion test (Tinel's) - Night pain or pain at rest (unlike pure plantar fasciitis) - Failed injections that temporarily relieved pain (suggests nerve component) **Contraindications** - Acute plantar fasciitis less than 6 months duration - Inadequate conservative treatment trial - Active infection - Severe peripheral vascular disease - Inflammatory arthropathy (relative) - Workers' compensation with secondary gain issues (relative) - Unrealistic patient expectations **Pre-operative Assessment** - Detailed pain history - first step pain characteristic of plantar fasciitis - Point tenderness at medial calcaneal tubercle - Pain with passive great toe dorsiflexion (windlass test) - Assess for Baxter's nerve entrapment - burning quality, Tinel's sign - Rule out differential diagnoses: stress fracture, tarsal tunnel syndrome, fat pad atrophy, referred S1 radiculopathy - Imaging: weight-bearing radiographs (heel spur in 50% but not causative), MRI if atypical features - Document conservative treatment failures thoroughly ## Critical Anatomy **Plantar Fascia Structure** - **Three bands**: medial (thin), central (3-4mm thick - primary pathology), lateral (thin) - **Origin**: Medial calcaneal tubercle on inferior calcaneus - **Insertion**: Five slips to proximal phalanges of toes via plantar plates - **Function**: Windlass mechanism - arch support during gait, shock absorption - **Pathology location**: Typically at calcaneal origin (enthesopathy) **Baxter's Nerve Detailed Anatomy** - **Proper name**: First branch of lateral plantar nerve (LPN) - **Course**: Arises from LPN beneath flexor retinaculum, travels between FDB (superficial) and quadratus plantae/abductor hallucis (deep) - **Path**: Crosses inferior to medial calcaneal tuberosity, 5-10mm from plantar fascia insertion - **Destination**: Innervates abductor digiti minimi muscle - **Entrapment sites**: Deep fascia of abductor hallucis (most common), fascial bands between FDB and quadratus plantae, bone spurs - **Sensation**: Purely motor nerve - NO sensory loss with injury (key exam point) **Medial Calcaneal Nerve Branches** - **Origin**: Tibial nerve, arise proximal to tarsal tunnel - **Number**: Variable 3-5 branches - **Location**: Cross operative field in subcutaneous tissue - **Arise**: Average 1cm proximal to calcaneal tuberosity - **Function**: Sensory to medial heel skin - **Injury consequence**: Painful neuroma, numbness, CRPS **Plantar Nerves** - **Medial plantar nerve**: Beneath abductor hallucis, runs more medially, less at risk - **Lateral plantar nerve (trunk)**: Runs deep between muscle layers, 10-15mm from medial fascia border **Muscle Layers (Superficial to Deep)** 1. **Superficial layer**: Abductor hallucis (medial), flexor digitorum brevis (central), abductor digiti minimi (lateral) 2. **Second layer**: Quadratus plantae, lumbricals 3. **Third layer**: Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis 4. **Fourth layer**: Interossei **Vascular Anatomy** - Lateral plantar artery runs with lateral plantar nerve - at risk during Baxter's decompression - Medial calcaneal branches from posterior tibial artery - Careful hemostasis essential - hematoma causes prolonged recovery ## Comparison of Techniques **Technique Selection Algorithm** - **Isolated plantar fasciitis without nerve entrapment**: Endoscopic preferred (less morbidity, faster recovery) - **Plantar fasciitis WITH Baxter's nerve entrapment**: Open mandatory for nerve decompression - **Surgeon inexperienced with endoscopy**: Open approach safer - **Revision surgery**: Open approach for adhesiolysis and better visualization - **Large heel spur requiring removal**: Open approach for better spur access ## Detailed Operative Technique ### Step 1: Patient Assessment & Planning **Pre-operative Confirmation** - Verify diagnosis clinically: inferior heel pain worst with first steps, tenderness at medial calcaneal tubercle - Differentiate plantar fasciitis from Baxter's nerve entrapment (burning vs aching pain) - Rule out stress fracture (MRI), fat pad atrophy (clinical), tarsal tunnel (nerve conduction) - Review conservative treatment timeline - document minimum 6 months - Consent discussion: partial vs complete release, arch collapse risk, nerve injury risk **Exam Answer Template**: "I confirm plantar fasciitis diagnosis clinically with medial heel pain, point tenderness at calcaneal origin of fascia, and pain with first steps after rest. If patient describes burning or radiating pain, I suspect Baxter's nerve entrapment and