Patient Outcomes after Surgical Release of the Tarsal Tunnel and Baxter’s Nerve in Addition to Partial Plantar Fasciectomy for Chronic Heel Pain

Abstract

Category: Hindfoot; Midfoot/Forefoot; Sports; Other Introduction/Purpose: Chronic heel pain often presents diagnostic and treatment challenges, in part because symptoms attributed to chronic plantar fasciitis may be part of a larger constellation of associated symptoms. This could explain unsatisfactory symptom relief in many patients who undergo surgical partial plantar fascia release after failing conservative therapy. While previous studies have suggested that additional releases of the distal tarsal tunnel and first branch of lateral plantar (Baxter’s) nerve may improve outcomes in the setting of chronic and recalcitrant heel pain, this combined surgical approach has yet to be documented. Surgically addressing constricted neurologic structures of the tarsal tunnel and Baxter’s nerve alongside partial plantar fasciectomy may lead to improved pain relief and overall patient outcomes. Methods: Study participants were retrospectively identified by database search for relevant criteria and specific CPT codes. Patient outcomes post operation were evaluated using the Foot and Ankle Ability Measurement (FAAM) and sports subscale questionnaires as outcome measures. Inclusion criteria included age greater than 18 years old, at least 6 months since surgery at time of survey, and clinical diagnosis of chronic plantar fasciitis surgically treated by partial plantar fasciectomy with Baxter’s nerve release and tarsal tunnel release performed by either of two staff surgeons between January 1, 2010 and December 31, 2018. Patients with Charcot-Marie-Tooth disease, all patients who were unwilling to participate in the phone survey or were unable to be reached, and all non-English speaking patients were excluded. Eligible patients (N=87) were consented and surveyed by phone. Results: Mean surgery-to-survey time was 39.25 +- 24.33 months. Mean duration of symptoms prior to surgery was 26.73 +- 30.58 months. Mean visual analogue pain (VAS) pre-surgery was 8.47 +- 1.82 (n=84). Survey respondents reported mean scores of 73.10 +- 22.09 and 49.13 +- 1.82 on the ADL score and sports subscale of the FAAM respectively. In retrospectively assessing whether patients would have chosen the surgery again, 70.93% (n=61) reported ‘yes’ while 29.07% (n=25) reported ‘no.’ Significant positive confounders were longer surgery to survey time in months (B= 0.21, p<0.01) and longer pre-surgical symptom length in months (B= 0.169, p<0.04). History of prior foot surgery (B= -22.128, p<0.0001) was identified as a significant negative confounding variable. Conclusion: Patients with chronic plantar fasciitis may benefit from a combined surgical approach involving Baxter’s nerve release and tarsal tunnel release in addition to standard partial plantar fasciectomy. This study demonstrated that this surgical approach is successful with FAAM ADL scores of 73.10 +- 22.09 (n=87) along with 70.9% (n=61) of patients reporting satisfaction with surgical outcome. Considering these implications, future high-quality studies further investigating any comparative benefit of this combined approach over traditional methods are warranted.