Calcaneal Osteotomy for Recalcitrant Planter Fasciosis

Plantar fasciosis is a leading cause of heel pain in adults and represents a degenerative rather than inflammatory condition of the plantar fascia. Most cases resolve with conservative measures; however, up to 10-15% remain symptomatic and may require surgical intervention.

Plantar fascia release-either open or endoscopic-remains a standard surgical option for recalcitrant cases. However, this procedure may compromise foot biomechanics. Recent biomechanical and clinical studies have demonstrated that partial or complete release reduces longitudinal arch height and increases midfoot strain, particularly when more than 50% of the fascia is divided. Such alterations in load distribution can result in lateral column overload, metatarsalgia, and sinus tarsi pain. Endoscopic release has also been associated with medial arch reduction and the development of lateral column symptoms within months postoperatively, further highlighting these risks. Additionally, comparative studies report wound complications, nerve irritation, and recurrence of heel pain in a notable subset of patients undergoing plantar fasciotomy. Up to 50% of patients may experience persistent or recurrent pain following the procedure.

Entrapment of the first branch of the lateral plantar nerve (Baxter's nerve) is another under-recognized cause of chronic heel pain, often coexisting with or mimicking plantar fasciosis. Decompression of Baxter's nerve, either alone or combined with limited plantar fascia release, has been shown to improve outcomes in resistant cases.

Given these limitations, calcaneal osteotomy has emerged as alternative surgical strategies. By altering the mechanical axis of the calcaneus and inducing localized bone remodeling, these techniques aim to unload the plantar fascia insertion without compromising arch stability. Early reports suggest that calcaneal osteotomy, particularly when combined with Baxter's nerve release, may offer superior pain relief and functional recovery in recalcitrant plantar fasciosis.

Inclusion criteria

• All adult patients with age range from 18 to 65 years with unilateral or bilateral planter fasciosis after clinical and radiological diagnosis confirmation, who failed conservative treatment for at least 6 months or recurrent cases.
• MRI & US proof of planter fasciosis showing thickness of planter fascia >4mm

Exclusion criteria

• All other causes of heel pain including polyneuropathy, planter fascia rupture, seronegative arthropathies, rheumatoid arthritis in bilateral cases, abscess or neoplasm affecting the soft tissue, and bone occult fracture or infection.
• Age groups below 18 years old and above 65 years old.
• Plantar fasciosis cases having pes planus with diffuse foot pain not only localized to the planter fascia origin (the medial tubercle of the calcaneus - a bony prominence on the inferomedial aspect of the calcaneus).
• Diabetic patients
• Primary tarsal tunnel syndrome (not presented secondary to a deformity or another cause)