plan open approach with nerve decompression. I ensure minimum 6 months conservative treatment has failed." - Wrong diagnosis leads to failed surgery - differentiate nerve entrapment from pure fasciitis - Operating on acute fasciitis (less than 6 months) has poor outcomes - Missing Baxter's nerve component when present leads to persistent pain - Inadequate conservative treatment trial leads to medico-legal issues ### Step 2: Positioning and Anesthesia **Patient Position** - **Open approach**: Supine with bump under ipsilateral hip, foot at end of table for access - **Endoscopic approach**: Supine preferred (some surgeons prone), foot at table end - Ensure ankle can be manipulated through full dorsiflexion/plantarflexion **Anesthesia Options** - **Ankle block**: Tibial nerve and sural nerve blocks - excellent for post-op analgesia - **Popliteal block**: Alternative regional option - **General anesthesia**: If patient preference or contraindication to regional - Consider sedation with regional for patient comfort **Tourniquet Application** - Ankle tourniquet (250mmHg) or thigh tourniquet (300mmHg) - Minimize tourniquet time (typically under 30 minutes for release alone) - Exsanguinate with elastic wrap ### Step 3: Incision & Superficial Dissection (OPEN) **OPEN TECHNIQUE - Medial Approach** - Mark incision: 3-4cm oblique or longitudinal at junction of plantar and non-plantar skin - Start 1cm distal to medial malleolus, extend toward plantar aspect - Stay at junction to avoid direct plantar scar (painful weight bearing) - Incise skin and subcutaneous tissue carefully - IDENTIFY and PROTECT medial calcaneal nerve branches - Retract nerve branches gently with vessel loops or small retractor - Divide deep fascia overlying abductor hallucis muscle - Identify thick white glistening plantar fascia on plantar aspect **Technical Pearl**: "For open approach, I make a medial oblique incision at the junction of plantar and non-plantar skin. This allows excellent access to plantar fascia origin while avoiding direct plantar scar which is painful with weight bearing. I meticulously identify and protect the multiple medial calcaneal nerve branches - average 3-5 branches in subcutaneous tissue." - Medial calcaneal nerve branches (3-5) in subcutaneous tissue - injury causes painful neuroma - Direct plantar incision creates painful scar with weight bearing - Skin flap necrosis if dissection plane too superficial or excessive cautery - Identify deep fascia before assuming you have reached plantar fascia ### Step 4: Portal Placement (ENDOSCOPIC) **ENDOSCOPIC TECHNIQUE - Two Portal** - **Medial portal**: 1cm distal and 1cm plantar to medial malleolus - **Lateral portal**: Mirror image on lateral side of heel - Use mosquito clamp to develop space SUPERFICIAL to plantar fascia with blunt dissection - Stay in correct plane (superficial to fascia) - feels white and smooth - Insert obturator and cannula through medial portal - Place 4.0mm 30-degree arthroscope through medial portal - Insert blade (banana blade, hook knife, or retrograde knife) through lateral portal - Confirm visualization of plantar fascia under direct vision **Technical Pearl**: "For endoscopic approach, I place medial and lateral portals at inferior heel level. I develop a plane SUPERFICIAL to the plantar fascia using careful blunt dissection with a mosquito clamp. Camera goes medial, blade lateral. Staying superficial to fascia minimizes risk to lateral plantar nerve which runs deep." - Too deep with medial portal risks lateral plantar nerve injury - Aggressive plantar dissection risks Baxter's nerve damage - Incomplete visualization leads to inadequate or excessive release - Portal placement too anterior may miss calcaneal origin ### Step 5: Plantar Fascia Identification **Identify Plantar Fascia Anatomy** - Three distinct bands visible: medial (thin), central (thick 3-4mm), lateral (thin) - Central band is PRIMARY PATHOLOGY in plantar fasciitis - Appears as white, glistening, thick fibrous structure - Distinguish from deeper red muscle bellies: abductor hallucis (medial), FDB (central) - Palpate thickness of central band with instrument - Identify clear calcaneal origin at medial calcaneal tubercle **Anatomical Key**: "The plantar fascia has three bands - central is thickest and the primary pathology. I clearly identify the white glistening central band at its calcaneal origin before release. Deep to fascia are the intrinsic muscle bellies which are red and soft, not white and firm like