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BACKGROUND:
Achilles tendon lengthening can decrease plantar pressures, leading to resolution of forefoot ulceration in patients with diabetes mellitus. However, this procedure has been reported to have a complication rate of 10% to 30% and can require a long period of postoperative immobilization. We have developed a new technique, selective plantar fascia release, as an alternative to Achilles tendon lengthening for managing these forefoot ulcers.
METHODS:
We evaluated sixty patients with diabetes for a mean of 23.5 months after selective plantar fascia release for the treatment of nonhealing diabetic neuropathic ulcers in the forefoot. Preoperative and postoperative dorsiflexion range of motion of the affected metatarsophalangeal joint and wound-healing data were used to evaluate the effectiveness of the procedure and to determine the relationship between plantar fascia release and ulcer healing. Complications were recorded.
RESULTS:
Thirty-six (56%) of the ulcers healed within six weeks, including twenty-nine (60%) of the plantar toe ulcers and seven (44%) of the metatarsophalangeal joint ulcers. The mean range of motion of the affected metatarsophalangeal joint increased from 15.3° ± 7.8° to 30.6° ± 14.1° postoperatively (p < 0.05). All patients in whom the preoperative dorsiflexion of the affected metatarsophalangeal joint was between 5° and 30° and in whom the range of motion of that joint increased by ≥13° after the procedure experienced healing of the ulcer. No ulcer recurrence in the original location was identified during follow-up. No patients experienced any complications associated with the selective plantar fascia release.
CONCLUSIONS:
Our results suggest that selective plantar fascia release can lead to healing of neuropathic plantar forefoot ulcers in diabetic patients. Ulcers in patients in whom the preoperative dorsiflexion angle of the affected metatarsophalangeal joint is between 5° and 30° and in whom the increase in range of motion is ≥13° postoperatively have the greatest chance of being cured.
Re: Plantar fascia release for nonhealing diabetic plantar ulcer
I'd like to see the long term follow up with this procedure. I think it was Dr Javier Pascual Huerta that I was talking to regarding Charcot joint aetiology. As I recall, his contention was that it was preceded by a rupture of the plantar fascia.
Re: Plantar fascia release for nonhealing diabetic plantar ulcer
Quote:
Originally Posted by Simon Spooner
I'd like to see the long term follow up with this procedure. I think it was Dr Javier Pascual Huerta that I was talking to regarding Charcot joint aetiology. As I recall, his contention was that it was preceded by a rupture of the plantar fascia.
Aim The aim of this study was to investigate the prevalence of limited joint mobility at the first metatarsophalangeal joint (MPJ) and dysfunction of the plantar fascia in people with diabetes mellitus and Charcot's neuroarthropathy and a control group.
Methods Fifteen subjects with a history of mid-foot Charcot's neuroarthro pathy and 26 controls with sensory neuropathy but no Charcot's neuro arthropathy were recruited. Ranges of ankle and first MPJ dorsiflexion were measured for each participant. Plantar fascia function was assessed using Jack's test.
Results The range of dorsiflexion at the first MPJ was significantly reduced in the subject group compared with the control group (51.2 vs. 64.8; P < 0.001). Jack's test demonstrated the plantar fascia to be ruptured or dysfunctional in all feet in the subject group and to be functioning in all feet in the control group.
Conclusions It is not possible to determine from this study if the limited joint mobility at the first MPJ and dysfunction of the plantar fascia preceded or followed the development of Charcot's neuroarthropathy; however, these results are a previously unreported finding in Charcot's neuroarthropathy.
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Re: Plantar fascia release for nonhealing diabetic plantar ulcer
Intrinsic minus foot-type = increase load on plantar fascia +glycosylation of plantar fascia = plantar fascia rupture = increased inter-osseous compression and joint trauma = Charcot neuropathy
Something like that.
So, should foot orthoses that are designed to reduce tensile loading in the plantar fascia be prescribed prophylactically in diabetic populations?
Re: Plantar fascia release for nonhealing diabetic plantar ulcer
Along the same lines, an acquired pes cavus foot type develops w/intrinsic minus atrophy associated extensor substitution hammertoes, etc. Also, if you buy that the AGE's stiffen the PF, the Achilles is also affected. It exerts a much more powerful plantarflexory force. I would be hesitant to lengthen it in this particular intrinsic minus foot type vs Steindler stripping (not just PF release). The vast majority of my Charcot patients do not have a cavus foot-type asnd therefore, I do a percutaneous TAL with 90% of all my Charcot patients, whether a reconstructive procedure is performed or not. That said, interesting concept indeed.
Both Tendo Achilles and Plantar Fascial releases are biomechanically unsound (less so in the rigid rearfoot functional foot types) gifting the patient to a healed ulcer and a poorer quality of life for their remaining years which seemingly, is not being considered.
I thought that we were biomechanically oriented foot surgeons?
Isn't there a better way?
I have healed 7000 wounds+ in my career and I have never done a TAL (illegal in New York State for DPM's until recently) or PF release on any of them.
My goals include improving the quality of life for the involved individuals as I heal wounds.
Re: Plantar fascia release for nonhealing diabetic plantar ulcer
Quote:
Originally Posted by Simon Spooner
So, should foot orthoses that are designed to reduce tensile loading in the plantar fascia be prescribed prophylactically in diabetic populations?
I do this all the time however, I call this preventive and quality of life upgrading not prophylactic and I can be more selective than considering all diabetics as you suggest.
They should be dispensed foot type-specific to the stable and flexible rearfoot, stable and flexible forefoot FFT's, especially in the face of other risk factors such as obesity, functional deficits, high energy occupations and lifestyles, etc.
Plantar fascia release for nonhealing diabetic plantar ulcer
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