EPF

Endoscopic Plantar Facial Release

By Jay Lieberman, DPM
Director of Podiatric Residency Education
Northwest Medical Center
Margate, Florida

In residency training, you pick up a pearl here and a pearl there.  Then you take the best ideas and eventually incorporate them into your own practice patterns.   At Northwest Medical Center, we have compiled a list of ideas and pearls that may help you improve upon the success of your endoscopic plantar fascial release procedures.  I personally believe there is no better "surgical" approach to resilient plantar fasciitis. 

In past years,  I often grew weary  of repeatedly explaining  to patients, why the prominence seen on  x ray was not overly significant.  Things have gotten somewhat easier.  Today's patient is a bit more knowledgeable, often bringing with them a fist full of papers from their "Google" search.  They understand that their heel pain is plantar fasciitis and not just a spur.  Before the physician has a chance to discuss treatment options, they are inquiring about orthotics, night splints, and shockwave therapy. 

Endoscopic Plantar Fascial Release is a simple procedure as a result of the outstanding instrumentation that is available.  Over the years, we have tweaked the process a bit and have gotten better results.  Prior to considering a surgical alternative, all of our patients have had a reasonable course of conservative care including custom orthotics.  They are also made aware of the need for orthotic control post operatively, despite successful resolution of their symptoms. 

  1. Our incision placement is based upon palpation of the medial tubercle rather than measurements of the bisection of the posterior and plantar heel.  There is too much inconsistency in the shape and contour of the plantar fat pad in the weight bearing and non weight bearing positions. 
  2. The actual incision is dorsal to plantar rather than proximal to distal.  Using this approach, we are more likely to encounter the fascia at variable locations.
  3. We limit the dissection of the superior aspect of the plantar fascia.  The less disruption of the first muscle layer, the less apt your are to cause hemorrhage.  Release of the fascia without any muscular bleeding is the ultimate goal. 
  4. As you insert the trochar; use caudal pressure so that the cannula sits firmly against the fascia and there is very little intervening fat.  Remember that the medial tubercle is larger than the lateral tubercle.  Therefore, the trochar is inserted in a distal medial to proximal lateral direction.  Ideally, the exit incision should be the same distance from the plantar surface as the entry incision.  This avoids puncturing through the fascia into the muscle or into the plantar fat pad.
  5. Once the cannula is in place, rotate it 360o four to five times.  This tends to clear fat away from your field of vision.


     

  6. The outer portion of the cannula has a small dell which identifies the slotted area.  To avoid inadvertent rotation of the cannula, I mark the skin to insure the position remains unchanged throughout the procedure.  In this way "one" incision is made in the fascia, not many.  A small amount of rotation may cause the surgeon to lose his original release site.
  7. A sharp hook blade is imperative.  Often, one attempt to release the  fascia is all that is necessary.  Repeated passes of the blades will cause unnecessary trauma.
  8. Prior to completion, I rotate the cannula 180o  to insure that no fibers are missed plantarly.  I also extract the cannula 1/4" and pass the hook blade one final time to release fibers that may be positioned superiorly .
  9. The wound is flushed with the cannula in place.  This insures a thorough lavage. 
  10. Once the cannula is removed, a freer elevator is passed plantar to dorsal to insure that the release is complete.

Endoscopic Plantar Fascial release is a minimally invasive procedure.  When done appropriately, it limits trauma to the surrounding tissue.  Invariable this speeds healing and allows your patient to comfortably return to daily activities.  

There is an excellent video presentation of the procedure on the Instratek website.  I would also recommend that you view Dr. Barrett's lecture in the PRESENT curriculum. 

Dr. Barrett's Video Presentation on the EPF Procedure

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CLICK below to view Dr. Barrett's excellent lecture
on the EPF procedure

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