fascia." - Misidentifying muscle belly as fascia leads to incomplete treatment - Inadequate exposure makes partial release difficult to gauge - Damaging lateral structures during identification - Not appreciating three-band anatomy leads to excessive release ### Step 6: PARTIAL Plantar Fascia Release (CRITICAL STEP) **Perform PARTIAL Release Only** - **CRITICAL PRINCIPLE**: Release ONLY medial 1/3 to 1/2 of central band - DO NOT release entire central band or any lateral fascia - Release at calcaneal origin using knife (open) or specialized blade (endoscopic) - Cut in controlled manner - feel release of tension - STOP at mid-width of central band - **NEVER** extend release laterally beyond midline of central band - Leave lateral half of central band INTACT - Lateral fascia MUST remain completely intact for arch support - Confirm separation of cut ends with ankle dorsiflexion **MOST CRITICAL EXAM POINT**: "I perform PARTIAL release - medial one-third to one-half of central band only at the calcaneal origin. Complete release of central band or injury to lateral fascia causes devastating arch collapse and lateral column overload pain. Success depends on adequate release for pain relief while preserving lateral structures for arch stability. This is the most critical technical point." - Complete release of central band = 10-25% arch collapse rate - Lateral fascia injury = chronic lateral column pain and disability - Inadequate release (less than 1/3) = persistent pain, treatment failure - Optimal is medial 1/3 to 1/2 - balance between release and stability - Palpate lateral fascia at end to confirm intact ### Step 7: Baxter's Nerve Identification (If Indicated) **Indications for Baxter's Decompression** - Burning quality heel pain (not just aching) - Radiation of pain medial to lateral - Tenderness over nerve course - Positive Tinel's sign - Night pain or pain at rest **Identification Technique** - Retract abductor hallucis superiorly - Identify flexor digitorum brevis belly (central) - Identify quadratus plantae (deeper, more lateral) - Baxter's nerve runs BETWEEN FDB (superficial) and quadratus plantae (deep) - Nerve crosses plantar aspect of medial calcaneal tuberosity - Located 5-10mm from plantar fascia insertion - Often compressed by deep fascia of abductor hallucis at its origin - May see fibrous bands crossing nerve **Anatomical Landmark**: "Baxter's nerve is the first branch of lateral plantar nerve. It runs between FDB superficially and quadratus plantae deeply, crossing the medial heel. It's a MOTOR nerve to abductor digiti minimi, so injury doesn't cause sensory loss - a key exam distinction from medial calcaneal nerve injury." - Gentle dissection to avoid iatrogenic nerve injury during identification - Confusion with medial plantar nerve (runs more medially) - Lateral plantar artery runs with nerve - hemostasis important - Incomplete identification leads to inadequate decompression ### Step 8: Baxter's Nerve Decompression **Decompression Technique** 1. **Release deep fascia of abductor hallucis** - most common compression site 2. **Release fascia between FDB and quadratus plantae** - bands often present 3. **Release any fibrous bands crossing nerve** - use tenotomy scissors 4. **Trace nerve proximally and distally** - ensure complete decompression along course 5. **Remove bone spurs** if compressing nerve (use rongeur) 6. **Confirm nerve mobility** - should move freely without tethering 7. **Gentle handling** - use vessel loop for retraction, not forceps **Decompression Principle**: "I decompress Baxter's nerve by releasing the deep fascia of abductor hallucis where the nerve enters from the tarsal tunnel, releasing fascial bands between FDB and quadratus plantae, and ensuring the nerve is free along its entire course to abductor digiti minimi. Complete decompression requires tracing the nerve both proximally and distally." - Iatrogenic nerve injury during release - use scissors not cautery near nerve - Incomplete decompression of all compression points = persistent symptoms - Lateral plantar artery injury - runs with nerve - Excessive traction on nerve during decompression ### Step 9: Heel Spur Removal (If Present) **Indications for Spur Removal** - Large spur compressing Baxter's nerve - Prominently symptomatic spur on clinical exam - NOT indicated solely based on radiographic presence **Technique** - Expose calcaneal bone at fascia origin - Use rongeur or small osteotome to remove spur - Smooth bone edge with rongeur - Minimal periosteal stripping - Spur removal is ADJUNCT not primary treatment **Evidence-Based Pearl**: "Heel spurs are radiographic finding in 50% of general population - they are NOT causative of plantar fasciitis. Modern evidence shows spurs are traction phenomenon, not cause of pain. I remove large spurs ONLY if they appear to compress Baxter's nerve or are prominently symptomatic on exam. Spur removal alone without fascia release has poor outcomes." - Excessive bone removal risks calcaneal fracture (rare but devastating) - Over-emphasis on spur removal when it's not primary pathology - Periosteal stripping causes delayed healing and hematoma - Cautery near bone increases infection risk ### Step 10: Fascial Release Confirmation **Confirm Adequate Release** - Visualize separation of cut fascial ends - Dorsiflex ankle - cut ends should separate 5-10mm - Palpate lateral fascia - must be INTACT and taut - Check medial longitudinal arch visually - should be maintained - Ensure no inadvertent lateral extension of release - Confirm smooth muscle belly beneath (FDB) - no injury **Confirmation Technique**: "I confirm adequate release by visualizing cut fascial ends separate with ankle dorsiflexion. Most critically, I palpate the lateral half of central band and the entire lateral fascia to ensure they remain intact and taut - this preserves arch stability and prevents the most serious complication." - Incomplete release (less than 1/3) leads to treatment failure - Excessive release (more than 1/2) leads to arch instability - Lateral fascia inadvertently released - check carefully - Muscle injury from excessive dissection ### Step 11: Hemostasis & Irrigation **Meticulous Hemostasis** - Release tourniquet to identify bleeding - Bipolar cautery for vessels - AVOID nerves (especially medial calcaneal branches) - Direct pressure for oozing - Consider topical hemostatic agents if persistent ooze - Hematoma is common cause of prolonged pain and delayed recovery **Copious Irrigation** - Normal saline irrigation to remove debris and bone particles - Inspect wound for foreign material - Final inspection of all structures **Post-op Recovery Pearl**: "I achieve meticulous hemostasis because postoperative hematoma is a significant cause of prolonged pain and delayed recovery. I use bipolar cautery carefully to avoid nerve injury, particularly medial calcaneal nerve branches. Copious irrigation removes bone debris if spur was removed." - Hematoma causes prolonged recovery (weeks to months), infection risk - Nerve injury from injudicious use of cautery - Inadequate irrigation risks infection if bone was removed - Drain rarely needed - creates portal for infection ### Step 12: Closure **OPEN Approach Closure** - Close deep fascia if possible with absorbable suture (3-0 Vicryl) - Provides soft tissue coverage over release site - Subcutaneous closure with 3-0 or 4-0 absorbable suture - Skin closure with 3-0 or 4-0 non-absorbable suture or staples - Avoid tension on closure - Some surgeons leave deep layers open to prevent hematoma compression **ENDOSCOPIC Approach Closure** - Close each portal with single 3-0 or 4-0 nylon suture - Minimal wound to close - Steri-strips for additional skin approximation - Significantly less wound to manage compared to open **Closure Strategy**: "For open approach, I close in layers to provide soft tissue coverage. Tension-free skin closure is critical to prevent dehiscence. For endoscopic approach, each portal requires only a single suture - this is a major advantage with less wound morbidity." - Tension closure causes wound dehiscence - especially on medial heel - Excessive deep closure can compress hematoma - Painful plantar scar if incision extends too plantar - Portal site infection rare but occurs ### Step 13: Dressing & Immobilization **Immediate Post-op Dressing** - Bulky compressive dressing with fluff and Ace wrap - Compression minimizes hematoma and swelling - Elevate foot post-operatively **Immobilization Protocol** - **ENDOSCOPIC**: Supportive shoe with heel cushion, immediate heel weight bearing allowed - **OPEN**: Short leg cast or CAM boot for 2 weeks protected weight bearing - Transition to supportive athletic shoe with cushioned heel insert - Avoid barefoot walking for 6-8 weeks **Rehabilitation Advantage**: "Endoscopic approach allows immediate heel weight bearing which is a significant advantage over open technique. Open approach typically requires 2 weeks protected weight bearing in CAM boot to allow wound healing. Both techniques benefit from compression dressing to minimize hematoma which prolongs recovery." - Excessive immobilization causes ankle/subtalar stiffness - Early unprotected weight bearing on open incision risks dehiscence - Inadequate compression leads to hematoma formation - Overly tight compression dressing can cause compartment syndrome (rare) ### Step 14: Neurovascular Check & Documentation **Final Assessment** - Release tourniquet and assess perfusion - Check plantar skin color and capillary refill - Test medial calcaneal nerve distribution sensation on heel - Confirm no motor deficit (wiggle toes) - Palpate pedal pulses - Check for expanding hematoma - Ensure dressing comfortable, not too tight **Documentation** - Procedure performed (open vs endoscopic) - Extent of release (medial 1/3 vs 1/2) - Baxter's nerve decompression performed (yes/no) - Heel spur removed (yes/no) - Complications (nerve injury, excessive bleeding, etc.) - Tourniquet time - Estimated blood loss (typically minimal) **Medico-Legal Pearl**: "I release tourniquet and check perfusion and sensation systematically. The medial calcaneal nerve supplies heel sensation - I document this is intact. I thoroughly document extent of release (medial 1/3 to 1/2), whether Baxter's decompression was performed, and any intraoperative findings or complications." - Unrecognized medial calcaneal nerve injury causes painful neuroma - Vascular compromise from overly tight dressing - Compartment syndrome (extremely rare but possible) - Inadequate documentation creates medico-legal risk ## Complications ## Outcomes **Success Rates** - Overall success (good/excellent outcome): 70-90% - Higher success with proper patient selection (exhausted conservative treatment) - Endoscopic vs open: similar success rates in most studies - Partial vs complete release: partial has better outcomes with less morbidity **Failure Rate Analysis** - 10-30% persistent pain despite adequate surgery - Common causes of failure: inadequate conservative treatment trial, wrong diagnosis (missed Baxter's, tarsal tunnel, stress fracture), inadequate release, excessive release causing arch collapse **Return to Activity Timeline** - **Endoscopic**: Return to normal shoe 1-2 weeks, return to sports 6-8 weeks, full recovery 2-4 months - **Open**: Return to normal shoe 4-6 weeks, return to sports 8-12 weeks, full recovery 3-6 months - Athletes: May require 4-6 months for high-level competition return - Heavy laborers: Modified duty 6-8 weeks typical **Long-term Outcomes (5+ years)** - Most patients maintain improvement if initial surgery successful - Risk of arch collapse increases over time if excessive release performed - Recurrence rare if adequate release performed (less than 5%) - Contralateral heel pain develops in 10-15% over time ## References 1. **Digiovanni BF, et al.** Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis: a prospective clinical trial with two-year follow-up. *J Bone Joint Surg Am.* 2006;88(8):1775-1781. PMID: 16882906. 2. **Davies MS, Weiss GA, Saxby TS.** Plantar fasciitis: how successful is surgical intervention? *Foot Ankle Int.* 1999;20(12):803-807. PMID: 10609710. 3. **Baxter DE, Pfeffer GB.** Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. *Clin Orthop Relat Res.* 1992;279:229-236. PMID: 1600660. 4. **Jerosch J, Schunck J, Liebsch D, Filler T.** Endoscopic plantar fasciotomy: a standardized surgical technique. *Knee Surg Sports Traumatol Arthrosc.* 2004;12(5):453-457. PMID: 15124093. 5. **Neufeld SK, Cerrato R.** Plantar fasciitis: evaluation and treatment. *J Am Acad Orthop Surg.* 2008;16(6):338-346. PMID: 18524985. 6. **Thomas JL, et al.** The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. *J Foot Ankle Surg.* 2010;49(3 Suppl):S1-19. PMID: 20439021. 7. **Coughlin MJ, Saltzman CL, Anderson RB.** Mann's Surgery of the Foot and Ankle, 9th Edition. Elsevier, 2014. Chapter on plantar fasciitis and heel pain syndrome. 8. **DiGiovanni CW, Kuo R, Tejwani N, et al.** Isolated gastrocnemius tightness. *J Bone Joint Surg Am.* 2002;84(6):962-970. PMID: 12063330. 9. **Saxena A, Fullem B.** Plantar fascia ruptures in athletes. *Am J Sports Med.* 2004;32(3):662-665. PMID: 15090381. 10. **Daly PJ, Kitaoka HB, Chao EY.** Plantar fasciotomy for intractable plantar fasciitis: clinical results and biomechanical evaluation. *Foot Ankle.* 1992;13(4):188-195. PMID: 1634152.

Plantar Fascia Release (Open/Endoscopic) + Baxter's Nerve Decompression

Plantar Fascia Release (Open/Endoscopic) + Baxter's Nerve Decompression